Distinguishing Deference from Deferment: Assisted Suicide Is the Wrong Response

Distinguishing Deference from Deferment: Assisted Suicide Is the Wrong Response Abstract In this article, I examine the practice of assisted suicide. I aim to do so by, first, briefly sketching a description of the current context with a particular focus on Canadian law and the prominent role that autonomy plays there. I point to resources from within the Roman Catholic tradition that serve as a counterbalance to the focus on autonomy. Second, given the prevalence of appeals to autonomy in the lives of practitioners and patients and how claims of autonomy influence considerations associated with assisted suicide, I describe the account of autonomy that is operative in these discussions and sketch an account of deference that should replace the commonplace account of autonomy. Finally, having considered popular appeals to medical assistance in dying, I ask whether cases of assisted suicide are best thought of as nonmedical cases and what appeals to traditions of thought outside of explicitly medical professions have to add to this discussion. I. INTRODUCTION In closing his seminal paper on the situation faced by Mr. Dax Cowart, Stanley Johannesen implores his readers, “None of us should wait for a decent society before we can say to a man that we are simply glad he is still with us” (Johannessen, 1989, 185). The sentiment expressed in this statement is in need of attention and further exploration today in the face of growing opportunities for the taking of life shrouded in the claims of good medicine. Johannesen’s assertion weighs heavily on those who are concerned with these opportunities, especially in light of recent legal decisions in Canada and their possible implications for patients and practitioners there, in the United States, and throughout the international medical communities. Much has been written on suicide, assisting patients in dying, and the medical and moral issues that are raised in hastening the death of a patient or directly killing a patient. In this article, my focus is more narrow. I believe that Johannesen’s sentiment is an appeal to make space for others to influence the decisions of a patient about her own life. This is tricky terrain for medical ethicists as this kind of influence could violate the autonomy of patients. I aim to explore this kind of influence by, first, briefly sketching a description of the current context with a particular focus on Canadian law and the prominent role that autonomy plays there. I also point to resources from within the Roman Catholic tradition that serve as a useful dialogical partner for defenses of assisted suicide. Second, given the prevalence of principles of autonomy in arguments about the lives of practitioners and patients and how claims of autonomy influence considerations associated with assisted suicide, I describe an account of autonomy that is operative in these discussions. The operative account of autonomy suffers from a failure to allow genuine engagement with a patient, partly due to an implicit understanding of medicine as a service provided to patients and not as a practice involving a relationship between patients and practitioners. I describe this account of autonomy as deferment and argue that an account of autonomy as deference is superior. Finally, having considered popular appeals to medical assistance in dying, I ask whether cases of assisted suicide are best thought of as nonmedical cases and what appeals to traditions of thought outside of explicitly medical professions have to add to this discussion. These steps are sufficient to illustrate that we ought to slow movement toward the endorsement of assisted suicide in medicine and, instead, reconsider what are the proper roles of the medical profession, reflecting on this role in future policy decisions. In the very least, in light of these arguments, medical practitioners should neither be required nor encouraged to participate in the ending of the lives of patients. II. A TOUGH CASE The case of Dax Cowart requires little rehearsing for students of medicine and applied ethics, at least in the United States. For those coming to the debate over assisted suicide from other disciplines or locations, here is an all too brief recap: due to an explosion, most of Mr. Cowart’s body was badly burned. Were he not taken quickly to a hospital, eventually a burn center, and given painful treatment over an extended period of time (all against his expressed will), he would certainly have succumbed to his injuries and died. The case involved Cowart’s request to be killed when he was first discovered after the explosion, as well as a series of clear refusals of treatment, and a patient advocate (his mother) who deferred to medical practitioners over her son’s wishes and whose views were influenced by a theological tradition not shared by the patient undergoing the painful treatment. Mr. Cowart’s case is often discussed in medical ethics courses, and at the risk of trivializing the horrific situations that he underwent, I engage it here. I do so, as I do in teaching, because his situation is instructive on a variety of fronts, in part, because so much went wrong. The case involves failures of communication and what appears to be treatment akin to imprisonment, uncertain roles of authority, ethical challenges regarding emerging medical technologies, deep philosophical disagreements between proponents of best interest and those of liberty, and many more. Additionally, it is instructive because Mr. Cowart would not have been treated this way were he to present with those injuries at a hospital today, nor had he presented 10 or even 5 years prior. This is not only due to the state of medical science, but also due to changes in the power that patients have over their own treatment. It is important to keep in mind at this juncture that what constitutes treatment is one of the issues at the heart of the debate over assisted suicide. There is a difference between requesting that someone end your life—mirroring the initial request that Mr. Cowart made—and determining that a course of treatment, in a medical context, is too burdensome to undergo.1 Distinctions of this kind, like other aspects of Mr. Cowart’s case, need little rehearsing; this ground is well trodden. What I wish to ask is, “What sense is there to be made from claims like, ‘None of us should wait for a decent society before we can say to a man that we are simply glad he is still with us’?” Were such a line uttered to Mr. Cowart during the time that he had little control over his own life and treatment, it is hard to imagine the utterance being met with anything but disdain. Yet, this is not the sentiment that is intended by that expression. Rather, it is an attempt to see the person: the person who can sometimes be forgotten in assessing a burn patient or in policy disputes about healthcare resource allocations. Even in courses in medical ethics and articles about cases—there is a patient present, a person in need of care.2 Given the vulnerable state such a person is in, is it morally acceptable to tell that patient that we are glad he is here, even in his great suffering? Is this not an instance of manipulation? An instance of undue influence? A failure to respect his autonomy and the decision-making that appropriately is his, as are decisions over his own life? I contend that this kind of engagement with the patient is ruled out by arguments in support of assisted suicide, like those referenced in the recent Canadian legislation, Bill C-14, which reflects the position that if a person is deemed competent and wishes to die, medical practitioners should aid in her death. This is how such an utterance would be viewed today, and I believe we can see this in movements in favor of medical practitioners assisting in the deaths of their patients, which rely on the notion of medicine as an all-encompassing set of services which ought to provide to a patient anything that she orders. The focus on the patient as a person—telling a man that we are glad he is still with us—is needed and fitting. One might wonder whether we, broadly speaking, have overcorrected for failures in cases like Mr. Cowart’s and placed ourselves in a situation where medical practitioners kill their patients upon request.3 This overcorrection can be seen in legal documents, like Canada’s Bill C-14. It is to this example and an aforementioned dialogical partner that I now turn. III. LEGAL KILLING AND THE CATHOLIC TRADITION One example of a tradition with rich resources that might serve as a dialogical partner with an autonomy-focused ethic is a medical ethics rooted in the Roman Catholic tradition.4 Reflecting on the resources of this tradition can guide decision-making and, in a fairly clear way, challenge the acceptance of assisted suicide. This has been exhibited well in the recent and prominent discussion of assisted suicide and euthanasia in Canada; in particular, the Medical Assistance in Dying (Parliament of Canada, 2016), which received assent last year in the Canadian Parliament. The bill allows adults to seek medical assistance in dying and ensures that medical practitioners will not be held criminally accountable for such assistance. This bill may be emblematic of a sea change in views on the role of medicine and death5—allowing both voluntary euthanasia and physician-assisted suicide. Though Canada is neither the first nation nor government to go in this direction, it does offer an opportunity to question the merits of this trend.6 Those familiar with the procedural requirements for assisted suicide in those states in which it is legal in the United States will be not be surprised by the usual requirements that Medical Assistance in Dying (MAID) applies to those who have “a grievous and irremediable medical condition” (Parliament of Canada, 2016, 5). This condition applies to persons if: (a) they have a serious and incurable illness, disease, or disability; (b) they are in an advanced state of irreversible decline in capability; (c) that illness, disease, or disability or that state of decline causes them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable; and (d) their natural death has become reasonably foreseeable, taking into account all of their medical circumstances, without a prognosis necessarily having been made as to the specific length of time that they have remaining (Parliament of Canada, 2016, 6). Safeguards are in place to ensure that persons seeking MAID meet the criteria, are well-informed, can withdraw, and can understand and communicate their decision (Parliament of Canada, 2016, 6–7). Though the aforementioned features merit attention, the focus of this article is not the procedural details of assisting in death but rather the justification of a nation for its citizens, as patients, to seek their own death and for its citizens, as medical practitioners, to kill or help to kill their fellow citizens. What is that justification? It can be found, clearly stated, in the opening line of the Preamble of the Bill: “Whereas the Parliament of Canada recognizes the autonomy of persons who have a grievous and irremediable medical condition that causes them enduring and intolerable suffering and who wish to seek medical assistance in dying . . . ” (Parliament of Canada, 2016, 1). The justification is, simply put, the autonomy of persons, and the appeal to the autonomy of persons in this case is strong enough to provide a counterbalance to considerations of the protection of vulnerable persons, as noted later in the Preamble: Whereas, in light of the above considerations, permitting access to medical assistance in dying for competent adults whose deaths are reasonably foreseeable strikes the most appropriate balance between the autonomy of persons who seek medical assistance in dying, on one hand, and the interests of vulnerable persons in need of protection and those of society, on the other. (Parliament of Canada, 2016, 1) Persons, in this case citizens, possess autonomy, and respect for their autonomy requires that states allow and even support their being killed and their being assisted in killing themselves. Before addressing this account of autonomy, it is worth contrasting this kind of approach with that of the aforementioned Roman Catholic Tradition. There is a plethora of resources from within the Roman Catholic Tradition, which might assist in guiding understanding on this topic.7 Recent statements by Canadian Bishops are good examples. Consider, for instance, Archbishop Prendergast’s Statement on Bill C-14 (Prendergast, 2016), in which he lays out clearly and concisely that killing is morally wrong and that requesting assistance in dying is also morally wrong. He reminds Canadians that, according to the Roman Catholic Tradition, “To kill an innocent person is always morally wrong, and Catholics must understand requesting an assisted suicide or euthanasia is also morally wrong and puts their souls at risk.”8 Clear statements like this can be read as lacking empathy for persons undergoing terrible circumstances, but this would be a misreading. It does not necessarily follow from a claim that persons ought not take their own lives (and that others should not assist them in doing so) that one cannot imagine being in such a situation or that one does not “feel for” that person. However, it would not follow if one has a particular account of autonomy (which I discuss in the next section) and prioritizes this particular moral concept above all others.9 Another helpful and clear statement comes from the President of the Canadian Conference of Catholic Bishops, Archbishop Paul-André Durocher. In that statement, the Archbishop, relying on the Catechism, states: Helping someone commit suicide, however, is neither an act of justice or mercy, nor is it part of palliative care. The decision of the Supreme Court of Canada today does not change Catholic teaching. “[A]n act or omission which, of itself or by intention, causes death in order to eliminate suffering constitutes a murder gravely contrary to the dignity of the human person and to the respect due to the living God, our Creator.” (citing Catechism of the Catholic Church, 2277). (Durocher, 2015) He continues, emphasizing a notion of empathy and care that is consistent with a disapproval of suicide, stating: The Bishops of our country invite Canadians, especially Catholics, to do all they can to bring comfort and support for all those who are dying and for their loved ones, so that no one, because of loneliness, vulnerability, loss of autonomy, or fear of pain and suffering, feels they have no choice but to commit suicide. The Canadian Conference of Catholic Bishops will continue to promote palliative and home care, and to encourage all the faithful to work for the betterment of the elderly, the disabled, the ill, and those who are socially isolated. (Durocher, 2015) These ideals are emphasized further in a statement from the Catholic Bishops of Alberta, relying on claims from Evangelium Vitae. They wrote: Death by assisted suicide and euthanasia has been made legal in Canada. These grievous affronts to the dignity of human life from beginning to natural end are never morally justified. The legal permission now granted to these practices does not change the moral law. The teaching of the Church on these matters is clear. Euthanasia “is a grave violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person.” Since suicide, objectively speaking, is a gravely immoral act, it follows that “to concur with the intention of another person to commit suicide and to help in carrying it out through so-called ‘assisted suicide,’ means to co-operate in, and at times to be the actual perpetrator of, an injustice which can never be excused.” (Smith et al., 2016; cf. St. John Paul II, 1995, 65–66)10 With these recent statements reliant on Roman Catholic resources in hand, it is worth recalling the aforementioned quotation from Johannesen, and interpreting it is not merely as an invitation to a patient to remain with us,11 but an invitation to others to share with patients who are suffering the care and concern with which they are held. This interpretation captures well a key component of the Roman Catholic position on assisted suicide. To kill another or to assist another in killing herself is a “gravely immoral act.” Categorizing it as such need not be viewed as a draconian restriction on the autonomy of persons or their conscience. Rather, it is an ethic of care focused on the whole person, a being embedded within a community, whose life matters not only to her. However, there is a tension between this position, articulated from the Roman Catholic Tradition and with Johannesenian resources and an interpretation from cultures in which autonomy (in particular, certain accounts of autonomy) is the preeminent bioethical principle. To express to a patient that one is happy she is here, glad she has not left us, appears, on these accounts, to be an undue influence on a vulnerable person (especially given the power dynamics in play in many practitioner–patient relationships), often by a member of a service industry who is providing a requested commodity. In the next section, I attempt to illustrate this tension by sketching the account of autonomy that is operative in the Canadian legal documents, what I call autonomy as deferment. Then, I sketch a different account of autonomy, autonomy as deference, which does not clash with the kind of orientation expressed by Johannesen and is supported by the rich resources of the Roman Catholic Tradition. IV. AUTONOMY AS DEFERENCE, AUTONOMY AS DEFERMENT Consider a patient who wishes to end her life by means of medical aid in dying. She meets (a)–(d) of the Canadian requirements, and she seeks out a physician to end her life. This manner of treating a patient is in accord with respecting her autonomy, a respect that is strong enough to require someone to end her life at her request. I propose that we might think of autonomy as deferment or as deference. I consider each in turn. Autonomy as deferment is meant to express the idea that persons are entitled to respect in light of some specialness that they possess and that respecting them in this way requires deferring to them on a variety of matters that are important to them and intimately related to their lives, which includes their medical treatment. A proponent of autonomy as deferment conceives of individuals as individuals first, not as members of a community nor as members of deep relationships. It does not rule these out as important aspects of a person’s life, but the value given to these aspects is defined and measured solely in terms of the individual and her preferences. My original articulation of autonomy as deferment is not very precise, but I hope the general idea is clear.12 It is worth pointing out both that this is not the only account of autonomy and that this very account may seem unproblematic to many readers.13 What is also worth noticing is that autonomy as deferment would rule out attempts by medical practitioners to influence the medical decisions that the patient makes. A medical practitioner would not, in deferring to the patient, do anything more than fully inform the patient of the details of the procedure, the possible risks and benefits, and any other relevant information for a fully informed consent. To do anything more would not make sense, as I shall argue below, because the practitioner is merely one individual providing a requested service for another. On this view, the practitioner should not preemptively express the Johannesian sentiment that she hopes the patient stays with us. To do so would be to manipulate the patient. For those who do not subscribe to autonomy as deferment,14 as I have described the concept, it may appear to be an extreme position and therefore an easy target—set up only to be knocked down and to make way for another account of autonomy. Autonomy as deferment should not be ignored so quickly, and for two reasons—language and context—in addition to its prevalence.15 First, deferring to patients is appropriate and fitting in discussions of matters of their health, but what this language leaves out is consideration of others—family members, friends, and the person of whom the service is requested, the practitioner! It does not consider the practitioner, as if someone would not be required to satisfy the request for death.16 The case here, according to the Canadian law, is about medical aid in dying, not merely the legality or illegality of suicide. It does not consider other members of the community or institutions such as hospitals and clinics in which the person would be killed. Second, this extreme sense of deferring would take place in a context in which medicine is viewed as a commodity. Medical services are things to be bought and sold, and medical practitioners are merely providers on a service line, responding to an order much like someone in a packaging facility might fill a request for paper towels to shipped. Autonomy as deference leaves little room for the kind of engagement—moral discussions about life and death—which might have otherwise occurred between patients and practitioners. An expansive notion of “medical treatment” is also part of the context that I am describing,17 and an idea I take up at the end of the article. If this context and language are in place, the seeming extremeness of the situation I describe fades a bit. Consider, for example, the argument offered this year in the New England Journal of Medicine against conscious protection for medical practitioners—requiring practitioners to be of the same mind on moral matters associated with medicine or to leave the profession (Stahl and Emanuel, 2017). This extreme account of autonomy, autonomy as deferment, becomes more plausible given the language and context operative in healthcare today, at least in the United States and, it seems, in Canada. Contrast this account of autonomy with another conception of appropriate authority over oneself and one’s decisions: autonomy as deference. Autonomy as deference is also meant to express the idea that persons are entitled to respect in light of some specialness that they possess and that respecting them in this way requires deferring to them on a variety of matters that are important to them and intimately related to their lives, including medical treatment, but autonomy as deference does not conceive of the individual as an isolable entity. Here, individuals are understood as situated within social contexts in which other individuals, such as family members and physicians, are appreciated as essential for advising and guiding proper decision-making. Perhaps the final word belongs to the patient, but others are invited, indeed encouraged, to be part of this conversation. This account is not at home in a context where medicine is viewed as a commodity, but rather fits better with a conception of medicine that prizes the relationships between patients and other persons, not least of all the person from whom she is requesting aid. Here, physicians are not merely skilled technicians, but important discussion partners in medical decision-making, who also have moral status in their own right. I hope the contrast between these accounts of autonomy is clear. At this point, though, one may simply wish to jettison any notion of autonomy as deference or deferment. This would be a mistake as notions of deference and deferment capture aspects of commonly held views of autonomy. To help illustrate the benefit of these notions and to further clarify their difference, I borrow an example from the work of Jeremy Waldron on respect as it relates to deference. This work appears in a number of places, most notably in his work on dignity, from which I take the example.18 One interpretation of dignity that Waldron offers is explained through an emphasis on deference as part of the language of respect associated with dignity and the offices that historically conferred dignity on their inhabitants (Waldron 2007). As he is not aiming to distinguish deference from deferment, as I am, this distinction in language does not arise. In retelling the example, I will use his language of deference, and then clarify how this maps on to my usage with respect to the case of assisted suicide. Waldron offers an example of a judge, a person who occupies an important office with which a certain dignity is (or has often been) associated.19 A judge is deferred to, so claims Waldron, not only in the courtroom in which she presides over legal proceedings, but in other areas of life, as well. Waldron’s aim here is to show that deferring to the inhabitant of a dignity-conferring office can be extended beyond that office. This move, in the context of his argument in favor of a particular account of dignity, allows him to explain a transvaluation in society’s attributions of dignity: the respect given (i.e. the deferring) to those who held particular offices is extended to all persons.20 In discussions of assisted suicide, patients are deferred to in this way. The well-known case of Brittany Maynard and those who supported her is a fitting example. Ms. Maynard was diagnosed with an inoperable brain tumor, which if it ran its course would eventually take her life. She claimed she had a right to die with dignity and that she should be supported in this by members of the medical profession. She eventually moved to a state in which assisted suicide was legal and, going through the legal and medical protocols, obtained the means to take her own life and did so. What is interesting for my purposes here is how Ms. Maynard conceived of herself and those from whom she was requesting assistance. She was due what Waldron would call “extensive and diffuse deference.” For Waldron, this deference goes beyond the instances in which persons merit such treatment. It is important to keep this in mind in analyzing cases of assisted suicide. In taking Waldron’s theoretical resource and applying it to assisted suicide, the notion that persons might not merit the dignity they possess, the deference with which they are treated, is not a problem but an accounting of a now commonplace, societal view. Similarly, in the case of assisted suicide, patients who have met the relevant requirements and followed legal protocol have a decision sanctioned by professionals.21 I am concerned about the kind of move that Waldron makes for two reasons. First, merely because deference is given to one person because of an office she possesses does not illustrate that deference is (or should) be given to that person outside of the tasks or roles of that office, and if it is, it very well might be that she is given deference due to particular qualities she possesses that are on display in those other contexts. Second, it is not clear that if, for the sake of argument, we were to grant the first move that we should also think that deference that extends beyond a particular office of one person would extend to all persons (or patients)—these are, in fact, different persons (distinct patients). Waldron’s account of dignity warrants attention because of its sophistication, but also because it captures well a commonly held view. I believe that it is this kind of thought—the deference that Waldron connects with the concept of dignity—that motivates common views about autonomy in medicine: accounts of autonomy that amount to a simple statement that the patient chooses, and that is the final and only say in the matter. This view aligns with the understanding of medicine as a commodity, about which I have concern. If we take this view to its limits, it would require practitioners to hold back expressing positive sentiments that patients are “still with us” and motivate them fully to endorse the hastening and even direct ending of lives as tasks that have been ordered and that they and others have no say in, even with respect to their own roles in a killing.22 If it is right to defer to the patient in medical situations as one might defer to a judge in other situations, is this properly described as respecting autonomy as deference or respecting autonomy as deferment? Autonomy as deferment is a tricky concept for moral evaluation, in part because autonomy and deferring to a person about those things that fall within the sphere that appears properly hers to be governed is a good thing, especially in cases where we are considering persons who are making decisions about what they care about most deeply. It is their life. Turning to other important work on the concept of dignity supports this claim. For example, consider Ronald Dworkin’s account of the “two principles of human dignity.” Dworkin’s first principle, the principle of intrinsic value: . . . holds that each human life has a special kind of objective value. It has value as potentiality; once a human life has begun, it matters how it goes. It is good when that life succeeds and its potential is realized and bad when it fails and its potential is wasted. This is a matter of objective, not merely subjective value; I mean that a human life’s success or failure is not only important to the person whose life it is or only important if and because that is what he wants. The success or failure of any human life is important in itself, something we all have reason to want or to deplore. (Dworkin, 2006, 9–10) His second principle, the principle of personal responsibility, “holds that each person has a special responsibility for realizing the success of his own life, a responsibility that includes exercising his judgment about what kind of life would be successful for him” (Dworkin, 2006, 10). Dworkin, like Waldron and many others who offer accounts of dignity or autonomy, tries to account for the deference or deferment that is thought to be owed to persons, especially with respect to those things that are taken to be within a kind of autonomous sphere, things that they rightly should have control over. Dworkin articulates his position in terms of a couple of basic principles. First, that all lives are important and have objective value, but what counts as living a successful life is defined by the individual who is living that life. Second, respecting her dignity, deferring to her autonomous self, requires leaving up to her how she leads her life. Separately, the principles both appear laudable, but a tension arises when we consider them together, and it occurs in particular when thinking about cases of assisted suicide. Were the first principle all that we had to apply, assisted suicide seems like an unlikely possibility. According to the first principle, lives have objective value. They matter, and matter deeply, to those who hold them, but also to others. Ending a life is not something that would be permitted, at least in most cases, if lives have this value and if there are other options to address the more often addressed, direct concerns, like those of pain and suffering. However, according to the second principle, it is up to the person (the persons who hold their own lives) to determine what a successful life would be for that person. Were the second principle all that we had, assisted suicide would follow as a necessary intervention in cases where persons deemed it part of their account of a successful life.23 Additionally, the distinction between autonomy as deference and autonomy as deferment can be seen to emerge here. Consider Dworkin’s first principle alone, with a particular focus on his anti-subjectivist emphasis: “I mean that a human life’s success or failure is not only important to the person whose life it is or only important if and because that is what he wants.” This notion is also captured in autonomy as deference. However, consider the second principle alone, in particular the claim that persons possess “a responsibility that includes exercising his judgment about what kind of life would be successful for him.” This notion is also captured in autonomy as deferment. Thus, the tension is in place: the second principle requires assisting in a person’s death, but the first principle recommends the opposite. Which principle is correct, or can the tension be alleviated? One possible route to alleviation is through prioritizing one principle over the other. However, it is important to recognize that there is in fact a tension and that such prioritization is in need of an argument. It is also important to note that claiming that human beings are objectively valuable, that—to borrow Dworkin’s language—once a human life has begun it matters how it goes—does not require a vitalist interpretation of the relevant issues. One can embrace Dworkin’s first principle without espousing the somewhat silly claim that human beings should try to live forever. To be clear, this kind of approach is not what leads to the tension between these principles. Rather, it is that making claims of objective values brings with it a need for standards by which to judge objective values. If human beings are objectively valuable, this claim is most clear, most sensible when we can point to things that illustrate the value of human beings. The literatures on the concept of dignity and the concept of autonomy grow increasingly extensive on this point, but this is not the place to address the details of these literatures. What is crucial for my purposes here is to understand how we might reconcile the need for objective standards, which follows from the first principle, and the rejection of standards that seems to follow from the second (at least with respect to the issue of assisted suicide). I add this parenthetical note because there might be argumentative moves that address the in principle concerns, such as the prioritization discussed above. What such moves fail to address is the tension between claims of objective value and an extensive account of personal responsibility, which would allow persons to end their own lives while maintaining that their lives had objective value. This sort of claim also fails to account for the complicated terrain of personal relationships, societal influences (both beneficial and costly), and, in general, external factors that affect those who have the special responsibility over their own lives. Dworkin’s second principle offers an example of what I have called deferment: we defer to the person who has responsibility over her own life, and we do not seek to influence her.24 In contrast with this approach, I argue that it is proper to defer to a person with respect to a decision about her life, but that the appropriate stance is one of deference, not deferment. Deferment separates the decision-maker from others. Her doctor, her family, her friends, members of her religious community, and those in her social circle, they are all—at best—graduate students writing notes for a mentor’s research project or paralegals offering a partner notes for a brief. Deference, on the other hand, embodies the idea that human beings are connected as members of these communities, that considerations—even intimate considerations of one’s own life—are matters that deeply affect others and are matters on which others can legitimately express concern. In so relying on this particular account of autonomy, that of autonomy as deference, standards are admissible in a way that they are not for deferment. As an example of a theory that embodies standards of the kind that I have mind, consider a view consonant with many of the resources from the Roman Catholic Tradition that I described above. Gilbert Meilaender’s account of dignity is a view from a tradition, and it does not support assisted suicide. Meilaender offers an account of dignity that cannot coexist with an account of autonomy as deferment, but does allow for a fittingly extensive and deep deference, a respect for persons as human beings. On his account, human beings have absolute value, but this value is couched in an understanding of the kind of being humans are and, as such, there are standards that arise from that kind of being, things that are appropriate for beings of that kind (Meilaender, 2009). Human beings are treated with deference on a great number of the aspects of their lives that are most important to them: what kind of person they are to be, what kind of life they will lead, what their occupations, hobbies, and tasks are, what relationships to form, develop, and nurture, and what resources to devote to their own health. However, where Meilaender’s account helpfully differs is the additional resources that he is able to bring to bear on these questions, and the standards that arise. He argues that human beings are created in the image of God as creatures that are neither beasts nor God, and because of this they possess dignity equally (Meilaender, 2008). By relying on the rich resources of a theological tradition (for Meilaender, this is a Christian, and in particular, a Lutheran tradition), he is able to claim that human beings should act in accord “with the kind of creature a human being is . . . preserving a characteristically human life” (Meilaender, 2008, 268). This leads to specifications about how to live and what kind of life is best for all persons to lead. This, of course, does not mean that human beings will or should lead the same life. A proper deference to persons does not lead to homogeneity, but it does bring to bear normative standards that arise from consideration of the kind of beings that humans are. For example, on this view, there is a dignified way to procreate: the character of human life is degraded or diminished if we envision the relation between the generations in a way that makes some strong and other weak, in a way that makes some a ‘product’ of the will and choice of others. (Meilaender, 2008, 268) Thus, decisions about procreation are left to individual persons; human beings are treated with deference. However, this does not preclude (as it would seem to on an account of autonomy as deferment) considerations of justice, in particular justice between the generations. It allows in restrictions against kinds of procreation or reproduction which would enforce an unequal power dynamic between children and parents, between one generation and the next, wherein the latter generation could be seen to lack—given that it is merely a product—the specialness that human beings possess. More must be said to show why an account that relies on deferment would preclude the restrictions described in the previous paragraph. This is because on such an account, persons are deferred to wholly; they decide what is relevant for consideration within their own sphere. They may wish to impose “restrictions” on their own approach to procreation or reproduction, to continue with this example, but they might not. The standards, if they can be described as such, are not objective, but rather something closer to impersonally expressed personal preferences. One reason why an account of autonomy as deference is superior to an account of autonomy as deferment is that the former more accurately describes the ground for the kind of treatment that is expected with respect to other persons—the idea that human beings are objectively valuable. V. CONCLUSION Thus, there arises a tension between the claim of the objective value of persons and practice of deferment that is common in discussions of assisted suicide. This tension arises in an account like Dworkin’s two principle account and in common discussions of autonomy in cases of assisted suicide where something like Waldron’s notion of deference is informed by autonomy as deferment and not autonomy as deference. I have argued here that deference, and not deferment, is the correct way to articulate the kind of relationship that should exist with other persons with respect to their health, and in turn, a concept that should inform conversations and arguments on the topic of assisted suicide. This approach has the benefit of taking persons seriously, respecting them as beings that have objective value, while alleviating a tension between that claim of their value and mere deferment to them. As a result, this distinction between autonomy as deference and autonomy as deferment is a helpful one in medical ethics and for discussions of assisted suicide. The approach that I recommend relies on autonomy as deference, which is consonant with Roman Catholicism, a tradition which considers human beings within a broader social and spiritual context. Within medicine, autonomy as deference requires conversations with medical practitioners, patients, and the patient’s family members. This approach is different from that taken by those who conceive of persons as unconnected individuals, who rely on an impoverished conception of autonomy, autonomy as deferment. It is not surprising that on accounts relying on autonomy as deferment, assisted suicide is permitted. It is a short step from this approach to endorsement and societal funding for assisted suicide. This need not be the case if deference is embraced, as deference embodies the excellent intentions of those operating from deferment—respect for others, empathy with persons in challenging situations—but it also allows in limits informed by the kinds of beings that humans are, beings who depend on others. One can empathize with those who have not been in such situations as Mr. Cowart, but one need not, in seeking to respect his wishes (and those of many described in the popular cases above) defer to him. He is owed deference, but not deferment. We should, as Johannessen declares, still be able to tell him and others that we are glad they are still with us. I end this article with two sets of questions that an emphasis on autonomy as deference brings to mind. First, in focusing on the human being, the patient who is suffering and in need of care, the person who is before us, one might seek to extend this notion of deference beyond questions of health. This is fitting and raises questions about why the moral evaluation of assisted suicide is a medical question, as opposed to a more broadly human one. Surely, there are medical issues involved—the need for medical knowledge, skill, and resources about related issues—but why is the hastening or ending of a life, due to a request, a properly (or exclusively) medical question? One might ask oneself: if faced with a request to assist another in ending her life, would I? If the answer is in the negative, why should medicine (as a set of institutions) offer a different answer? If the answer is in the affirmative, then why require medical practitioners to assist in death?25 These reflections lead to a second set of questions, questions about the role of medicine, health policy, and related health and social institutions, at a more abstract level: what is the proper role of medical practice? What is the ethos of a hospital system? What are the necessary health-related tasks for a society to consider in collective thought about its citizens? These kinds of questions should be admitted into the conversation, not ruled out before being considered. There are too many such questions to offer more than this sampling, but what I have in mind are the kinds of questions that have recently been under attack in discussions of conscience protection. In a New England Journal of Medicine article I have already referred to, Ronit Stahl and Ezekiel Emanuel (2017) offer an account of medicine and medical ethics that blocks any questions like those articulated above because all matters are to be determined by the medical profession. On their view, the profession is defined in terms of a bare majority of voting members of politically connected medical societies, with an implicit articulation of medicine as a commodity. Thus, it is no surprise that autonomy as deferment is operative, nor is it a surprise that the kinds of questions I raised above are, on their view, not admissible. In fact, a mere discussion of conscience is only acceptable in cases where there is disagreement within such societies over a particular topic. Their example of a contentious topic where such a conversation would be allowed, and where claims of conscience might be invoked, is assisted suicide. Bracketing concerns about the uniformity of professions and the divergent views of members of professions, and about shifts in views throughout history, this approach would not allow for deference to patients, only for deferment.26 In treating practitioners as singly minded technicians and abandoning serious consideration of relationships, like that between practitioners and patients and the role of families in patient’s lives, the Stahl and Emanuel view offers a different approach of medicine than the approach I propose. Their approach would not allow for someone to engage with a patient and express a desire that she remain with us because it views individuals, like any account rooted in autonomy as deferment, as isolated individuals purchasing health services. Finally, and worst of all, these kinds of accounts block without argument the resources of traditions of thought, such as the Roman Catholic Tradition, that mean a great deal to many involved in these situations. NOTES 1. Much argument exists in the literature, a sampling of positions can be found in the following work: Clark (2006), Brody et al. (2011), Singer (2007), and John Paul II (2004). 2. For more on this case, see the collection edited by Kliever (1989). Additional essays of note are Engelhardt (1989), White (1989), and May (1989). 3. One interpretation of the aforementioned quotation is that it is an invitation to a patient who is considering hastening her death or directly ending her life to remain with us. It is instructive in a post-Enlightenment mindset where, though we aim to offer reasons to others for their consideration, reflection, and evaluation, we too often offer them only some kinds of reasons, and we surely do not press them. There are good reasons for this, and the case of Mr. Cowart illustrates both the need for deep respect for the autonomy of patients and explains the rhetorical power of patient autonomy movements. Gone are the days, and thankfully so, where physicians without serious consultation with other health practitioners acted upon a passive “patient” without engaging her as to her wishes. Today, reasons, relevant health information, outcomes and predictions, and in some cases a medical team’s best judgement are offered to a patient for her evaluation. The decision is hers. What can be lost in this approach are resources that require further information, further context, and further argument—claims rooted in traditions of thought and practice that require more nuanced articulations of what would be described now as personal values. As some, most notably Alasdair MacIntyre (2007), have argued: a consequence of the embodiment of emotivism in our culture is a failure for us to critique the ends of others, an embracing of bureaucratic, means-ends rationality as the only publicly acceptable kind of rational claim. In this context, requesting Mr. Cowart to stay with us or even letting him know that we are “glad” he is here would be seen as manipulation, as undue influence. If we wish him to remain with us, we may offer him some kinds of reasons, but only the kind that fits the structures set in place: the details of the relevant procedures, likely outcomes, possibilities of pain, future complications, etc. Once he is deemed competent and his consent is ascertained, the reasons end. This is one of the great benefits of considering Johannesen’s line as an invitation. It recognizes that a great deal is asked of the patient who is suffering in asking her to continue. To invite someone, with hope, in this way may require resources beyond those appealed to in legal documents, like Canada’s Bill C-14 or legal documents supporting euthanasia and assisted suicide in other locales. 4. I follow Alasdair MacIntyre in conceiving of traditions as sustained arguments and, as a tradition, Roman Catholicism—and work in medical ethics rooted in the resources of the Roman Catholic Tradition—is no different. The argument is multifaceted: it is internal, which is to say it occurs between and among members of the tradition, relying on some common resources and a history of debate over a particular set of issues; it is external, which is to say that its arguments, with their history and resources, are offered to address situations faced by all and, reciprocally, is open to critique from proponents of other traditions who aim to address similar situations. Thus, the Roman Catholic tradition will not have a hold on or be of interest to all patients and practitioners, let alone all relevant members of society. The religious convictions of some should never be forced on others, especially those in a vulnerable situation, but nor should arguments rooted in such traditions be discounted without arguments in support of such discounting. For a clearer and more detailed account of the notion of tradition that I am borrowing, see MacIntyre (2007). For a helpful passage on the concept of traditions, consider the following: A living tradition then is an historically extended, socially embodied argument, and an argument precisely in part about the goods which constitute that tradition. Within a tradition the pursuit of goods extends through generations, sometimes through many generations. Hence the individual’s search for his or her good is generally and characteristically conducted within a context defined by those traditions of which the individual’s life is a part, and this is true both of those goods which are internal to practices and of the goods of a single life. Once again the narrative phenomenon of embedding is crucial: the history of a practice in our time is generally and characteristically embedded in and made intelligible in terms of the larger and longer history of the tradition through which the practice in its present form was conveyed to us; the history of each of our own lives is generally and characteristically embedded in and made intelligible in terms of the larger and longer histories of a number of traditions. (MacIntyre, 2007, 222) 5. See Span (2017) or consider the well-known case of Brittany Maynard (for an article written in her own words, see Maynard, 2014). For a study on the role that religious affiliation plays in views on assisted suicide, see Burdette, Hill, and Moulton (2005). This study found that Catholics were strongly opposed to assisted suicide. For a study on the views of physicians practicing in the United States and their view on assisted suicide, see Curlin et al. (2008). This study found that the majority of physicians practicing in the United States object to assisted suicide. 6. For an excellent article that analyzes this situation in Belgium, particularly with respect to Catholic hospitals, see Iltis (2006). Also, for those interested in the implications of discussions for the United States, consider that assisted suicide is legal in five states: Washington, Oregon, California, Colorado, and Vermont. For a map of states and current status, see “Take Action: Death with dignity around the U.S.” Death with Dignity [On-line]. https://www.deathwithdignity.org/take-action/ (accessed December 9, 2017). 7. Chief among these resources are those from the USCCB, the CDF, and papal encyclicals themselves, in particular John Paul II’s (1995),Evangelium Vitae. Additionally, for useful resources within the Roman Catholic tradition specifically addressing the situation in Canada, consider documents put forth by the Catholic Organization for Life and Family (2016). Two additional noteworthy resources include Seper and Hamer (1980) and USCCB (1991). 8. For a more full view, consider the context from which this quotation was taken: The constant teaching of the Catholic Church is life must be respected from conception to natural death. To kill an innocent person is always morally wrong, and Catholics must understand requesting an assisted suicide or euthanasia is also morally wrong and puts their souls at risk. By opting for an assisted death, they will not have the proper disposition to receive the Last Rites which includes Confession, Holy Communion, and the Anointing of the Sick. It is also morally wrong for physicians, nurses, pharmacists to participate in euthanasia or assisted suicide and that includes making referrals. Thus it is disappointing the bill does not include express protection for the conscientious rights of health care professionals and for faith-based health care institutions. (Prendergast, 2016) 9. Some of the reaction to such claim is due to consideration of what might happen with respect to specific Catholic rites were it to be known that a person intentionally sought to take their own life, that she sought aid in dying. Is anointing of the sick an appropriate sacrament for someone who is about to undergo aid in dying? This is a fair question, but it is a question to be addressed by members of the tradition. For more on this, see Smith et al. (2016). For a helpful discussion of these topics, see Christopher White’s interview with Archbishop Christian Lépine of Montreal (White, 2016). 10. Here, it is worth noting the reliance of the Bishops on the rich resources of the Roman Catholic tradition, including concepts like dignity. It is also worth noting that these resources are accessible, in many respects, by those who are members of other traditions. Atheists and, to a degree, agnostics might have trouble relying on resources that appeal to the divine or for examples dependent upon the law of God. But, notice that in these crucial passages there is not a great deal of discussion of concepts that require a significant degree of theological theory and understanding, such as, for example, sin. This presents as a double-edged sword, with benefits of broader accessibility and costs of a lack of theological clarity and loss of content. 11. See footnote 3. 12. As I am primarily concerned with medical treatment, and not to extending this principle further, I put the vagueness worry to the side. 13. Much work has been done in this area already to add further detail to this conception of autonomy. I have in mind critiques of libertarianism and welfare liberalism that cite the individual as primary, for example, Alasdair MacIntyre’s critique of the political philosophy of John Rawls and Robert Nozick (MacIntyre, 2007, chapter 17), and critiques of political and moral philosophies that conceive of persons, or citizens, as atomistic, for example, Taylor (1985). 14. Though my evidence is merely anecdotal, I believe there are more subscribers to this view than one might think. It is a view clearly expressed in discussion of medical ethics where autonomy is nothing more than a patient’s choice. 15. See footnote 13. 16. See Aulisio and Arora (2014) for an analysis of instances where autonomy conflicts. See Pilkington (2016) for a response to that analysis. 17. Consider concerns about overmedicalization, including Burgess (1993) and Doust, Walker, and Rogers (2017). 18. For a selection of his work on dignity, see Waldron (2007, 2009, 2011). 19. Though there is good reason to distinguish many accounts of dignity from many accounts of autonomy and, in general, the concepts themselves, this is not the focus of this article. In fact, it is a telling sign that some think of dignity and autonomy as interchangeable (Macklin, 2003) and that “death with dignity” is the common nomenclature for laws associated with and provisions for assisted suicide and euthanasia. 20. Waldron writes, “. . . if we were to make the radical move—the reversal—and transfer this demand for respect from the nobility to every last ordinary person, what we would be transferring would not be a functional deference [deference only connected to the office], but this diffuse deference owed to the whole person. Or—and this is what I really want to say—we might think about the respect demanded by ordinary people as right-bearers in this light. A right-bearer is an ordinary person to whom this extensive and diffuse deference is due” (Waldron, 2007, 223–24). 21. For an instructive paper on the challenges associated with this for those in the psychological professions, consider Johnson et al. (2014). 22. I believe is an idea that is common in discussions of autonomy and some discussions of dignity, especially in medical and, more broadly, bioethical situations but it is not always, or often, named. 23. Consider, again, the case of Ms. Maynard or the cases of Dr. Ezekiel Emanuel (who hopes to die at the age of 75, Emanuel, 2014), Dr. Sandy Bem (Henig, 2015), or Dr. Jessica Nutik Zitter (Zitter, 2017), who now considers it right for her to assist in the deaths of her patients. 24. It is worth remembering at this point in the argument that autonomy as deferment may appear to be an extreme position, but I have argued that it is more plausible than it first appeared. It would be a problem for this kind of view and thinking about autonomy of this kind as a ground for assisted suicide, which appears to be the case offered in Canadian legal documents, if one thought that medical professions should influence their patients or if one thought that it was acceptable generally for persons to influence others. This is an issue for that account of autonomy, not for my critique of that account. 25. For an account of the legalization of euthanasia and assisted suicide in Switzerland, see Hurst and Mauron (2003). 26. Interestingly, it might not even allow for deferment in all cases. It would allow for deferment in cases where medicine has determined that particular questions are up to patients. ACKNOWLEDGMENTS I owe thanks to a number of people for helpful discussions on this topic, most especially Mark Cherry. I am grateful for the helpful comments from two anonymous reviewers. I owe special thanks to Joanna Flores for helpful discussions of the topics in this article and research assistance. REFERENCES Aulisio, M. P. and K. S. Arora. 2014. Speak no evil? Conscience and the duty to inform, refer or transfer care. Healthcare Ethics Committee Forum  26(3): 257– 66. Burgess, M. 1993. The medicalization of dying. The Journal of Medicine and Philosophy  18(3): 269– 79. Google Scholar CrossRef Search ADS   Brody, H., L. D. Hermer, L. D. Scott, L. L. Grumbles, J. E. Kutac, and S. D. McCammon. 2011. Artificial nutrition and hydration: The evolution of ethics, evidence, and policy. Journal of General Internal Medicine  26(9): 1053– 58. Google Scholar CrossRef Search ADS   Burdette, A., T. Hill, and B. Moulton. 2005. Religion and attitudes toward physician-assisted suicide and terminal palliative care. Journal for the Scientific Study of Religion  44(1): 79– 93. Google Scholar CrossRef Search ADS   Catechism of the Catholic Church . 1997. 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Current dilemmas in defining the boundaries of disease. The Journal of Medicine and Philosophy  42(4): 350– 66. Google Scholar CrossRef Search ADS   Durocher, P. 2015, Feb. 6. Statement on physician-assisted suicide . Canadian Conference of Catholic Bishops [On-line]. Available: http://www.cccb.ca/site/images/stories/pdf/Statement_on_Physician_Assisted_Suicide_-_EN.pdf (accessed December 9, 2017). Dworkin, R. 2006. Is Democracy Possible Here? Principles for a New Political Debate . Princeton, NJ: Princeton University Press. Emanuel, E. 2014. Why I hope to die at 75: An argument that society and families—and you—will be better off if nature takes its course swiftly and promptly . The Atlantic [On-line]. Available: https://www.theatlantic.com/magazine/archive/2014/10/why-i-hope-to-die-at-75/379329/ (accessed December 9, 2017). Engelhardt, H. T. 1989. Freedom vs. best interest: A conflict at the roots of health care. In Dax’s Case: Essays in Medical Ethics and Human Meaning , ed. L. Kliever, 79– 96. Dallas, TX: Southern Methodist University Press. Henig, R. 2015, May 14. The last day of her life. The New York Times  [On-line]. Available: https://www.nytimes.com/2015/05/17/magazine/the-last-day-of-her-life.html (accessed December 9, 2017). Hurst, S. and A. Mauron. 2003. Assisted suicide and euthanasia in Switzerland: Allowing a role for non-physicians. BMJ  326(7383): 271. Google Scholar CrossRef Search ADS   Iltis, A. 2006. On the impermissibility of euthanasia in Catholic healthcare organizations. Christian Bioethics  12(3): 281– 90. Google Scholar CrossRef Search ADS   Johannessen, S. 1989. On why we should not agree with Dax. In Dax’s Case: Essays in Medical Ethics and Human Meaning , ed. L. Kliever, 169– 86. Dallas, TX: Southern Methodist University Press. John Paul II. 1995. Evangelium Vitae [On-line]. Available: http://w2.vatican.va/content/john-paul-ii/en/encyclicals/documents/hf_jp-ii_enc_25031995_evangelium-vitae.html (accessed December 10, 2017). ———. 2004, Mar. 20. Address of John Paul II to the participants in the International Congress on ‘Life-sustaining treatments and vegetative state: Scientific advances and ethical dilemmas’ [On-line]. Available: http://w2.vatican.va/content/john-paul-ii/en/speeches/2004/march/documents/hf_jp-ii_spe_20040320_congress-fiamc.html (accessed December 9, 2017). Johnson, S., R. Cramer, M. Conroy, and B. Gardner. 2014. The role of and challenges for psychologists in physician assisted suicide. Death Studies  38(6–10): 582– 88. Google Scholar CrossRef Search ADS   Kliever, L., ed. 1989. Dax’s Case: Essays in Medical Ethics and Human Meaning . Dallas, TX: Southern Methodist University Press. MacIntyre, A. 2007. After Virtue . 3rd ed. Notre Dame, IN: University of Notre Dame Press. Macklin, R. 2003. Dignity is a useless concept. BMJ  327(7429): 1419– 20. Google Scholar CrossRef Search ADS   May, W. B. 1989. Dealing with catastrophe. In Dax’s Case: Essays in Medical Ethics and Human Meaning , ed. L. Kliever, 131–50. Dallas, TX: Southern Methodist University Press. Maynard, B. 2014, Nov. 2. My right to death with dignity at 29. CNN [On-line]. Available:http://www.cnn.com/2014/10/07/opinion/maynard-assisted-suicide-cancer-dignity/index.html (accessed December 9, 2017). Meilaender, G. 2008. Human dignity: Exploring and explicating the Council’s vision. In Human Dignity and Bioethics: Essays Commissioned by the President’s Council on Bioethics , 253– 77. Washington, DC: President’s Council on Bioethics. ———. 2009. Neither Beast Nor God: The Dignity of the Human Person . New York, NY: New Atlantis Books, Encounter Books. Parliament of Canada, 2016. Bill C-14. An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying), 1st sess., 42nd Parliament, 2016, S.C. 2016, c. 3 . Parliament of Canada [On-line]. Available: http://www.parl.ca/DocumentViewer/en/42-1/bill/C-14/royal-assent (accessed December 9, 2017). Pilkington, B. 2016. Do no evil: Unnoticed assumptions in accounts of conscience protection. Health Care Ethics Committee Forum  28(1): 1– 10 Prendergast, T. 2016. Archbishop Prendergast’s statement on Bill C-14 . Archdioceses of Ottawa [On-line]. Available: https://www.catholicottawa.ca/documents/2016/4/2016-04-15%20ABS%20Statement%20on%20Bill%20C-14-2.pdf (accessed December 9, 2017). Seper, F. and J. Hamer. 1980. Declaration on euthanasia . Sacred Congregation for the Doctrine of the Faith [On-line]. Available: http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19800505_euthanasia_en.html (accessed December 9, 2017). Singer, P. 2007, Jan. 16. A dubious distinction. The Guardian [On-line]. Available: https://www.theguardian.com/commentisfree/2007/jan/17/comment.health (accessed December 9, 2017). Smith, R., G. Bittman, M. Hagemoen, F. Henry, G. Pettipas, and P. Terrio. 2016. Guidelines for the celebration of the sacraments with persons & families considering or opting for death by assisted suicide or euthanasia: A vademecum for priests and parishes . Catholic Bishops of Alberta and the Northwest Territories [On-line]. Available: http://caedm.ca/Portals/0/documents/family_life/2016-09-14_SacramentalPracticeinSituationsofEuthanasia.pdf (accessed December 9, 2017). Span, P. 2017, Jan. 16. Physician aid in dying gains acceptance in the U.S . The New York Times [On-line]. Available: https://nyti.ms/2jPJUap (accessed December 9, 2017). Stahl, R. Y. and E. J. Emanuel. 2017. Physicians, not conscripts—Conscientious objection in health care. The New England Journal of Medicine  376(14): 1380– 5. Google Scholar CrossRef Search ADS   Taylor, C. 1985. Atomism. In Philosophy and the Human Sciences: Philosophical Papers 2 , 187– 210. Cambridge, United Kingdom: Cambridge University Press. Google Scholar CrossRef Search ADS   USCCB. 1991, Sep. 12. Euthanasia statement . USCCB [On-line]. Available: http://www.usccb.org/issues-and-action/human-life-and-dignity/end-of-life/euthanasia/statement-on-euthanasia-1991.cfm (Accessed October 10, 2017). Waldron, J. 2007. Dignity and rank. Archives Européennes de Sociologie  48(2): 201– 37. ———. 2009. Dignity, rank, and rights: The 2009 Tanner Lectures at UC Berkeley . New York University Public Law and Legal Theory Working Papers151 [On-line]. Available: http://lsr.nellco.org/nyu_plltwp/151 (accessed December 9, 2017). ———. 2011, July 29. Does ‘Equal Moral Status’ Add Anything to Right Reason? NYU School of Law, Public Law Research Paper No. 11-52 [On-line]. Available: https://ssrn.com/abstract=1898689 (accessed January 24, 2018). White, C. 2016, Dec. 5. Montreal archbishop: “Physician-assisted suicide plants seed of death in democracy.”  Crux [On-line]. Available: https://cruxnow.com/global-church/2016/12/05/montreal-archbishop-physician-assisted-suicide-plants-seed-death-democracy/ (accessed December 9, 2017). White, R. B. 1989. A memoir: Dax’s case twelve years later. In Dax’s Case: Essays in Medical Ethics and Human Meaning , ed. L. Kliever, 13–22. Dallas, TX: Southern Methodist University Press. Zitter, J. 2017, Aug. 5. Should I help my patients die?  The New York Times, Sunday Review [On-line]. Available: https://www.nytimes.com/2017/08/05/opinion/sunday/dying-doctors-palliative-medicine.html (accessed December 9, 2017). © The Author(s) 2018. Published by Oxford University Press, on behalf of The Journal of Christian Bioethics, Inc. All rights reserved. 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Distinguishing Deference from Deferment: Assisted Suicide Is the Wrong Response

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Abstract

Abstract In this article, I examine the practice of assisted suicide. I aim to do so by, first, briefly sketching a description of the current context with a particular focus on Canadian law and the prominent role that autonomy plays there. I point to resources from within the Roman Catholic tradition that serve as a counterbalance to the focus on autonomy. Second, given the prevalence of appeals to autonomy in the lives of practitioners and patients and how claims of autonomy influence considerations associated with assisted suicide, I describe the account of autonomy that is operative in these discussions and sketch an account of deference that should replace the commonplace account of autonomy. Finally, having considered popular appeals to medical assistance in dying, I ask whether cases of assisted suicide are best thought of as nonmedical cases and what appeals to traditions of thought outside of explicitly medical professions have to add to this discussion. I. INTRODUCTION In closing his seminal paper on the situation faced by Mr. Dax Cowart, Stanley Johannesen implores his readers, “None of us should wait for a decent society before we can say to a man that we are simply glad he is still with us” (Johannessen, 1989, 185). The sentiment expressed in this statement is in need of attention and further exploration today in the face of growing opportunities for the taking of life shrouded in the claims of good medicine. Johannesen’s assertion weighs heavily on those who are concerned with these opportunities, especially in light of recent legal decisions in Canada and their possible implications for patients and practitioners there, in the United States, and throughout the international medical communities. Much has been written on suicide, assisting patients in dying, and the medical and moral issues that are raised in hastening the death of a patient or directly killing a patient. In this article, my focus is more narrow. I believe that Johannesen’s sentiment is an appeal to make space for others to influence the decisions of a patient about her own life. This is tricky terrain for medical ethicists as this kind of influence could violate the autonomy of patients. I aim to explore this kind of influence by, first, briefly sketching a description of the current context with a particular focus on Canadian law and the prominent role that autonomy plays there. I also point to resources from within the Roman Catholic tradition that serve as a useful dialogical partner for defenses of assisted suicide. Second, given the prevalence of principles of autonomy in arguments about the lives of practitioners and patients and how claims of autonomy influence considerations associated with assisted suicide, I describe an account of autonomy that is operative in these discussions. The operative account of autonomy suffers from a failure to allow genuine engagement with a patient, partly due to an implicit understanding of medicine as a service provided to patients and not as a practice involving a relationship between patients and practitioners. I describe this account of autonomy as deferment and argue that an account of autonomy as deference is superior. Finally, having considered popular appeals to medical assistance in dying, I ask whether cases of assisted suicide are best thought of as nonmedical cases and what appeals to traditions of thought outside of explicitly medical professions have to add to this discussion. These steps are sufficient to illustrate that we ought to slow movement toward the endorsement of assisted suicide in medicine and, instead, reconsider what are the proper roles of the medical profession, reflecting on this role in future policy decisions. In the very least, in light of these arguments, medical practitioners should neither be required nor encouraged to participate in the ending of the lives of patients. II. A TOUGH CASE The case of Dax Cowart requires little rehearsing for students of medicine and applied ethics, at least in the United States. For those coming to the debate over assisted suicide from other disciplines or locations, here is an all too brief recap: due to an explosion, most of Mr. Cowart’s body was badly burned. Were he not taken quickly to a hospital, eventually a burn center, and given painful treatment over an extended period of time (all against his expressed will), he would certainly have succumbed to his injuries and died. The case involved Cowart’s request to be killed when he was first discovered after the explosion, as well as a series of clear refusals of treatment, and a patient advocate (his mother) who deferred to medical practitioners over her son’s wishes and whose views were influenced by a theological tradition not shared by the patient undergoing the painful treatment. Mr. Cowart’s case is often discussed in medical ethics courses, and at the risk of trivializing the horrific situations that he underwent, I engage it here. I do so, as I do in teaching, because his situation is instructive on a variety of fronts, in part, because so much went wrong. The case involves failures of communication and what appears to be treatment akin to imprisonment, uncertain roles of authority, ethical challenges regarding emerging medical technologies, deep philosophical disagreements between proponents of best interest and those of liberty, and many more. Additionally, it is instructive because Mr. Cowart would not have been treated this way were he to present with those injuries at a hospital today, nor had he presented 10 or even 5 years prior. This is not only due to the state of medical science, but also due to changes in the power that patients have over their own treatment. It is important to keep in mind at this juncture that what constitutes treatment is one of the issues at the heart of the debate over assisted suicide. There is a difference between requesting that someone end your life—mirroring the initial request that Mr. Cowart made—and determining that a course of treatment, in a medical context, is too burdensome to undergo.1 Distinctions of this kind, like other aspects of Mr. Cowart’s case, need little rehearsing; this ground is well trodden. What I wish to ask is, “What sense is there to be made from claims like, ‘None of us should wait for a decent society before we can say to a man that we are simply glad he is still with us’?” Were such a line uttered to Mr. Cowart during the time that he had little control over his own life and treatment, it is hard to imagine the utterance being met with anything but disdain. Yet, this is not the sentiment that is intended by that expression. Rather, it is an attempt to see the person: the person who can sometimes be forgotten in assessing a burn patient or in policy disputes about healthcare resource allocations. Even in courses in medical ethics and articles about cases—there is a patient present, a person in need of care.2 Given the vulnerable state such a person is in, is it morally acceptable to tell that patient that we are glad he is here, even in his great suffering? Is this not an instance of manipulation? An instance of undue influence? A failure to respect his autonomy and the decision-making that appropriately is his, as are decisions over his own life? I contend that this kind of engagement with the patient is ruled out by arguments in support of assisted suicide, like those referenced in the recent Canadian legislation, Bill C-14, which reflects the position that if a person is deemed competent and wishes to die, medical practitioners should aid in her death. This is how such an utterance would be viewed today, and I believe we can see this in movements in favor of medical practitioners assisting in the deaths of their patients, which rely on the notion of medicine as an all-encompassing set of services which ought to provide to a patient anything that she orders. The focus on the patient as a person—telling a man that we are glad he is still with us—is needed and fitting. One might wonder whether we, broadly speaking, have overcorrected for failures in cases like Mr. Cowart’s and placed ourselves in a situation where medical practitioners kill their patients upon request.3 This overcorrection can be seen in legal documents, like Canada’s Bill C-14. It is to this example and an aforementioned dialogical partner that I now turn. III. LEGAL KILLING AND THE CATHOLIC TRADITION One example of a tradition with rich resources that might serve as a dialogical partner with an autonomy-focused ethic is a medical ethics rooted in the Roman Catholic tradition.4 Reflecting on the resources of this tradition can guide decision-making and, in a fairly clear way, challenge the acceptance of assisted suicide. This has been exhibited well in the recent and prominent discussion of assisted suicide and euthanasia in Canada; in particular, the Medical Assistance in Dying (Parliament of Canada, 2016), which received assent last year in the Canadian Parliament. The bill allows adults to seek medical assistance in dying and ensures that medical practitioners will not be held criminally accountable for such assistance. This bill may be emblematic of a sea change in views on the role of medicine and death5—allowing both voluntary euthanasia and physician-assisted suicide. Though Canada is neither the first nation nor government to go in this direction, it does offer an opportunity to question the merits of this trend.6 Those familiar with the procedural requirements for assisted suicide in those states in which it is legal in the United States will be not be surprised by the usual requirements that Medical Assistance in Dying (MAID) applies to those who have “a grievous and irremediable medical condition” (Parliament of Canada, 2016, 5). This condition applies to persons if: (a) they have a serious and incurable illness, disease, or disability; (b) they are in an advanced state of irreversible decline in capability; (c) that illness, disease, or disability or that state of decline causes them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable; and (d) their natural death has become reasonably foreseeable, taking into account all of their medical circumstances, without a prognosis necessarily having been made as to the specific length of time that they have remaining (Parliament of Canada, 2016, 6). Safeguards are in place to ensure that persons seeking MAID meet the criteria, are well-informed, can withdraw, and can understand and communicate their decision (Parliament of Canada, 2016, 6–7). Though the aforementioned features merit attention, the focus of this article is not the procedural details of assisting in death but rather the justification of a nation for its citizens, as patients, to seek their own death and for its citizens, as medical practitioners, to kill or help to kill their fellow citizens. What is that justification? It can be found, clearly stated, in the opening line of the Preamble of the Bill: “Whereas the Parliament of Canada recognizes the autonomy of persons who have a grievous and irremediable medical condition that causes them enduring and intolerable suffering and who wish to seek medical assistance in dying . . . ” (Parliament of Canada, 2016, 1). The justification is, simply put, the autonomy of persons, and the appeal to the autonomy of persons in this case is strong enough to provide a counterbalance to considerations of the protection of vulnerable persons, as noted later in the Preamble: Whereas, in light of the above considerations, permitting access to medical assistance in dying for competent adults whose deaths are reasonably foreseeable strikes the most appropriate balance between the autonomy of persons who seek medical assistance in dying, on one hand, and the interests of vulnerable persons in need of protection and those of society, on the other. (Parliament of Canada, 2016, 1) Persons, in this case citizens, possess autonomy, and respect for their autonomy requires that states allow and even support their being killed and their being assisted in killing themselves. Before addressing this account of autonomy, it is worth contrasting this kind of approach with that of the aforementioned Roman Catholic Tradition. There is a plethora of resources from within the Roman Catholic Tradition, which might assist in guiding understanding on this topic.7 Recent statements by Canadian Bishops are good examples. Consider, for instance, Archbishop Prendergast’s Statement on Bill C-14 (Prendergast, 2016), in which he lays out clearly and concisely that killing is morally wrong and that requesting assistance in dying is also morally wrong. He reminds Canadians that, according to the Roman Catholic Tradition, “To kill an innocent person is always morally wrong, and Catholics must understand requesting an assisted suicide or euthanasia is also morally wrong and puts their souls at risk.”8 Clear statements like this can be read as lacking empathy for persons undergoing terrible circumstances, but this would be a misreading. It does not necessarily follow from a claim that persons ought not take their own lives (and that others should not assist them in doing so) that one cannot imagine being in such a situation or that one does not “feel for” that person. However, it would not follow if one has a particular account of autonomy (which I discuss in the next section) and prioritizes this particular moral concept above all others.9 Another helpful and clear statement comes from the President of the Canadian Conference of Catholic Bishops, Archbishop Paul-André Durocher. In that statement, the Archbishop, relying on the Catechism, states: Helping someone commit suicide, however, is neither an act of justice or mercy, nor is it part of palliative care. The decision of the Supreme Court of Canada today does not change Catholic teaching. “[A]n act or omission which, of itself or by intention, causes death in order to eliminate suffering constitutes a murder gravely contrary to the dignity of the human person and to the respect due to the living God, our Creator.” (citing Catechism of the Catholic Church, 2277). (Durocher, 2015) He continues, emphasizing a notion of empathy and care that is consistent with a disapproval of suicide, stating: The Bishops of our country invite Canadians, especially Catholics, to do all they can to bring comfort and support for all those who are dying and for their loved ones, so that no one, because of loneliness, vulnerability, loss of autonomy, or fear of pain and suffering, feels they have no choice but to commit suicide. The Canadian Conference of Catholic Bishops will continue to promote palliative and home care, and to encourage all the faithful to work for the betterment of the elderly, the disabled, the ill, and those who are socially isolated. (Durocher, 2015) These ideals are emphasized further in a statement from the Catholic Bishops of Alberta, relying on claims from Evangelium Vitae. They wrote: Death by assisted suicide and euthanasia has been made legal in Canada. These grievous affronts to the dignity of human life from beginning to natural end are never morally justified. The legal permission now granted to these practices does not change the moral law. The teaching of the Church on these matters is clear. Euthanasia “is a grave violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person.” Since suicide, objectively speaking, is a gravely immoral act, it follows that “to concur with the intention of another person to commit suicide and to help in carrying it out through so-called ‘assisted suicide,’ means to co-operate in, and at times to be the actual perpetrator of, an injustice which can never be excused.” (Smith et al., 2016; cf. St. John Paul II, 1995, 65–66)10 With these recent statements reliant on Roman Catholic resources in hand, it is worth recalling the aforementioned quotation from Johannesen, and interpreting it is not merely as an invitation to a patient to remain with us,11 but an invitation to others to share with patients who are suffering the care and concern with which they are held. This interpretation captures well a key component of the Roman Catholic position on assisted suicide. To kill another or to assist another in killing herself is a “gravely immoral act.” Categorizing it as such need not be viewed as a draconian restriction on the autonomy of persons or their conscience. Rather, it is an ethic of care focused on the whole person, a being embedded within a community, whose life matters not only to her. However, there is a tension between this position, articulated from the Roman Catholic Tradition and with Johannesenian resources and an interpretation from cultures in which autonomy (in particular, certain accounts of autonomy) is the preeminent bioethical principle. To express to a patient that one is happy she is here, glad she has not left us, appears, on these accounts, to be an undue influence on a vulnerable person (especially given the power dynamics in play in many practitioner–patient relationships), often by a member of a service industry who is providing a requested commodity. In the next section, I attempt to illustrate this tension by sketching the account of autonomy that is operative in the Canadian legal documents, what I call autonomy as deferment. Then, I sketch a different account of autonomy, autonomy as deference, which does not clash with the kind of orientation expressed by Johannesen and is supported by the rich resources of the Roman Catholic Tradition. IV. AUTONOMY AS DEFERENCE, AUTONOMY AS DEFERMENT Consider a patient who wishes to end her life by means of medical aid in dying. She meets (a)–(d) of the Canadian requirements, and she seeks out a physician to end her life. This manner of treating a patient is in accord with respecting her autonomy, a respect that is strong enough to require someone to end her life at her request. I propose that we might think of autonomy as deferment or as deference. I consider each in turn. Autonomy as deferment is meant to express the idea that persons are entitled to respect in light of some specialness that they possess and that respecting them in this way requires deferring to them on a variety of matters that are important to them and intimately related to their lives, which includes their medical treatment. A proponent of autonomy as deferment conceives of individuals as individuals first, not as members of a community nor as members of deep relationships. It does not rule these out as important aspects of a person’s life, but the value given to these aspects is defined and measured solely in terms of the individual and her preferences. My original articulation of autonomy as deferment is not very precise, but I hope the general idea is clear.12 It is worth pointing out both that this is not the only account of autonomy and that this very account may seem unproblematic to many readers.13 What is also worth noticing is that autonomy as deferment would rule out attempts by medical practitioners to influence the medical decisions that the patient makes. A medical practitioner would not, in deferring to the patient, do anything more than fully inform the patient of the details of the procedure, the possible risks and benefits, and any other relevant information for a fully informed consent. To do anything more would not make sense, as I shall argue below, because the practitioner is merely one individual providing a requested service for another. On this view, the practitioner should not preemptively express the Johannesian sentiment that she hopes the patient stays with us. To do so would be to manipulate the patient. For those who do not subscribe to autonomy as deferment,14 as I have described the concept, it may appear to be an extreme position and therefore an easy target—set up only to be knocked down and to make way for another account of autonomy. Autonomy as deferment should not be ignored so quickly, and for two reasons—language and context—in addition to its prevalence.15 First, deferring to patients is appropriate and fitting in discussions of matters of their health, but what this language leaves out is consideration of others—family members, friends, and the person of whom the service is requested, the practitioner! It does not consider the practitioner, as if someone would not be required to satisfy the request for death.16 The case here, according to the Canadian law, is about medical aid in dying, not merely the legality or illegality of suicide. It does not consider other members of the community or institutions such as hospitals and clinics in which the person would be killed. Second, this extreme sense of deferring would take place in a context in which medicine is viewed as a commodity. Medical services are things to be bought and sold, and medical practitioners are merely providers on a service line, responding to an order much like someone in a packaging facility might fill a request for paper towels to shipped. Autonomy as deference leaves little room for the kind of engagement—moral discussions about life and death—which might have otherwise occurred between patients and practitioners. An expansive notion of “medical treatment” is also part of the context that I am describing,17 and an idea I take up at the end of the article. If this context and language are in place, the seeming extremeness of the situation I describe fades a bit. Consider, for example, the argument offered this year in the New England Journal of Medicine against conscious protection for medical practitioners—requiring practitioners to be of the same mind on moral matters associated with medicine or to leave the profession (Stahl and Emanuel, 2017). This extreme account of autonomy, autonomy as deferment, becomes more plausible given the language and context operative in healthcare today, at least in the United States and, it seems, in Canada. Contrast this account of autonomy with another conception of appropriate authority over oneself and one’s decisions: autonomy as deference. Autonomy as deference is also meant to express the idea that persons are entitled to respect in light of some specialness that they possess and that respecting them in this way requires deferring to them on a variety of matters that are important to them and intimately related to their lives, including medical treatment, but autonomy as deference does not conceive of the individual as an isolable entity. Here, individuals are understood as situated within social contexts in which other individuals, such as family members and physicians, are appreciated as essential for advising and guiding proper decision-making. Perhaps the final word belongs to the patient, but others are invited, indeed encouraged, to be part of this conversation. This account is not at home in a context where medicine is viewed as a commodity, but rather fits better with a conception of medicine that prizes the relationships between patients and other persons, not least of all the person from whom she is requesting aid. Here, physicians are not merely skilled technicians, but important discussion partners in medical decision-making, who also have moral status in their own right. I hope the contrast between these accounts of autonomy is clear. At this point, though, one may simply wish to jettison any notion of autonomy as deference or deferment. This would be a mistake as notions of deference and deferment capture aspects of commonly held views of autonomy. To help illustrate the benefit of these notions and to further clarify their difference, I borrow an example from the work of Jeremy Waldron on respect as it relates to deference. This work appears in a number of places, most notably in his work on dignity, from which I take the example.18 One interpretation of dignity that Waldron offers is explained through an emphasis on deference as part of the language of respect associated with dignity and the offices that historically conferred dignity on their inhabitants (Waldron 2007). As he is not aiming to distinguish deference from deferment, as I am, this distinction in language does not arise. In retelling the example, I will use his language of deference, and then clarify how this maps on to my usage with respect to the case of assisted suicide. Waldron offers an example of a judge, a person who occupies an important office with which a certain dignity is (or has often been) associated.19 A judge is deferred to, so claims Waldron, not only in the courtroom in which she presides over legal proceedings, but in other areas of life, as well. Waldron’s aim here is to show that deferring to the inhabitant of a dignity-conferring office can be extended beyond that office. This move, in the context of his argument in favor of a particular account of dignity, allows him to explain a transvaluation in society’s attributions of dignity: the respect given (i.e. the deferring) to those who held particular offices is extended to all persons.20 In discussions of assisted suicide, patients are deferred to in this way. The well-known case of Brittany Maynard and those who supported her is a fitting example. Ms. Maynard was diagnosed with an inoperable brain tumor, which if it ran its course would eventually take her life. She claimed she had a right to die with dignity and that she should be supported in this by members of the medical profession. She eventually moved to a state in which assisted suicide was legal and, going through the legal and medical protocols, obtained the means to take her own life and did so. What is interesting for my purposes here is how Ms. Maynard conceived of herself and those from whom she was requesting assistance. She was due what Waldron would call “extensive and diffuse deference.” For Waldron, this deference goes beyond the instances in which persons merit such treatment. It is important to keep this in mind in analyzing cases of assisted suicide. In taking Waldron’s theoretical resource and applying it to assisted suicide, the notion that persons might not merit the dignity they possess, the deference with which they are treated, is not a problem but an accounting of a now commonplace, societal view. Similarly, in the case of assisted suicide, patients who have met the relevant requirements and followed legal protocol have a decision sanctioned by professionals.21 I am concerned about the kind of move that Waldron makes for two reasons. First, merely because deference is given to one person because of an office she possesses does not illustrate that deference is (or should) be given to that person outside of the tasks or roles of that office, and if it is, it very well might be that she is given deference due to particular qualities she possesses that are on display in those other contexts. Second, it is not clear that if, for the sake of argument, we were to grant the first move that we should also think that deference that extends beyond a particular office of one person would extend to all persons (or patients)—these are, in fact, different persons (distinct patients). Waldron’s account of dignity warrants attention because of its sophistication, but also because it captures well a commonly held view. I believe that it is this kind of thought—the deference that Waldron connects with the concept of dignity—that motivates common views about autonomy in medicine: accounts of autonomy that amount to a simple statement that the patient chooses, and that is the final and only say in the matter. This view aligns with the understanding of medicine as a commodity, about which I have concern. If we take this view to its limits, it would require practitioners to hold back expressing positive sentiments that patients are “still with us” and motivate them fully to endorse the hastening and even direct ending of lives as tasks that have been ordered and that they and others have no say in, even with respect to their own roles in a killing.22 If it is right to defer to the patient in medical situations as one might defer to a judge in other situations, is this properly described as respecting autonomy as deference or respecting autonomy as deferment? Autonomy as deferment is a tricky concept for moral evaluation, in part because autonomy and deferring to a person about those things that fall within the sphere that appears properly hers to be governed is a good thing, especially in cases where we are considering persons who are making decisions about what they care about most deeply. It is their life. Turning to other important work on the concept of dignity supports this claim. For example, consider Ronald Dworkin’s account of the “two principles of human dignity.” Dworkin’s first principle, the principle of intrinsic value: . . . holds that each human life has a special kind of objective value. It has value as potentiality; once a human life has begun, it matters how it goes. It is good when that life succeeds and its potential is realized and bad when it fails and its potential is wasted. This is a matter of objective, not merely subjective value; I mean that a human life’s success or failure is not only important to the person whose life it is or only important if and because that is what he wants. The success or failure of any human life is important in itself, something we all have reason to want or to deplore. (Dworkin, 2006, 9–10) His second principle, the principle of personal responsibility, “holds that each person has a special responsibility for realizing the success of his own life, a responsibility that includes exercising his judgment about what kind of life would be successful for him” (Dworkin, 2006, 10). Dworkin, like Waldron and many others who offer accounts of dignity or autonomy, tries to account for the deference or deferment that is thought to be owed to persons, especially with respect to those things that are taken to be within a kind of autonomous sphere, things that they rightly should have control over. Dworkin articulates his position in terms of a couple of basic principles. First, that all lives are important and have objective value, but what counts as living a successful life is defined by the individual who is living that life. Second, respecting her dignity, deferring to her autonomous self, requires leaving up to her how she leads her life. Separately, the principles both appear laudable, but a tension arises when we consider them together, and it occurs in particular when thinking about cases of assisted suicide. Were the first principle all that we had to apply, assisted suicide seems like an unlikely possibility. According to the first principle, lives have objective value. They matter, and matter deeply, to those who hold them, but also to others. Ending a life is not something that would be permitted, at least in most cases, if lives have this value and if there are other options to address the more often addressed, direct concerns, like those of pain and suffering. However, according to the second principle, it is up to the person (the persons who hold their own lives) to determine what a successful life would be for that person. Were the second principle all that we had, assisted suicide would follow as a necessary intervention in cases where persons deemed it part of their account of a successful life.23 Additionally, the distinction between autonomy as deference and autonomy as deferment can be seen to emerge here. Consider Dworkin’s first principle alone, with a particular focus on his anti-subjectivist emphasis: “I mean that a human life’s success or failure is not only important to the person whose life it is or only important if and because that is what he wants.” This notion is also captured in autonomy as deference. However, consider the second principle alone, in particular the claim that persons possess “a responsibility that includes exercising his judgment about what kind of life would be successful for him.” This notion is also captured in autonomy as deferment. Thus, the tension is in place: the second principle requires assisting in a person’s death, but the first principle recommends the opposite. Which principle is correct, or can the tension be alleviated? One possible route to alleviation is through prioritizing one principle over the other. However, it is important to recognize that there is in fact a tension and that such prioritization is in need of an argument. It is also important to note that claiming that human beings are objectively valuable, that—to borrow Dworkin’s language—once a human life has begun it matters how it goes—does not require a vitalist interpretation of the relevant issues. One can embrace Dworkin’s first principle without espousing the somewhat silly claim that human beings should try to live forever. To be clear, this kind of approach is not what leads to the tension between these principles. Rather, it is that making claims of objective values brings with it a need for standards by which to judge objective values. If human beings are objectively valuable, this claim is most clear, most sensible when we can point to things that illustrate the value of human beings. The literatures on the concept of dignity and the concept of autonomy grow increasingly extensive on this point, but this is not the place to address the details of these literatures. What is crucial for my purposes here is to understand how we might reconcile the need for objective standards, which follows from the first principle, and the rejection of standards that seems to follow from the second (at least with respect to the issue of assisted suicide). I add this parenthetical note because there might be argumentative moves that address the in principle concerns, such as the prioritization discussed above. What such moves fail to address is the tension between claims of objective value and an extensive account of personal responsibility, which would allow persons to end their own lives while maintaining that their lives had objective value. This sort of claim also fails to account for the complicated terrain of personal relationships, societal influences (both beneficial and costly), and, in general, external factors that affect those who have the special responsibility over their own lives. Dworkin’s second principle offers an example of what I have called deferment: we defer to the person who has responsibility over her own life, and we do not seek to influence her.24 In contrast with this approach, I argue that it is proper to defer to a person with respect to a decision about her life, but that the appropriate stance is one of deference, not deferment. Deferment separates the decision-maker from others. Her doctor, her family, her friends, members of her religious community, and those in her social circle, they are all—at best—graduate students writing notes for a mentor’s research project or paralegals offering a partner notes for a brief. Deference, on the other hand, embodies the idea that human beings are connected as members of these communities, that considerations—even intimate considerations of one’s own life—are matters that deeply affect others and are matters on which others can legitimately express concern. In so relying on this particular account of autonomy, that of autonomy as deference, standards are admissible in a way that they are not for deferment. As an example of a theory that embodies standards of the kind that I have mind, consider a view consonant with many of the resources from the Roman Catholic Tradition that I described above. Gilbert Meilaender’s account of dignity is a view from a tradition, and it does not support assisted suicide. Meilaender offers an account of dignity that cannot coexist with an account of autonomy as deferment, but does allow for a fittingly extensive and deep deference, a respect for persons as human beings. On his account, human beings have absolute value, but this value is couched in an understanding of the kind of being humans are and, as such, there are standards that arise from that kind of being, things that are appropriate for beings of that kind (Meilaender, 2009). Human beings are treated with deference on a great number of the aspects of their lives that are most important to them: what kind of person they are to be, what kind of life they will lead, what their occupations, hobbies, and tasks are, what relationships to form, develop, and nurture, and what resources to devote to their own health. However, where Meilaender’s account helpfully differs is the additional resources that he is able to bring to bear on these questions, and the standards that arise. He argues that human beings are created in the image of God as creatures that are neither beasts nor God, and because of this they possess dignity equally (Meilaender, 2008). By relying on the rich resources of a theological tradition (for Meilaender, this is a Christian, and in particular, a Lutheran tradition), he is able to claim that human beings should act in accord “with the kind of creature a human being is . . . preserving a characteristically human life” (Meilaender, 2008, 268). This leads to specifications about how to live and what kind of life is best for all persons to lead. This, of course, does not mean that human beings will or should lead the same life. A proper deference to persons does not lead to homogeneity, but it does bring to bear normative standards that arise from consideration of the kind of beings that humans are. For example, on this view, there is a dignified way to procreate: the character of human life is degraded or diminished if we envision the relation between the generations in a way that makes some strong and other weak, in a way that makes some a ‘product’ of the will and choice of others. (Meilaender, 2008, 268) Thus, decisions about procreation are left to individual persons; human beings are treated with deference. However, this does not preclude (as it would seem to on an account of autonomy as deferment) considerations of justice, in particular justice between the generations. It allows in restrictions against kinds of procreation or reproduction which would enforce an unequal power dynamic between children and parents, between one generation and the next, wherein the latter generation could be seen to lack—given that it is merely a product—the specialness that human beings possess. More must be said to show why an account that relies on deferment would preclude the restrictions described in the previous paragraph. This is because on such an account, persons are deferred to wholly; they decide what is relevant for consideration within their own sphere. They may wish to impose “restrictions” on their own approach to procreation or reproduction, to continue with this example, but they might not. The standards, if they can be described as such, are not objective, but rather something closer to impersonally expressed personal preferences. One reason why an account of autonomy as deference is superior to an account of autonomy as deferment is that the former more accurately describes the ground for the kind of treatment that is expected with respect to other persons—the idea that human beings are objectively valuable. V. CONCLUSION Thus, there arises a tension between the claim of the objective value of persons and practice of deferment that is common in discussions of assisted suicide. This tension arises in an account like Dworkin’s two principle account and in common discussions of autonomy in cases of assisted suicide where something like Waldron’s notion of deference is informed by autonomy as deferment and not autonomy as deference. I have argued here that deference, and not deferment, is the correct way to articulate the kind of relationship that should exist with other persons with respect to their health, and in turn, a concept that should inform conversations and arguments on the topic of assisted suicide. This approach has the benefit of taking persons seriously, respecting them as beings that have objective value, while alleviating a tension between that claim of their value and mere deferment to them. As a result, this distinction between autonomy as deference and autonomy as deferment is a helpful one in medical ethics and for discussions of assisted suicide. The approach that I recommend relies on autonomy as deference, which is consonant with Roman Catholicism, a tradition which considers human beings within a broader social and spiritual context. Within medicine, autonomy as deference requires conversations with medical practitioners, patients, and the patient’s family members. This approach is different from that taken by those who conceive of persons as unconnected individuals, who rely on an impoverished conception of autonomy, autonomy as deferment. It is not surprising that on accounts relying on autonomy as deferment, assisted suicide is permitted. It is a short step from this approach to endorsement and societal funding for assisted suicide. This need not be the case if deference is embraced, as deference embodies the excellent intentions of those operating from deferment—respect for others, empathy with persons in challenging situations—but it also allows in limits informed by the kinds of beings that humans are, beings who depend on others. One can empathize with those who have not been in such situations as Mr. Cowart, but one need not, in seeking to respect his wishes (and those of many described in the popular cases above) defer to him. He is owed deference, but not deferment. We should, as Johannessen declares, still be able to tell him and others that we are glad they are still with us. I end this article with two sets of questions that an emphasis on autonomy as deference brings to mind. First, in focusing on the human being, the patient who is suffering and in need of care, the person who is before us, one might seek to extend this notion of deference beyond questions of health. This is fitting and raises questions about why the moral evaluation of assisted suicide is a medical question, as opposed to a more broadly human one. Surely, there are medical issues involved—the need for medical knowledge, skill, and resources about related issues—but why is the hastening or ending of a life, due to a request, a properly (or exclusively) medical question? One might ask oneself: if faced with a request to assist another in ending her life, would I? If the answer is in the negative, why should medicine (as a set of institutions) offer a different answer? If the answer is in the affirmative, then why require medical practitioners to assist in death?25 These reflections lead to a second set of questions, questions about the role of medicine, health policy, and related health and social institutions, at a more abstract level: what is the proper role of medical practice? What is the ethos of a hospital system? What are the necessary health-related tasks for a society to consider in collective thought about its citizens? These kinds of questions should be admitted into the conversation, not ruled out before being considered. There are too many such questions to offer more than this sampling, but what I have in mind are the kinds of questions that have recently been under attack in discussions of conscience protection. In a New England Journal of Medicine article I have already referred to, Ronit Stahl and Ezekiel Emanuel (2017) offer an account of medicine and medical ethics that blocks any questions like those articulated above because all matters are to be determined by the medical profession. On their view, the profession is defined in terms of a bare majority of voting members of politically connected medical societies, with an implicit articulation of medicine as a commodity. Thus, it is no surprise that autonomy as deferment is operative, nor is it a surprise that the kinds of questions I raised above are, on their view, not admissible. In fact, a mere discussion of conscience is only acceptable in cases where there is disagreement within such societies over a particular topic. Their example of a contentious topic where such a conversation would be allowed, and where claims of conscience might be invoked, is assisted suicide. Bracketing concerns about the uniformity of professions and the divergent views of members of professions, and about shifts in views throughout history, this approach would not allow for deference to patients, only for deferment.26 In treating practitioners as singly minded technicians and abandoning serious consideration of relationships, like that between practitioners and patients and the role of families in patient’s lives, the Stahl and Emanuel view offers a different approach of medicine than the approach I propose. Their approach would not allow for someone to engage with a patient and express a desire that she remain with us because it views individuals, like any account rooted in autonomy as deferment, as isolated individuals purchasing health services. Finally, and worst of all, these kinds of accounts block without argument the resources of traditions of thought, such as the Roman Catholic Tradition, that mean a great deal to many involved in these situations. NOTES 1. Much argument exists in the literature, a sampling of positions can be found in the following work: Clark (2006), Brody et al. (2011), Singer (2007), and John Paul II (2004). 2. For more on this case, see the collection edited by Kliever (1989). Additional essays of note are Engelhardt (1989), White (1989), and May (1989). 3. One interpretation of the aforementioned quotation is that it is an invitation to a patient who is considering hastening her death or directly ending her life to remain with us. It is instructive in a post-Enlightenment mindset where, though we aim to offer reasons to others for their consideration, reflection, and evaluation, we too often offer them only some kinds of reasons, and we surely do not press them. There are good reasons for this, and the case of Mr. Cowart illustrates both the need for deep respect for the autonomy of patients and explains the rhetorical power of patient autonomy movements. Gone are the days, and thankfully so, where physicians without serious consultation with other health practitioners acted upon a passive “patient” without engaging her as to her wishes. Today, reasons, relevant health information, outcomes and predictions, and in some cases a medical team’s best judgement are offered to a patient for her evaluation. The decision is hers. What can be lost in this approach are resources that require further information, further context, and further argument—claims rooted in traditions of thought and practice that require more nuanced articulations of what would be described now as personal values. As some, most notably Alasdair MacIntyre (2007), have argued: a consequence of the embodiment of emotivism in our culture is a failure for us to critique the ends of others, an embracing of bureaucratic, means-ends rationality as the only publicly acceptable kind of rational claim. In this context, requesting Mr. Cowart to stay with us or even letting him know that we are “glad” he is here would be seen as manipulation, as undue influence. If we wish him to remain with us, we may offer him some kinds of reasons, but only the kind that fits the structures set in place: the details of the relevant procedures, likely outcomes, possibilities of pain, future complications, etc. Once he is deemed competent and his consent is ascertained, the reasons end. This is one of the great benefits of considering Johannesen’s line as an invitation. It recognizes that a great deal is asked of the patient who is suffering in asking her to continue. To invite someone, with hope, in this way may require resources beyond those appealed to in legal documents, like Canada’s Bill C-14 or legal documents supporting euthanasia and assisted suicide in other locales. 4. I follow Alasdair MacIntyre in conceiving of traditions as sustained arguments and, as a tradition, Roman Catholicism—and work in medical ethics rooted in the resources of the Roman Catholic Tradition—is no different. The argument is multifaceted: it is internal, which is to say it occurs between and among members of the tradition, relying on some common resources and a history of debate over a particular set of issues; it is external, which is to say that its arguments, with their history and resources, are offered to address situations faced by all and, reciprocally, is open to critique from proponents of other traditions who aim to address similar situations. Thus, the Roman Catholic tradition will not have a hold on or be of interest to all patients and practitioners, let alone all relevant members of society. The religious convictions of some should never be forced on others, especially those in a vulnerable situation, but nor should arguments rooted in such traditions be discounted without arguments in support of such discounting. For a clearer and more detailed account of the notion of tradition that I am borrowing, see MacIntyre (2007). For a helpful passage on the concept of traditions, consider the following: A living tradition then is an historically extended, socially embodied argument, and an argument precisely in part about the goods which constitute that tradition. Within a tradition the pursuit of goods extends through generations, sometimes through many generations. Hence the individual’s search for his or her good is generally and characteristically conducted within a context defined by those traditions of which the individual’s life is a part, and this is true both of those goods which are internal to practices and of the goods of a single life. Once again the narrative phenomenon of embedding is crucial: the history of a practice in our time is generally and characteristically embedded in and made intelligible in terms of the larger and longer history of the tradition through which the practice in its present form was conveyed to us; the history of each of our own lives is generally and characteristically embedded in and made intelligible in terms of the larger and longer histories of a number of traditions. (MacIntyre, 2007, 222) 5. See Span (2017) or consider the well-known case of Brittany Maynard (for an article written in her own words, see Maynard, 2014). For a study on the role that religious affiliation plays in views on assisted suicide, see Burdette, Hill, and Moulton (2005). This study found that Catholics were strongly opposed to assisted suicide. For a study on the views of physicians practicing in the United States and their view on assisted suicide, see Curlin et al. (2008). This study found that the majority of physicians practicing in the United States object to assisted suicide. 6. For an excellent article that analyzes this situation in Belgium, particularly with respect to Catholic hospitals, see Iltis (2006). Also, for those interested in the implications of discussions for the United States, consider that assisted suicide is legal in five states: Washington, Oregon, California, Colorado, and Vermont. For a map of states and current status, see “Take Action: Death with dignity around the U.S.” Death with Dignity [On-line]. https://www.deathwithdignity.org/take-action/ (accessed December 9, 2017). 7. Chief among these resources are those from the USCCB, the CDF, and papal encyclicals themselves, in particular John Paul II’s (1995),Evangelium Vitae. Additionally, for useful resources within the Roman Catholic tradition specifically addressing the situation in Canada, consider documents put forth by the Catholic Organization for Life and Family (2016). Two additional noteworthy resources include Seper and Hamer (1980) and USCCB (1991). 8. For a more full view, consider the context from which this quotation was taken: The constant teaching of the Catholic Church is life must be respected from conception to natural death. To kill an innocent person is always morally wrong, and Catholics must understand requesting an assisted suicide or euthanasia is also morally wrong and puts their souls at risk. By opting for an assisted death, they will not have the proper disposition to receive the Last Rites which includes Confession, Holy Communion, and the Anointing of the Sick. It is also morally wrong for physicians, nurses, pharmacists to participate in euthanasia or assisted suicide and that includes making referrals. Thus it is disappointing the bill does not include express protection for the conscientious rights of health care professionals and for faith-based health care institutions. (Prendergast, 2016) 9. Some of the reaction to such claim is due to consideration of what might happen with respect to specific Catholic rites were it to be known that a person intentionally sought to take their own life, that she sought aid in dying. Is anointing of the sick an appropriate sacrament for someone who is about to undergo aid in dying? This is a fair question, but it is a question to be addressed by members of the tradition. For more on this, see Smith et al. (2016). For a helpful discussion of these topics, see Christopher White’s interview with Archbishop Christian Lépine of Montreal (White, 2016). 10. Here, it is worth noting the reliance of the Bishops on the rich resources of the Roman Catholic tradition, including concepts like dignity. It is also worth noting that these resources are accessible, in many respects, by those who are members of other traditions. Atheists and, to a degree, agnostics might have trouble relying on resources that appeal to the divine or for examples dependent upon the law of God. But, notice that in these crucial passages there is not a great deal of discussion of concepts that require a significant degree of theological theory and understanding, such as, for example, sin. This presents as a double-edged sword, with benefits of broader accessibility and costs of a lack of theological clarity and loss of content. 11. See footnote 3. 12. As I am primarily concerned with medical treatment, and not to extending this principle further, I put the vagueness worry to the side. 13. Much work has been done in this area already to add further detail to this conception of autonomy. I have in mind critiques of libertarianism and welfare liberalism that cite the individual as primary, for example, Alasdair MacIntyre’s critique of the political philosophy of John Rawls and Robert Nozick (MacIntyre, 2007, chapter 17), and critiques of political and moral philosophies that conceive of persons, or citizens, as atomistic, for example, Taylor (1985). 14. Though my evidence is merely anecdotal, I believe there are more subscribers to this view than one might think. It is a view clearly expressed in discussion of medical ethics where autonomy is nothing more than a patient’s choice. 15. See footnote 13. 16. See Aulisio and Arora (2014) for an analysis of instances where autonomy conflicts. See Pilkington (2016) for a response to that analysis. 17. Consider concerns about overmedicalization, including Burgess (1993) and Doust, Walker, and Rogers (2017). 18. For a selection of his work on dignity, see Waldron (2007, 2009, 2011). 19. Though there is good reason to distinguish many accounts of dignity from many accounts of autonomy and, in general, the concepts themselves, this is not the focus of this article. In fact, it is a telling sign that some think of dignity and autonomy as interchangeable (Macklin, 2003) and that “death with dignity” is the common nomenclature for laws associated with and provisions for assisted suicide and euthanasia. 20. Waldron writes, “. . . if we were to make the radical move—the reversal—and transfer this demand for respect from the nobility to every last ordinary person, what we would be transferring would not be a functional deference [deference only connected to the office], but this diffuse deference owed to the whole person. Or—and this is what I really want to say—we might think about the respect demanded by ordinary people as right-bearers in this light. A right-bearer is an ordinary person to whom this extensive and diffuse deference is due” (Waldron, 2007, 223–24). 21. For an instructive paper on the challenges associated with this for those in the psychological professions, consider Johnson et al. (2014). 22. I believe is an idea that is common in discussions of autonomy and some discussions of dignity, especially in medical and, more broadly, bioethical situations but it is not always, or often, named. 23. Consider, again, the case of Ms. Maynard or the cases of Dr. Ezekiel Emanuel (who hopes to die at the age of 75, Emanuel, 2014), Dr. Sandy Bem (Henig, 2015), or Dr. Jessica Nutik Zitter (Zitter, 2017), who now considers it right for her to assist in the deaths of her patients. 24. It is worth remembering at this point in the argument that autonomy as deferment may appear to be an extreme position, but I have argued that it is more plausible than it first appeared. It would be a problem for this kind of view and thinking about autonomy of this kind as a ground for assisted suicide, which appears to be the case offered in Canadian legal documents, if one thought that medical professions should influence their patients or if one thought that it was acceptable generally for persons to influence others. This is an issue for that account of autonomy, not for my critique of that account. 25. For an account of the legalization of euthanasia and assisted suicide in Switzerland, see Hurst and Mauron (2003). 26. Interestingly, it might not even allow for deferment in all cases. It would allow for deferment in cases where medicine has determined that particular questions are up to patients. ACKNOWLEDGMENTS I owe thanks to a number of people for helpful discussions on this topic, most especially Mark Cherry. I am grateful for the helpful comments from two anonymous reviewers. 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