Medical Ethics Paper Outline on Physician Assisted Suicide

Introduction

In history and cultures, suicide has been seen as a typical 'bad death,' going against the human nature instinct towards self-preservation (Hobbes 1996). In Europe, suicide was regarded as an offense to God, law, or society, and the act has been saw as a crime until 1961 (Minois 1999). This history continues to influence public attitudes toward suicide today (Richards, 2017). For Christians, it was St Augustine who first spread the sixth commandment 'Thou shalt not kill' (Richards, 2017) which includes suicide (Richards, 2017). Since that time, Christian opinion has been a priority for the principle that human life is not only a natural value but also a divine gift (Richards, 2017).

Assisted dying is when an individual with a terminal illness is helped by a doctor to take their one life, usually with lethal drugs (NHS, 2020).

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Euthanasia is when a doctor intentionally administrates a lethal drug to a patient with a terminal illness to end his suffering (NHS, 2020).

The ethical dilemmas involved in public health practice are due to an inherent conflict between the needs of individuals and the needs of the wider community of which individuals form a part (Chadwick, 1998).

The acceptance comes with the knowledge that health professionals can actively help the patient's last days free from pain, and anxiety, spiritually rewarding, and shorter (PubMed, 2018). The difference between active involvement in death and the active relief of suffering can be fine and confusing and this could not be better pictured than by the 'doctrine of double effect': where the administration of medication will decrease life, but this is not the primary reason for doing so; the primary reason usually being pain, anxiety and suffering relief (PubMed, 2018). 

Therefore, the question is not simply a moral and ethical one. Obviously has practical implications (PubMed, 2018). For example, if euthanasia and assisted dying were legal it would fall to the doctor to authorize these matters through prescription (PubMed, 2018). It is essential that the doctors, both at the individual and governing level be actively involved in the discussion (PubMed, 2018). Royal College of Physicians' Council decided to consult with its members on these issues to decide how to position itself in the debate (PubMed, 2018).

Assisted dying or assisted suicide is a controversial and sensitive subject for many people, not only because we are bound by ethics and law, but every individual has a different culture, and with that comes different values, morals and religion, political aspects which will influence people decisions (Fontalis, 2018).

If everyone has so many rights while alive, they should also have these rights before dying (Prousali, 2018). It is a hard profession to work in health and social care, but palliative care is different than any other care for all medical professionals, patients, and the family (Kulkarni, 2018).

Clinically talking medicine advanced a lot, so while so many treatments are found every day to prolong and save human life, it is peculiar to end someone's life at the same time (Harris, 2006). How can this decision be made by anyone? (Richard, 2006). There are so many debates about this subject, but because everyone is different, it is a dilemma how we decide that a person should die, even if that person has a terminal illness, they are in a lot of pain and is sometimes in a coma, so enable to talk for themselves (Khanna, 2006).

The power and the restraint of this debate will be a literature review on the provision of medical-assisted dying (Saleh, 2016). The approach will include a strategy of an extensive and precise search of databases, and literature, including conference proceedings, clinical trial registries, and clinical protocols from jurisdictions where assisted dying has been permitted (Miller, 2015).

Assisted Dying and Human Rights

The Human Rights Declaration and law is referring only to the right to life, but nothing about dying painlessly and with dignity: 'Everyone has the right to life, liberty and security of person' (Human Rights Act 3, 1998). There is no mention in none of the articles in Human Rights that if a person decides to die, what are their rights? However, if someone commits suicide, no one will be blamed, while if that person is helped to do so is considered murder (Human Rights Act, 1998).

Examples of countries where assisted dying and euthanasia are legal

There are countries that by law assisted suicide and euthanasia are legal in some circumstances (Lewis, 2015).

Switzerland is the first country that the list will start with because assisted dying does not come with many conditions (Lewis, 2015). Switzerland allows physician-assisted dying no matter the age, diagnosis, or how severe the symptoms are (Cianflone, 2021). It will be illegal only if the reason is an early inheritance or the burden to take care of a sick person (Cianflone, 2021).

Canada is one of the countries where assisted dying is legal, in a passive way, when family members withhold the necessities such as food, water, and medicine, to help them die (Davis,2019).

Passive euthanasia is also legal in Albania, where the family signs a legal consent when the family member is in a coma, without being able to decide (Russell, 2014).

When a patient in Colombia with cancer, AIDS, liver or kidney failure is in excruciating pain they have the right to assisted suicide (Russell, 2014).

The Netherlands is another country where assisted dying is allowed if the patient is in excruciating pain and there is no chance of recovery, even when is not a terminal illness (Mercer, 2010).

Spain has some different opinions about assisted dying, the patient not only needs to have a terminal illness and be in terrible pain, but they also must be widely aware and without any mental health issues and the request must be summited twice (Cianflone, 2021).

Belgium agrees with assisted death if the individual is in terrible pain, with a terminal illness, but only after a period of one month of waiting (Mercer, 2010).

Assisted dying and euthanasia are both legal in Luxembourg when a person has a terminal illness, and experience terrible mental and physical pain (Cianflone, 2021).

In Australia, euthanasia can be approved only if the person is a resident of the country, and the life expectancy is less than 6 months or 12 months of neurogenerative disease (Russell, 2014).

Some states of the USA approved assisted death by administrating lethal medicine and the person must have two verbal requests and two in writing and wait for 15 days before is approved (Browne, 2011).

New Zealand approves euthanasia if the patient has last than 6 months left, and the procedure is approved by two doctors (Cianflone, 2021).

France's approach is different, without agreeing neither euthanasia nor assisted dying but choosing palliative sedation, where a person can ask to be extremely sedative until they die (Browne, 2011).

Assisted dying and euthanasia

Assisted dying and euthanasia is a taboo subject and illegal; euthanasia is punished with life in prison and assisted dying with up to 14 years of imprisonment (The Medical Portal, 2020). There were several attends to legalize it, but all failed.

Supporting arguments

No matter how good the care is, some of the patients cannot endure the terrible pain.

Free will is one of the pillars of medical ethics; individuals are able to decide for themselves when to end their life because drugs cannot help anymore.

A lot of people decided to travel to other countries, for example, Switzerland to end their life, just because the law in this country did not allow them to die surrounded by family and friends.

People knowing that they have this option in case of a terminal illness can help, even if some will not do it.

In our society we let people decide about their health and lifestyle, why should they not choose when to die with dignity if they do not harm anyone?

Some people cannot afford to travel to other countries, so they will just commit suicide, in a painful way, which will also affect loved ones.

Arguments against

Many people argue that if it will be legal, more doctors will become murderers when their oaths are to protect life.

So many argue if this law will be approved, it will also be for children.

Vulnerable people will be under pressure

There will be no full control over it.

The's debate on assisted dying is achieving power (BMJ, 2021). The Scottish parliament will be able to make a law that would allow doctors to assist a dying patient (BMJ, 2021). Both laws will include solid safeguards, and doctors who refuse to take part in the process would not have to (BMJ, 2021).

By changing the law would bring into the group of countries that already allow doctors to aid people who are terminally ill to die with dignity (BMJ, 2021). In some areas, this expands to people who are not dying but are experiencing excruciating pain and suffering (BMJ, 2021).

The Medical Journal's opinion is that terminally ill people should be able to choose an assisted death, and the journal asked for professional organizations to agree to an impartial stand on the decision to legalize assisted dying, which is for society and parliament to make this decision (BMJ, 2021).

A former archbishop of Canterbury and a rabbi assure those of religious faith that there is nothing in the bible or scripture that forbid assisting a death to end suffering (BMJ, 2021). However, a former chair of the Danish Council of Ethics argues, that the freedom in choosing an assisted death is an illusion because it is the people around the dying person who judge the quality and value of their life (BMJ, 2021).

Cases of assisted dying

Study case 1

P L is a prominent assisted dying campaigner who was paralyzed following a car accident in 1990 (Admin, 2019). He started a legal challenge in 2014 in partnership with two others T and J N, which got to the Supreme Court but was overcome by a 7-2 majority as the Supreme Court Justices referred to the matter as a moral question rather than a legal matter (Admin, 2019). The court recognized a disagreement between the existing legislation under the Suicide Act 1961 which advised prosecution for those who assisted another person's suicide, and Article 8 of the European Convention of Human Rights, which mandates respect for private and family life (Admin, 2019). Despite all of this, they could not allow the request and change the law as it was the Parliament's decision (Admin,2019). Lord N and Lady H blamed the existing laws in their reasoning for the case and announced a notice to Parliament to find a solution for the issue before coming to court again (Admin, 2019). Even after five years, the Parliament has made a decision on the issue of L case, who decided to take his case to the courts again, saying that he was 'afraid that under current criminal charges, anyone who compassionately assisted in ending life would be at risk of 14 years' imprisonment' (Admin, 2019). He started his legal review application in July 2019, helped by Humanists and represented by L D (Admin, 2019). The new dispute is on the suggestion that Article 8 ECHR is contradictory with Sections 2(1), 2A (1), and 2B of the Suicide Act 1961 when read beside Article 14 ECHR, which bans discrimination on the grounds of disability (Admin, 2019). This is still an open case after so many years, without a decision from the court.

Study case 2

Another example is P N 49, from Rutland, who was diagnosed with Motor Neurone Disease in 2014 and cannot walk or use his hands and lower arms (BBC, 2019). He raised £42,000 for the legal challenge as he wants people to have a right to choose to die with dignity (BBC, 2019). The High Court judges said the court is 'not an appropriate forum for the discussion of the sanctity of life' (BBC, 2019). Mr case proposed that judges should examine properly a large amount of expert evidence - including from countries where assisted dying is legal - before deciding whether the law is incompatible with his human rights (BBC, 2019). His lawyers told a hearing in that he faced an 'inhumane and intolerable' deterioration (BBC, 2019). They said Mr. N will appeal against the court's decision, but he still lost the case against the High Court.

Assisted dying is an area of continued political and professional debate both abroad (PubMed, 2018). While assisted dying remains illegal the past twenty years have seen legislative changes permitting euthanasia and assisted suicide in other parts of the world (PubMed, 2018). There have been a number of large research to study the attitudes of doctors toward assisted dying (PubMed, 2018). A systematic review on assisted dying published by McCormack in 2010 analyzed fifteen studies published between 1990 and 2010 and found that most doctors do not support a change in the law in favor of either active voluntary euthanasia or assisted dying (PubMed, 2018). Also, in line with the surveys conducted by the Royal College of Physicians, McCormack found that only a small number of doctors would accept to actively participate in active voluntary euthanasia or assisted dying (PubMed, 2018).

Even if several bills and high-profile court cases were supporting assisted death, it continues to be a criminal offense under the law (PubMed, 2018). In 2006 and 2014, most of the Royal College of Physicians members disputed a change in the current law on assisted dying and favored improvements in palliative care (PubMed, 2018).

References

1. Admin (2019), Assisted Dying: the Current Cases, https: the student lawyer.com20190918assisted-dying-the-current-cases, (data accessed on 10.04.2022).
2. BMJ (2021), Assisted dying around the world, Assisted dying around the world | The BMJ, (data accessed on 20.04.2022).
3. Human Rights Act (1998), Assisted Dying and Human Rights, Assisted Dying and Human Rights United Nations Association Coventry Branch (uncover. UK), (data accessed on 15.04.2022).
4. Karen Porter, Katharine G Warburton (2018), Physicians' views on current legislation around euthanasia and assisted suicide: Results of surveys commissioned by the Royal College of Physicians, Physicians' views on current legislation around euthanasia and assisted suicide: Results of surveys commissioned by the Royal College of Physicians - PMC (nih.gov), (data accessed on 27.04.2022).
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9. NHS (2020), Euthanasia and assisted suicide - NHS (www.nhs.uk), (data accessed on 15.04.2022).
10. Penny Lewis (2015), Assisted dying: What does the law in different countries say? Assisted dying: What does the law in different countries say? - BBC News, (data accessed on 25.04.2022).
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