The Physician Assisted Suicide Dilemma

Abstract

Physician Assisted Suicide (PAS) is when a physician provides a lethal medication that is used to end life. With an ever-increasing responsiveness of physician assisted suicide across the world, it is important to understand the beliefs and reasoning for those for and against PAS. There has been a long debate regarding the ethics surrounding these issues. PAS has a long history and there are many laws in place across the world that either ban, or have legalized, PAS. The debate regarding PAS is focused on the role of the physicians and patient autonomy. This paper will discuss the background of this issue, the surrounding ethics, and review articles regarding the topic.

Introduction

Physician assisted suicide (PAS) has been a long debate regarding the decision to end suffering of a terminal patient. Medicine was created to help prolong life and physicians take an oath to do no harm. Therefore, the act of ending life due to futile situations causes an ethical dilemma for many individuals. We allow and readily carry out do not resuscitate (DNR) orders in the hospital. We also allow for comfort measures for these patients. However, these terminal individuals with DNR orders are just waiting for their health to deteriorate. The agonizing wait for their death can further prolong the suffering and raises an ethical dilemma for healthcare workers and the patient’s families. Some feel respecting the wishes of a terminally ill patient is merciful; however, others feel that it is not ethical to take one’s life. This raises the question: should a patient who is terminally ill, while also mentally competent, decide the time of their death?

Physician assisted suicide occurs when a doctor causes death or provides the resources for the patient to take their own life.1 A physician may use two different types of suicide. One type is passive assisted suicide. This is when a physician prescribes a lethal dose of drugs and the patient takes the medication themselves. The other type of suicide is called active suicide (better known as euthanasia) where the physician is the one to administer the lethal medication.2 In all cases, these patients have been diagnosed with a terminal disease that would lead to death within a given timeframe, which is usually six months. The most discussed and accepted in the United States is passive assisted suicide.2

There are few states across the United States where this is legal and many where it is illegal. Federally, the ruling is left up to the decision of the states to determine whether they want to criminalize PAS or not. In areas where it is legal, there are many safeguards in place to prevent abuse and prevent physicians from being criminally prosecuted. Laws protecting physicians in a state where it’s legal, rule that it is not manslaughter, nor murder, to assist patients in dying if they are terminally ill, or suffering.1,2

I chose this topic due to experiencing many ends of life issues as a nurse in an intensive care unit. It is difficult to witness people in futile situations who are suffering at the end of their life. It’s hard to witness suffering when there is little one can do to help. At times it feels like torture and prolonging the inevitable death of a terminally ill patient. I personally feel that if a person is competent and wishes to pursue PAS, then it should be their right to do so. I know that if I were diagnosed with a terminal disease, I would want to decide the circumstances and time of my death instead of waiting for the inevitable.

History

Since 500 BC, euthanasia has been a topic of debate.3 In 500 BC, the ancient Greeks and romans believed in euthanasia.3 Then with the rise of Christianity, there was a change in the views of euthanasia, and it was widely opposed. 3 It was and still is considered a sin to take one’s life regardless of situation. The Hippocratic Oath which is estimated to be written in fourth century BC, includes a statement that states: I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan. 3 Nevertheless, in 2001, the Netherlands and Switzerland legalized assisted euthanasia and then Canada in 2016.3

Currently, the United States has varying opinions on the issue. In 1997, the US Supreme Court ruled in Washington v. Glucksberg and Vacco v. Quill that there is no right to die.3 However, the Supreme Court then ruled that individual states could create their own laws on the matter.3 Months later in 1997, Oregon voted to keep the Death with Dignity Act. In Michigan, Jack Kevorkian MD who was a pathologist, helped facilitate assisted suicide and became a central figure for assisted suicide in the 1990s. 3 In 1998 he assists with the suicide of his 92nd patient in eight years. 3 Michigan then makes this a crime in September of that year.3 Regardless of the new law, Kevorkian continued to practice assisted suicide, totaling 120 deaths by the following November.3 He was eventually convicted of murder in 1999 and sentenced to 10-25 years, but only served 8.3

Another very popular case is the case of Terri Schiavo.3 She was 41 years old and left in a persistent vegetative state for over ten years.3 She had a heart attack, was successfully resuscitated, but her brain was left without oxygen for too long.3 There was a major controversy over this case involving congress, courts and even George W. Bush, whom was the president at the time.3 Her parents believed in keeping her alive by feeding tube and hydration; however, her husband and legal guardian believed that Terri Schiavo would not have any desire to live in that state if she would have been able to decide for herself.3 After several years of debate, it was ruled in 2005, that she could die by removal of life support equipment.3

By 2008, some states started passing their own Death with Dignity Acts. As of right now, there are eight states that allow assisted dying. Currently, assisted suicide is legal in Washington, D.C. and the states of Oregon, Washington, California, Colorado, Montana, Vermont and Hawaii.3 In March of 2019, the governor of New Jersey stated that he plans on passing a bill to legalize PAS.

Literature Review

Implementing a Death with Dignity Program

Loggers, Starks and Shannon-Dudley (2013), sought to implement a Death with Dignity program at the Seattle Cancer Care Center Alliance. In this study, 80.5% of the participants had a terminal cancer diagnosis.4 The remaining patients had either a neurodegenerative disease, respiratory disease, heart disease or another disease.4 The researchers of the study determined why these participants wanted to participate in the program. The most common reasons for wanting to participate given by 36 participants was loss of autonomy (97.2%), inability to engage in enjoyable activities (88.9%), and loss of dignity (75.0%).4

The study described the extensive protocol which patients must endure before proceeding.4 Each patient is given an advocate where this advocate ensures proper diagnosis as well as conducts health questionnaires and generalized anxiety disorder questionnaires.4 The advocate also refers the patient to Psychiatry and Psychology Services if there is a history or positive screening for mental health issue or if there seems to be impaired decision making.4 The extensive process ensures that patients are aware of all available options including hospice or palliative care as well as having their fears or concerns addressed. 4 There is then a fifteen-day waiting period to ensure that the decision has been thoroughly decided. 4 After, if all requirements are met, a prescription if given of secobarbital or pentobarbital.4

The article stated that qualitatively, patient and families were thankful to receive the lethal prescription even if it was never used.4 Furthermore, families often described the death as peaceful even if the death had taken longer than intended. 4 Overall, the Death with Dignity program has been well accepted by the patients, their families and staff.

Mental Health Outcomes of Family Members

Ganzini, Goy, Dobscha and Prigerson (2009), aimed to determine the mental health of the family members who’s loved one chose to go through with PAS.5 It has been thought that the family members of those who chose this route were at a higher risk for severe grief. 5 Following the loss of a loved one grief is normal. However, there are levels of grief that are abnormal and can be disabling. 5 The objective of the study was to determine how this choice affected the family.5

In the treatment group, there was 95 people who were surveyed from Oregon who chose PAS.5 The control group consisted of family members of patients who had died from amyotrophic lateral sclerosis and who did not participate in PAS and died from the disease progression.5 Surveys were sent out to families that included grief after death as well any as new mental diagnosis or assistance from mental health centers following the death. 5

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No differences were found between the family members of patients who selected PAS versus the family members who’s loved one died from their illness. 5 There was no difference in depression symptoms after death or prolonged grief.5 However, it was found that PAS families were more prepared and were more accepting of the death.5

These results are important because these terminal patients often rely heavily on family members for support.5 It has been found that a main reason for a terminally ill patient to reject PAS is because of a family member’s disapproval of the matter.5 It brings relief for a patient to know that this decision, while sad, has been proven to not increase depression rates or prolonged grief. PAS has no negative effects on the family and instead makes the family feel more prepared and at ease with the death.5

Physician Views of PAS

Currently, there isn’t much research regarding the thoughts of PAS in the medical community. Some older research suggests that many medical professionals widely oppose assisted suicide. However, a recent Canadian review in the Journal of Medical Ethics looked at the current opinions of Canadian neurosurgeons.6

Since the legalization of PAS in Canada in 2016, many physicians have participated in the practice. A cross sectional survey of neurosurgeons and neurosurgery residents was conducted.6 89 physicians responded to the survey.6 71% were neurosurgeons and 29% were neurosurgery residents.6 Of this group, 74.2% supported PAS and 7.8% opposed.6

This data shows that there is increasing positivity and support regarding PAS in Canada.6 However, in the United States many states have made PAS illegal. The data from Canada where PAS has been legalized, has shown support from physicians. Overall, there is very little research regarding implementation and overall positivity of PAS since it is still illegal in most countries and states in the United States. More research is needed to fully see the overall benefit and satisfaction in the terminally ill and their families.

Ethical Principles

Autonomy, beneficence and justice are three ethical principles that apply to this situation. All three of these ethical principles support, or do not support, PAS depending on how one looks at the situation and principle.

The most important argument that applies to this situation is autonomy. Medical autonomy states that patients have the right to decide when enough is enough and make their own decisions in terms of their care.7 Patients should never be forced through pain and more procedures if they are not willing. If a doctor has determined that the situation is futile with no chance of quality of life, then the patient should have the right to end their life. Patients should always have the right to die with dignity. Denying one’s desire to end suffering is a direct disrespect of their autonomy. This is forcing the patient into a death that may be painful and even costly. On the other side, physicians have their own autonomy and if a physician finds PAS immoral, should not be forced to participate.

The ethical principle of beneficent is doing the most good.7 PAS can be viewed as kind and compassionate. If a physician prolongs suffering in a futile situation, then they are violating the principle of beneficence. Doctors take an oath to do no harm. While prolonging care, they are prolonging the pain and suffering the patient may feel. However, it can also be seen as abandonment and thus not beneficent.

The principle of justice involves fair treatment or fairly distributing benefits, risks and costs.7 We allow for patients to refuse treatment which could end their life. However, refusing treatment alone may not be adequate to end life in some situations. Therefore, allowing death in one situation but not the other would be unjust. On the other hand, allowing PAS will target those lacking appropriate medical care and support which would be an argument against PAS. Moreover, some may seek out this option as a cost saving option instead of seeking out appropriate healthcare. This situation would also be unjust and be a reason to oppose PAS.

Personal Position

While hospice and palliative care options are respectable ways to make the terminally ill comfortable at the end of their life, medications for pain are sometimes not affective. PAS is a compassionate way to relieve suffering to those who are terminally ill. With proper protocols in place to prevent abuse, PAS can give compassion and dignity to those who are terminal. In the United States, citizens have the right to pursue happiness without unfair restrictions from the government. If someone is suffering from an illness that will prevent them from living an acceptable quality of life, I believe it’s fair to make their own decision to end their life humanly as possible. It’s unfair to a terminally ill, suffering patient, to keep them alive against their will. PAS is beneficial to a terminally ill patient that does not want to live on in pain and suffering.

I also believe that a person’s autonomy should be respected. These life or death decisions should be for the patient to decide. As a nurse in the Intensive Care Unit, I have witnessed on many occasions, needless suffering. There are times when suffering is so extreme is seems cruel to prolong living in these patients. Not only is their quality of life poor, but they’re also suffering from unnecessary and debilitating pain.

Conclusion

There are many who are for PAS and many who are against PAS. Some are against physician assisted suicide because they believe that it leads to an ethical slippery slope. If this is allowed for terminally ill individuals, it opens a door for those that are not mentally competent such as those with mental illness. Religion is also an important factor for some. Some believe that life is precious, and life should never be taken by anyone other than God, regardless of their health. These are all valid arguments.

With few states legalizing PAS, it still has a long way to go in terms of acceptance from the United States. Some states have legalized PAS and there are documented safeguards in place to prevent misuse and abuse. While more research may be needed, articles show that PAS was successful and have not shown any negative harm in Oregon where it has been legalized.

Protecting the ethical principles of autonomy, justice and beneficence is important in this special population. The right to decide death for oneself in the face of a terminal disease is compassionate and kind. Allowing PAS gives those who are already in a compromised position, some control over their life in an already difficult time. Many states should take note from the successful nature of Oregon and enact change. Legalizing PAS not only gives patients a voice in their end of life care, but also makes the people and government take a closer look at the care and compassion given to this population of people. These vulnerable individuals deserve compassionate treatment during a difficult time and allowing them to preserve autonomy is momentous.

References

1. Shibata B. An Ethical Analysis of Euthanasia and Physician-Assisted Suicide: Rejecting Euthanasia and Accepting Physician Assisted Suicide with Palliative Care. Journal of Legal Medicine. 2017;37(1/2):155-166. doi:10.1080/01947648.2017.1303354.
2. Den Hartogh G. Two kinds of physician-assisted death. Bioethics. 2017;31(9):666-673. doi:10.1111/bioe.12371.
3. Historical Timeline - Euthanasia - ProCon.org. Should euthanasia or physician-assisted suicide be legal? https://euthanasia.procon.org/view.timeline.php?timelineID=000022. Accessed April 1, 2019.
4. Loggers ET, Starks H, Shannon-Dudley M, et al: Implementing a Death with Dignity program at a comprehensive cancer center. N Engl J Med 368:1417-1424, 2013
5. Mental Health Outcomes of Family Members of Oregonians Who Request Physician Aid in Dying Ganzini, Linda et al. Journal of Pain and Symptom Management, Volume 38, Issue 6, 807 - 815
6. Althagafi A, Ekong C, Wheelock BW, et al Canadian neurosurgeons’ views on medical assistance in dying (MAID): a cross-sectional survey of Canadian Neurosurgical Society (CNSS) members. Journal of Medical Ethics Published Online First: 12 March 2019. doi: 10.1136/medethics-2018-105160
7. American Medical Association: AMA Code of Medical Ethics, Opinion 5.7, PhysicianAssisted Suicide, 2016. http://www.ama-assn.org/ama/pub/physician-resources/medicalethics/code-medical-ethics/opinion2211.page