Between Philosophical Rigor and Policy Pragmatism

In “I Support the Right to Die. You Go First”: Bias and Physician-Assisted Suicide, Felicia Nimue Ackerman challenges the moral distinction between terminally ill patients who seek physician-assisted suicide (PAS) and nonterminal individuals who wish to die. She presents three possible positions: PAS should be prohibited for everyone, permitted only for terminally ill patients, or permitted for all competent adults. Although Ackerman does not choose between the first and third positions, she argues that the second position is morally untenable because distinctions based on terminal illness are difficult to reconcile with principles such as autonomy, competence, and relief of suffering.

I find Ackerman’s criticism persuasive, particularly when she examines the concept of dignity. Arguments for PAS often treat illness, disability, dependence, or loss of bodily control as conditions that diminish human dignity. Ackerman questions why these conditions should undermine dignity while other misfortunes, such as poverty or unemployment, do not receive the same treatment. Her analysis exposes how apparently neutral distinctions can reflect deeper assumptions about whose lives are worth preserving.

Yet her argument raises a further question: Does showing that a legal distinction is morally inconsistent mean that the distinction itself should be abandoned?

I am not convinced that it does. Public policy operates under constraints that pure moral philosophy does not. Human characteristics such as maturity, judgment, vulnerability, and competence exist on continuous spectrums, while law must often convert them into categorical rules. A person who is seventeen years and 364 days old and a person who is eighteen may have virtually identical judgment, yet a legal system must still establish a voting-age boundary. The fact that the boundary does not correspond to a dramatic difference between individuals does not, by itself, make the existence of a boundary irrational.

This distinction is crucial; the necessity of having a boundary is not the same as the moral justification of a particular boundary. I therefore do not claim that the six-month terminal-illness criterion is inherently correct, nor do I conclude that Position 2 is preferable to Position 1. My argument is more limited. Even if a particular boundary is philosophically imperfect, its imperfection alone does not demonstrate that public policy can function without boundaries.

PAS makes this problem especially difficult because policy must consider more than individual autonomy. A society must also consider social consequences, vulnerability, and the amount of suffering that different policies may prevent or produce. Universal access to PAS, for instance, raises not only questions about individual choice but also about how institutionalizing assisted death might affect society’s broader understanding of suicide. At the same time, prohibiting PAS may itself prolong severe suffering. Ackerman acknowledges this tension, noting that expanding access could increase suicides while restricting access could increase misery, without resolving which consideration should take priority.

I therefore do not see the issue as a simple choice between Ackerman’s philosophical consistency and practical policy. Rather, her argument reveals a deeper tension between them. Ethical reasoning asks whether a distinction is morally justified; public policy must additionally determine whether some distinction is necessary and what consequences follow from drawing it.

Ackerman successfully demonstrates that the terminal/nonterminal distinction cannot simply be treated as morally self-evident. But the failure of one boundary to withstand philosophical scrutiny does not necessarily mean that all legal boundaries should be rejected. The harder question is how a society can draw an imperfect boundary responsibly—while minimizing discrimination and suffering and remaining accountable for the consequences of drawing it.