Doctor-assisted dying
安乐死


The right to die
死的权利


Doctors should be allowed to help the suffering and terminally ill to die when they choose
如果正在承受痛苦和垂危的病人选择死亡,医生应当被允许协助他们结束生命。


Jun 27th 2015 | From the print edition



IT IS easy to forget that adultery was a crime in Spain until 1978; or that in America, where gay marriage is allowed by 37 states and may soon be extended to all others by the Supreme Court, the last anti-sodomy law was struck down only in 2003. Yet, although most Western governments no longer try to dictate how consenting adults have sex, the state still stands in the way of their choices about death. An increasing number of people—and this newspaper—believe that is wrong.

忘记通奸直到1978年前在西班牙还是一项罪名是容易的,忘记在同性婚姻已经在38个州得到允许且不久可能被联邦最高法院扩展至其他所有州的美国,最后的反鸡奸法直到2003年才被废除也是容易的。然而,在西方,尽管大多数政府已经不再试图指导成年同性恋者如何发生性关系。但是,国家仍是人们有关死亡选择的障碍。越来越多的人以及本报相信,这是错误的。

The argument is over the right to die with a doctor’s help at the time and in the manner of your own choosing. As yet only a handful of European countries, Colombia and five American states allow some form of doctor-assisted dying. But draft bills, ballot initiatives and court cases are progressing in 20 more states and several other countries. In Canada the Supreme Court recently struck down a ban on helping patients to die; its ruling will take effect next year. In the coming months bills will go before parliaments in Britain and Germany.

争论的核心是在医生的帮助下,以自己选择的时间和方式死亡的权力。时至今日,只有少数几个欧洲国家,以及哥伦比亚和美国的5个州允许某种形式的协助性自杀。但是,各种草案、公投议案和法庭案件正在美国的另外20个州和多个国家中取得进展。在加拿大,最高法院刚刚驳回了一项协助病人死亡的禁令;判决将在明年生效。在今后几个月中,将有多项提案将被提交至英国和德国议会。

The idea fills its critics with dismay. For some, the argument is moral and absolute. Deliberately ending a human life is wrong, because life is sacred and the endurance of suffering confers its own dignity. For others, the legalisation of doctor-assisted dying is the first step on a slippery slope where the vulnerable are threatened and where premature death becomes a cheap alternative to palliative care.

这种观点让批评者大失所望。在某些人看来,争论所涉及内容属于道德范畴,是绝对的。有意结束一个人的生命是错误的。因为,生命是神圣的,对于痛苦的忍耐授予生命以尊严。对于另外一些人来说,协助性自杀合法化是道德滑坡的第一步。这个滑坡会让弱者受到威胁,会让提前死亡成为姑息治疗的廉价替代品。

These views are deeply held and deserve to be taken seriously. But liberty and autonomy are sources of human dignity, too. Both add to the value of a life. In a secular society, it is odd to buttress the sanctity of life in the abstract by subjecting a lot of particular lives to unbearable pain, misery and suffering. And evidence from places that have allowed assisted dying suggests that there is no slippery slope towards widespread euthanasia. In fact, the evidence leads to the conclusion that most of the schemes for assisted dying should be bolder.

这些看法根深蒂固,值得认真对待。但是,自由和自主也是人类尊严之源,两者皆增加了生命的价值。在世俗社会中,通过让大量的个体生命被迫承受无法承受的身体和精神痛苦的方式,来支撑抽象意义上的生命尊严的做法是奇怪的。来自已经允许了协助性自杀之地的证据表明,不存在通向大范围安乐死的滑坡。实际上,这些证据所指向的结论是:大多数支持协助性自杀的计划都应当更大胆。

Nothing is hurt, nothing is lost
无所谓受伤,无所谓失去


The popular desire for assisted dying is beyond question. The Economist asked Ipsos MORI to survey people in 15 countries on whether doctors should be allowed to help patients to die, and if so, how and when. Russia and Poland are against, but we find strong support across America and western Europe for allowing doctors to prescribe lethal drugs to patients with terminal diseases. In 11 out of the 15 countries we surveyed, most people favoured extending doctor-assisted dying to patients who are in great physical suffering but not close to death.

民众对于协助性自杀的渴望是毫无疑问的。本报曾委托Ipsos MORI,就医生是否应当被允许协助病人死亡,以及如何与何时协助病人死亡,在15个国家做了一次民调。俄罗斯和波兰持反对态度。但是,我们却在美国和西欧各国发现了对于允许医生给身患绝症的病人开具致命药物的做法的强烈支持。在我们调查的15个国家中的11个,大多数人都支持将协助性自杀扩展到正在经受巨大身体痛苦但还没有接近死亡的病人。

No wonder that, just as adultery existed in Spain before 1978, so too many doctors help their patients die even if the law bans them from doing so. Usually this is by withdrawing treatment or administering pain-relief in lethal doses. Often doctors act after talking to patients and their relatives. Occasionally, when doctors overstep the mark, they are investigated, though rarely charged. Some people welcome this fudge because it establishes limits to doctor-assisted dying without the need to articulate the difficult moral choices this involves.

正如通奸行为在1978年之前还在西班牙存在一样,现在有如此多的医生纵然是在法律禁止他们的情况下,依旧帮助自己的病人死亡,这丝毫不令人感到奇怪。协助性自杀通常是通过撤回治疗或者是给予致死剂量的止痛药来实现。医生经常是在同病人和他们的亲属进行过交谈后才采取行动。医生偶尔会越过这个界限,这时,他们会被调查,但很少被指控。有的人对此持欢迎的态度,是因为这种模棱两可可以在不需要讲明其所涉及的艰难道德选择的情况下,为协助性自杀设定界限。

But this approach is unethical and unworkable. It is unethical because an explicit choice that should lie with the patient is wholly in the hands of a doctor. It is hypocritical because society is pretending to shun doctor-assisted dying while tacitly condoning it without safeguards. What may turn out to be more important, this system is also becoming impractical. Most deaths now take place in hospital, under teams of doctors who are working with closer legal and professional oversight. Death by nods and winks is no good.

但是,这种做法是不道德的,也是不可行的。不道德,是因为理应取决于病人的明确选择完全掌握在医生手中;伪善,是因为社会在假装回避协助性自杀的同时,又心照不宣在没有保障的情况下纵容它。更为重要的是,这个体系也在变得不切实际。如今,大多数死亡都是在医院中,在工作在更加严密的法律和职业监督的医生团队下发生的。在医生忙碌下的死亡毫无意义。

Better is to face the arguments. One fear is that assisted dying will be foisted on vulnerable patients, bullied by rogue doctors, grasping relatives, miserly insurers or a cash-strapped state. Experience in Oregon, which has had a law since 1997, suggests otherwise. Those who choose assisted suicide are in fact well-educated, insured and receiving palliative care. They are motivated by pain, as well as the desire to preserve their own dignity, autonomy and pleasure in life.

最好是直面争论。一个担心是,协助性自杀会被强加给弱势的病人,而弱势的病人又会被流氓医生、贪婪的亲属、吝啬的保险公司所欺凌,或是因为自己囊中羞涩而被迫选择死亡。但是,自1997年以来就有了一项这方面法律的俄勒冈州的经历却表明了另一种情况。实际上,选择了协助性自杀的人都受过良好教育、享受保险,并且正在接受临终关怀。他们选择死亡,既是被病痛所驱使,也是被保存自己的尊严、自主和生命中的乐趣的渴望所驱使。

Another fear is that assisted dying will downgrade care. But Belgium and Holland have some of the best palliative care in Europe. Surveys show that doctors are as trusted in countries with assisted dying as they are in those without. And there are scant signs of a slippery slope. In Oregon only 1,327 people have received lethal medicine—and just two-thirds of those have used it to take their lives. Assisted dying now accounts for about 3% of deaths in the Netherlands—a large number—but this is less a rush to assisted dying than the coming to light of an unspoken tradition in which doctors quietly brought their patients’ lives to an end.

另一个担心是,协助性自杀会使照料水平降低。但是,比利时和荷兰有着欧洲最好的一些姑息治疗。调查显示,医生在有协助性自杀国家所享受的信任同没有的国家是一样的。而且,这些地方几乎没有滑坡的迹象。在俄勒冈州,至今仅有1327人接受了致死药物,但是使用这些药物来结束自己的生命的人只有三分之二。如今,在荷兰,协助性自杀占死亡总数的3%左右——这是一个很大的数字。但是,相比医生可以安静地将其病人的生命带至终点的不言而喻的传统,并没有出现大量的安乐死。

Wear no forced air of solemnity or sorrow
请勿有被迫的严肃或者悲伤


How, then, should assisted dying work? For many the model is Oregon’s Death with Dignity Act. It allows (but does not oblige) doctors to prescribe lethal drugs to patients with less than six months to live who ask for them, if a second doctor agrees. There is a cooling-off period of 15 days.

那么,协助性自杀应当如何进行呢?对许多国家来说,俄勒冈州的《尊严死亡法案》是一个模板。这项法律允许医生(但是医生没有义务)在第二名医生同意的情况下,给生命剩余时间不到6个月且向他们提出要求的病人开出致死药物。这其间有一段15天的冷静期。

We would go further. Oregon insists that the lethal dose is self-administered, to avoid voluntary euthanasia. To the patient the moral distinction between taking a pill and asking for an injection is slight. But the practical consequence of this stricture is to prevent those who are incapacitated from being granted help to die. Not surprisingly, some of the fiercest campaigners for doctor-assisted dying suffer from ailments such as motor neurone disease, which causes progressive paralysis. They want to know that when they are incapacitated, they will be granted help to die, if that is their wish. Allowing doctors to administer the drugs would ensure this.

我们会走得更远一些。俄勒冈州法律坚持,致死剂量由病人自己开出,以回避自愿安乐死。对于病人来说,吃药和要求注射之间的道德差别微乎其微。但是,这种严格要求的实际后果却是让丧失行动能力的人想安乐死的时候得不到别人的帮助。一些最激烈地为协助性自杀造势的人承受的是诸如引发渐进性麻痹的运动神经元病这类病痛的折磨,这不令人惊讶。他们想知道的是,当自己丧失行动能力时,是否会如愿以偿地获准协助性自杀。允许医生控制药物能够保证这一点。

Oregon’s law covers only conditions that are terminal. Again, that is too rigid. The criterion for assisting dying should be a patient’s assessment of his suffering, not the nature of his illness. Some activists for the rights of the disabled regard the idea that death could be better than a chronic condition as tantamount to declaring disabled people to be of lesser worth. We regard it as an expression of their autonomy. So do many disabled people. Stephen Hawking has described keeping someone alive against his wishes as the “ultimate indignity”.

俄勒冈州法律只适用于临终情况,而且过于僵化了。协助性自杀的标准应当是病人对自身痛苦的评估,而不是病人对其疾病性质的评估。在一些为丧失行动能力之人的权利而造势的人看来,死亡可能好于慢性疾病的想法等于是宣布丧失行动能力的人命不那么值钱了。我们的观点是,这是丧失行动能力之人的自主权的一种表达,并且许多丧失行动能力的人也这样看。 斯蒂芬·霍金就把违背意愿而让一个人活着的行为称为“最大的侮辱”。

One exception to this distinction should be children. The decision of whether to endure chronic conditions should be left until adulthood. But, as with adults, children facing imminent death from terminal diseases should, in consultation with their parents and doctors, have the right to be spared their last agonising hours.

这种区别对待的一个例外应当是儿童。是否忍受慢性病的决定应当留待儿童成年以后。但是,如同成年人的情况一样,面对绝症引起的即将来临的死亡的儿童,在同他们的父母和医生商量后,应当有权利免受他们最后时刻的痛苦。

The hardest question is whether doctor-assisted dying should be available for those in mental anguish. No one wants to make suicide easier for the depressed: many will recover and enjoy life again. But mental pain is as real as physical pain, even though it is harder for onlookers to gauge. And even among the terminally ill, the suffering that causes some to seek a quicker death may not be physical. Doctor-assisted death on grounds of mental suffering should therefore be allowed.

最难的问题是,协助性自杀是否应当对承受精神痛苦的人适用。没有人想让自杀对于得了抑郁症的人来说变得更容易:许多得了这种病人以后都会康复,再次享受生活。但是,精神上的痛苦同身体上的痛苦是一样真实的,尽管这让旁观者更加难以判断。再者,即便是在临终的病人中,让有些人寻求更快死亡的那种痛苦可能不是身体上的。因此,基于精神痛苦的协助性自杀应该获得允许。

Because patients’ judgments may be ill-informed and states of mind can change, especially among the mentally ill, society should help people to die only when safeguards are in place. These should include mandatory counselling about alternatives, such as pain relief, psychotherapy and palliative care; a waiting period, to ensure that the intention is enduring; and a face-to-face consultation with a second, independent medical expert to confirm the patient’s prognosis and capacity. In cases of mental suffering the safeguards should be especially strong.

由于病人的判断可能会被疾病所左右,而且他们的思想状态也可能改变,这在承受精神病痛的病人之中尤为突出。因此,社会仅应在保障到位的时候,协助人们死亡。这些保障应当包括诸如缓解痛苦、 心理治疗和临终关怀等有关替代方案的强制性咨询;还应包括一段等待期和一次同第二名独立医疗专家的面对面咨询,前者是为了确保病人意向是持久的,后者是为了证实病人对今后情况的判断和能力。至于承受精神痛苦的病例,保障应当特别强大。

The most determined people do not always choose wisely, no matter how well they are counselled. But it would be wrong to deny everyone the right to assisted death for this reason alone. Competent adults are allowed to make other momentous, irrevocable choices: to undergo a sex change or to have an abortion. People deserve the same control over their own death. Instead of dying in intensive care under bright lights and among strangers, people should be able to end their lives when they are ready, surrounded by those they love.

决心最大的人,不管得到了多好的劝告,也不能总是做出明智的选择。但是,仅仅因此就否认每一个人协助性自杀的权力是错误的。有行为能力的成年人被允许做出其他一些重大且不可更改的选择,如变性或者堕胎。人们也理应对自己的死亡具有同样的掌控权。与其在重症监护室的明亮灯光和陌生人中死去,人们理应可以在自己已经做好准备,且为所爱之人的围绕下,结束自己的生命。