Despite the amount of attention to the choice between case-by-case judgements and rule-based decision making by some scholars, the importance of that choice has often been neglected in discussions of specific issues in medical ethics. In particular, discussants commonly do not give full recognition to the moral concerns that arise when principle is translated into rules or judgments. Rules or
judgments are frequently seen as fairly straightforward applications of an important moral principle. For example, if one considers it immoral for physicians to cause their patients' deaths, one might look favorably on a rule that prohibits physician-assisted suicide for all patients or a judgment that denies assisted suicide to a particular patient. In such a case, the rule or judgment codifies one way in which the underlying principle applies to physicians' practices. The principle against causing patient deaths might lead to other straightforward rules, including a prohibition of euthanasia and a prohibition of the negligent practice of open-heart surgery.
Although it is important that rules concretize key under lyıng principles,they often serve the other important goals that I have discussed. Drivers are in a much better position to predict whether they will be pulled over for speeding if the operative rule is "The speed limit is sixty-five miles per hour than if the operative rule is "Drive safely." At the same time, it is much easier for a police officer to decide when someone is speeding when the operative rule is based on a speed limit of sixty-five miles per hour than when it is based on the requirement that drivers proceed safely.
When the other roles of rules are neglected, rules may seem misguided. That is, ifa rule is thought to represent a straightforward application of principle, it will often be misunderstood, as with the previous example of a law permitting abortion for any reason before the fetus is viable. In the remainder of this part of the book, I will consider the importance of generally valid rules for end-of-life decision making. In doing so, I will argue that important moral principles in end-of-life decision making are captured by simple, categorical rules, much as the social concern about safe driving is captured in a simple, categorical rule of a speed limit, and the social concern about voter maturity is captured in a simple, categorical rule of a minimum voting age. Specifically, I will argue that the distinction between physician-assisted suicide and the withholding or withdrawing of the life-sustaining treatment exists because it provides a simple,"bright-line" way to distinguish between morally justified and morally unjustified patient deaths. That is, permitting treatment withdrawal (or withholding) and prohibiting suicide assistance is essentially a "proxy for permitting morally justified patient deaths and prohibiting morally unjustified patient deaths, just as permitting speeds below sixty-six miles and hour and prohibiting speeds above sixty-five miles per hour is a proxy for permitting safe driving and prohibiting unsafe driving. This proxy rule for end-of-life decision making exists because it would not be feasible to make case-by-case judgments regarding the moral acceptability of a patient's death.
By understanding the distinction between treatment withdrawal an suicide assistance in this way, we can understand both why scholars a correct to criticize the distinction between treatment withdrawal and Suicide assistance from the perspective of underlying principle and why still has made sense for societies to adopt the distinction. In other words, although the distinction between treatment withdrawal and suicide assistance may seem problematic in terms of underlying moral principle, it is in fact less problematic when one takes into account the moral concerns involved in translating principle into practice.
By understanding the assisted suicide-treatment withdrawal distinction in terms of its proxy role, we can also understand how a limited right to physician-assisted suicide can be recognized without any change in society's theory about what constitutes a morally justified patient death. Relaxing the prohibition against assisted suicide can be explained in terms of finding a better proxy for underlying principle while still accounting for the moral concerns involved in translating principle to practice.
In short, I have chosen to discuss the distinction between physician assisted suicide and treatment withdrawal because it demonstrates the importance of generally valid rules in medical ethics and law, and it does so in the context of a critical life-and-death issue.
