Health Care Ethics ; Medical Law

“Aid in dying” is the most extensive idea of assisting someone to die. One component of this extensive idea is physician assisted death. Physician assisted death includes all of the types of euthanasia such as, active and passive euthanasia, which can be either voluntary or involuntary. A small subset of physician assisted death is physician assisted suicide (PAS). The concept of PAS covers a range of activities.

On one end of the spectrum, there is the model used in Oregon; whereas the physician screens those who are seeking to commit suicide and, after determining the mental state, desire, and medical condition of the patient, assists in dying by writing a prescription for a lethal drug overdose. On the other end of the PAS spectrum is the active participation of a physician in assisting the patient by starting an intravenous solution and thereby more directly providing the means by which a patient can initiate the final act of committing suicide (Breitbart, 2012).

Though seldom discussed, it is widely understood that the principal role of the physician is to “comfort always,” a role especially important when all hope to benefit from further treatment has faded. This ethic has never included assisting in suicide. When eliminating pain requires large amounts of morphine, unintended death in palliative treatment to provide comfort care raises few ethical, or legal, concerns.

Almost certainly, physicians and other caregivers sometimes listen to the pleas of severe pain stricken patients to help them die, or solely from compassionate impulses they occasionally perform involuntary, active euthanasia on a medically hopeless patient who can no longer communicate (Sullivan, 2011). Indeed, both legal counsel and the healthcare administrators that provide advice must understand the legal and ethical implications of issues arising for patients at the end of life. One of the most nerve-racking, challenging issues facing health care providers focuses on end-of-life issues.

Although it is established that competent terminally ill patients may refuse life-sustaining treatment, physician-assisted suicide continues to raise much debate. This paper analyzes physician assisted suicide as one element of end of life decision-making and identifies the legal and ethical questions it raises. While it appears that the momentum for legalizing physician assisted suicide has declined somewhat in the United States, the issue is one that necessitates monitoring and thoughtful consideration of institutional policies.

To begin with, the history of assisted suicide is neither lengthy nor complex. Aided suicide has origins tracing all the way back to around the fourth century B. C. , when scholars estimate the Hippocratic Oath, an ethical vow taken by doctors, was written (Pozgar, 2013). Part of the Oath states, “I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan” (Pickert, 2009). According to this statement, doctors are not legally or morally allowed to assist when a terminally ill patient wants to end his life.

Within the last thirty years, however, instances of physician assisted suicide have been showing up all over the world. In 1982 in Alkmaar, Netherlands, Dr. Schoonheim participated in aided suicide when she helped a woman take her own life. The woman was Marie Barendregt, a ninety-five year old grandmother who was severely disabled. Initially, Barendregt signed an order which allowed her to refuse potentially “life-prolonging treatment. With her son’s awareness and the consultation of two other independent physicians, Barendregt decided she did not want to live any longer. Dr. Schoonheim inoculated Marie with a lethal injection, while ultimately ended her life (Pickert, 2009). Moreover, instances of assisted suicide in the United States have not been in the public eye until the late twentieth century when a Michigan doctor ignored the Hippocratic Oath. Dr. Jack Kevorkian, the proclaimed “Dr. Death,” first appeared in the national spotlight in 1990.

He became famous when the story leaked that he helped a fifty-four-year-old Alzheimer’s patient commit suicide by having her release a cocktail of lethal drugs into her system by pushing a button on the homemade “suicide machine” that Kevorkian had constructed. However, most of Kevorkian’s fame came from how many patients he had helped end their lives. In all, Kevorkian admittedly assisted one hundred and thirty patients in committing suicide (Pickert, 2009). Since Kevorkian, only Oregon and Washington have legalized assisted suicide.

In 1997, Oregon created the “Death with Dignity” law that “allows terminally ill patients to commit suicide with lethal doses of prescribed medication” (Pozgar, 2013). Within a span of ten years, from 1997 to 2007, forty-six people in all had ended their lives using legalized physician assisted suicide in Oregon (Pickert, 2009). Presently, there is court case pending in the Montana Supreme Court which could ultimately legalize physician assisted suicide in the state, making Montana the third state in the union to permit aided suicide (Pickert, 2009).

As more cases of assisted suicide surface, so to do the number of legal and ethical concerns associated with the issue. No doubt, this evolution toward recognizing the appropriateness of assistance in dying raises legal and ethical issues for physicians and healthcare institutions such as, nursing facilities and acute care hospitals. These issues include the effects on providers’ values systems, the trust between patient and provider, and the “slippery slope” that voluntary, active assistance in dying will become involuntary, active assistance (Spike, 2012).

The Hippocratic ethic is reflected in legal prohibitions against harm committed by physicians and the misdeed of assisting in suicide in many states. Here, as in many other portions of the delivery of health services, there is a dynamic between the right of patients to make an autonomous liberty driven decision, and the paternalistic interests of the state and healthcare providers to act in ways that presume to know the patient’s interests and wishes (Spike, 2012).

In turn, it is also important to think about what patient autonomy means and what boundaries can and should be set upon it. Does patient autonomy include a “right to die”? Certainly, it is well-accepted that a patient has the right to reject medical treatment even when the patient’s treating physician or nurse believes the treatment is in his or her best interest. In such a case, withholding treatment at the patient’s request is not considered physician-assisted suicide but, rather a gesture of respect towards the dignity and free-will of the patient.

However, according to most medical bodies and ethics boards, the duty to provide care to a patient does not encompass a duty to comply with a patient’s request to be put to death, no matter how hopeless the patient’s condition or how intense the patient’s pain (Sullivan, 2011). In order to honor a patient’s autonomy, nurses and other medical health professionals must be sure that a patient’s choices are informed, such as, the patient understanding the consequences of his or decision, and not the result of pressure or coercion.

Unfortunately, it may not always be clear whether a patient’s decision is actually well-informed and freely made. For example, some patients may request withdrawal of treatment or assisted suicide because they believe themselves to be a financial or emotional burden on their caretakers and thus feel a duty to die (Pozgar, 2013). In addition, there is the possibility that a patient who is ill or in pain will be depressed or suffer from some other mental disorder.

Although the patient is technically competent to make his or her own decisions, it is important to consider to what extent those decisions are affected by treated mood disorders or other mental illnesses. Thus, “autonomy” can be compromised by many factors, not all of which can be immediately detected or accurately judged by a treating medical professional. Likewise, another important consideration is “quality of life. ” Many questions surround this issue. At what point does life cease to have “quality” and who should decide how much “quality” a particular patient’s life has?

Another related and valid question is whether the patient is always capable of judging the “quality” of his or her life, and, if the patient is incapable of doing so, who should make that judgment? Considerations of quality of life are closely linked to a determination of what is in a patient’s best interests (Pozgar, 2013). The challenge is to define what a patient’s best interests are and, again, identify who should be allowed to determine what those best interests are and whether they are met by withdrawing or administering a particular treatment.

Some proponents of physician-assisted suicide argue that those who oppose it are placing their own abstract ethical concerns above a practical consideration of the patient’s best interests (Sjostrand, Helgesson, Eriksson, & Juth, 2013). These proponents argue that it is not in the best interests of a pain-wracked terminally ill patient to suffer needlessly when his or her life is almost over anyway. From this perspective, the failure to end that suffering, even if the only way of doing so is the end the patient’s life, is an abandonment of the health professional’s duty to do what is best for the patient’s well-being.

For such a patient, death is better than a continued existence of intense, unbearable suffering; however, such an argument presumes that medical professionals, who are trained to discern what is best for a patient’s health, will be able to determine what is best for the patient overall (Sjostrand, Helgesson, Eriksson, & Juth, 2013). This point of view, though well-intentioned, threatens to verge on paternalism, where the physician believes so much in his knowledge of what is best that he or she ignores the patient’s right to self-determination.

Therefore, there is an inherent tension between respecting a patient’s autonomy and acting in his or her best interests. In essence, physician-assisted suicide and euthanasia (PAS/E) are contrary to the 2,500 year old historic and vitally important professional ethic of caring and healing; hence, the alternative solution to PAS/E, is also the original solution. Undoubtedly, the professional ethic of medicine is to care for the patient. Francis Peabody said in 1927, “The secret of caring for the patient is in caring for the patient. (Sjostrand, Helgesson, Eriksson, & Juth, 2013). The proper response to a request for physician-assisted suicide or euthanasia is excellent palliative end of life care. The American Medical Association maintains an unequivocal position on this issue: “Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks. Instead of participating in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life” (Breitbart, 2012).

If we accept that PAS/E is against physician virtue and moral tradition, and further, that legalization of such activities would be bad public policy, what then is the alternative? (Sjostrand, Helgesson, Eriksson, & Juth, 2013) The alternative is excellent palliative care. This requires a commitment to compassion, a willingness to endure with the patient until the end. Moreover, in good palliative hospice care, the goal is to help patients to live each day as well as possible. Patients who receive good end-of-life care rarely request that their physicians hasten death (Breitbart, 2012).

All of the patient’s physical needs must be thoroughly addressed. This means intensive symptom control of pain and dyspnea, the two most feared symptoms at the end of life, as well as, the multitude of other symptoms experienced by patients as they approach death; for instance, psychological symptoms are common in dying patients. Included in these symptoms are anxiety and depression; both of which are expected in the majority of dying patients. In addition, both need treatment, whether that is drugs, counseling, or someone to sit with the patient.

People who are dying need only two things, comfort achieved through symptom control, and company achieved through human presence (Burgmann, 2013). The spiritual is the final element in whole person care and, while this is important in caring for any patient who is seriously ill, it becomes vital in dying patients. When facing death, patients often ponder on guilt about how they have lived their lives. Additionally, others may develop uncertainty or doubts about even longstanding beliefs. Also, they may have many questions about the meaning of life and the meaning of death.

Surely, it is rare that one professional is able to address all of the physical, psychological, social, and spiritual needs of dying patients. Therefore, it requires a multidisciplinary team including nurses, physicians, therapists, counselors, pastoral care workers, social workers, and lay volunteers. Such a team is usually best organized through a formal hospice or palliative care program. To reiterate, the moral, legal, and professional acceptable alternative to PAS/E is excellent palliative, end of life care. Undeniably, there are many strong points in the argument against physician-assisted suicide.

One of the most common arguments is the slippery slope; the fear is that the financial costs of treatment or pressures from the family will cause the decision of the patient to have physician-assisted suicide performed. The “slippery slope” claim is that the right to physician-assisted suicide will slowly spread to the disabled or mentally competent adults who are not terminally ill, eventually reaching a point of involuntary euthanasia (White & Brody, 2011). Yet another major objection to physician-assisted suicide is the loss of trust of a doctor.

What will a patient think if it is known that their physician actively aided in someone else’s death. One maxim of medical care is “Cure sometimes, relieve often, comfort always” (White ; Brody, 2011). Of course, many times a physician cannot cure a disease and or relieve the symptoms. Nevertheless, how would a patient feel knowing that the doctor gave up on another patient especially if they were terminally ill and allowed the suicide to occur. The doctor-patient relationship is the foundation of all interactions and to have aided in death, would surely make more than a few patients uncomfortable.

Also, another truism of a physician is to first do no harm; thus, suicide can be seen as harm to a patient. The argument along these lines states that “physician-assisted suicide distorts the healing purpose of medicine” (Seale, 2009). Whichever path society does choose in regards to physician-assisted suicide, moral objections will need to be addressed. Either way, the public needs to be educated about the different legal options concerning the end of life care and the consequences of any changes in laws governing such care.

In the final analysis, focus will be on how some of the course learning outcomes pertains to assisted suicide. First, a brief description as to how the Patient’s Bill of Rights pertains to assisted suicide, or as some put it, the “right to die”. A number of cases have addressed the right to refuse life-sustaining medical treatment. Widely speaking, under certain circumstances a person may have a right to refuse life-sustaining medical treatment or to have life-sustaining treatment withdrawn. On the one side in these cases is the patient’s interest in autonomy, privacy, and bodily integrity.

This side must be balanced against the state’s traditional interests in the preservation of life, prevention of suicide, protection of dependents, and the protection of the integrity of the medical profession. The first U. S. Supreme Court decision addressing the difficult question regarding the removal of life support was Cruzan v. Director, Missouri Department of Health, 497 U. S. 261, 110 S. Ct. 2841, 111 L. Ed. 2d 224 (1990). Cruzan involved a young woman rendered permanently comatose after a car accident. Her parents petitioned to have her feeding tube removed.

The Supreme Court ruled that the evidence needed to be clear and convincing that the young woman had explicitly authorized the termination of treatment prior to becoming incompetent. The Court ruled that the evidence had not been clear and convincing, but upon remands to the state courts the family presented new testimony that was deemed clear and convincing. The young woman died 12 days after her feeding tube was removed (Seale, 2009). Next, the elements of autonomy, fidelity, and confidentiality as they are incorporated in the ethics of assisted suicide are presented.

Autonomy, the right of patients to make decisions about their medical care, is one of the most important principles in the health care industry. This principle would be used when a physician who has discussed preferences about life-sustaining treatment with a woman who has just been diagnosed with metastatic breast cancer is then guided by those wishes (Pozgar, 2013). Next, the principle of Fidelity is of similar importance. The ethical principle of fidelity is a proposition that healthcare providers keep patients’ interests first in mind above all others. It requires maintenance of patient trust and confidences.

It obligates them to carry out their promises to care for patients with faithful attention, as with excellent palliative care for end of life situations (Pozgar, 2013). Last, but equally important, the principle of Confidentiality, the principle in medical ethics that the information a patient reveals to a health care provider is private and has limits on how and when it can be disclosed to a third party (Pozgar, 2013). In regards to the end of life process, issues with this principal may be avoided through Advance Directives which give patients a voice when they can’t speak for themselves.

In addition, a competent patient may make his/her wishes known in advance of losing the ability to make health care decisions (Tucker, 2009). The Living Will and the Durable Power of Attorney for Health Care (DPOA-HC) are such Advanced Directives. The latter is also known as “health care proxy” (HCP) because a surrogate has the power to make decisions but, only when the patient lacks decisional capacity (Burgmann, 2013). In such cases, physicians are morally and legally required to follow these health care preferences to the extent permissible by law.

One final note, the evolution and application of moral theory and ethical principles in health care as they pertain to assisted suicide have been continuously referred to, discussed, and explained throughout this paper. To elaborate further in this area would show to be redundant. In conclusion, the ethical issues associated with the debate over not legalizing (or legalizing) physician assisted suicide are numerous; therefore, without specific guidelines, requirements, and standards in place, the legality of PAS is not an issue in the near future.

For now (and always), concentration should be on what has, is, and, will always be legal—excellent palliative end of life care. Certainly, every individual is different and every case different, but providing excellent palliative care should be the same regardless of every unique situation. True compassion means finding ways to ease suffering and provide care for each person, while maintaining the individual’s life and dignity.

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