Legalize Physician-Assisted Suicide
Physician assisted suicide is one of the most controversial ethical, medical and legal issue in the US and across the globe. The consensus on whether to Legalize Physician-Assisted Suicide (PAS) should be considered a formal option of palliative care last resort is not forthcoming especially in the past two decades of discussions on the issue.
PAS presents a dilemma morally and participants are torn between honoring the wishes of their patients and respecting human life sanctity. PAS is considered very illegal in the US except in a few states including Montana, Washington and Oregon. The practice is however widespread in many parts of the country (Prokopetz and Lehmann 97). The present study also demonstrates that PAS falls within the ethical practice and therefore, it should be legalized.
Legalizing the practice will pave way for creation of safeguards to ensure that PAS is conducted in ways that serve the needs of patients’ best without compromising the quality of hospice or palliative care.
Historical Overview of Legalizing Physician-Assisted Suicide
Even though moral and legal discussions about the practice intensified in the past two decades, the notion of ‘‘good death’’ from which the PAS debate patented from, is known to have occurred in classical antiquity. According to Dowbiggin, romans and ancient Greeks strongly believed that suicide was an appropriate and rational way to end the suffering that arises from devastating health conditions such as cancer. It was also considered a way of avoiding defeat, shame and dishonor (7).
There are many cases where people would kill themselves by taking poison, hanging, fasting and stabbing themselves. Others would secretly request medical practitioners to provide them with the easiest means of death and it became to be known as physician-assisted suicide.
PAS was also less controversial in classical antiquity based on the fact that ethical believes tolerating suicide and euthanasia existed. Ancient religions on the other hand did not recognize the sanctity of life therefore; one could easily commit suicide without necessarily generating much of social disapproval (Dowbiggin 8).
Even so, suicidal views varied in schools of thought. Epicurean and Pythagorean schools consider suicide as disrespecting God while philosophers including Plato strongly believed that dying was much better compared to dishonor and suffer agony. Spartan Greek’s culture of eliminating disabled citizens and weak infants also inspired Plato’s thought that encouraged self-destruction in the event where death was inevitable rather than painful and shameful execution.
Suicide was also considered legal in ancient Rome and it was known as ‘‘triumph over fate’’ (Dowbiggin 9). Indeed, roman thinkers were amongst the first people to consider suicide as an exercise of an individual’s basic right or autonomy. Lack of strict regulation of medical practice on the other hand led to high tolerance levels towards PAS in ancient times.
Emergence of institutions to address professional, educational and legal aspects of healthcare placed the physician at the center of all medical practices as opposed to relatively free health practices in ancient Rome and Greece. Legitimating of the medical practices also led to creation of medical ethics to help physicians in their practice. For instance, Hippocratic Oath requires than a physician should take a vow not to ‘‘give a deadly drug to anybody if asked for it, nor make a suggestion to the effect’’ (Hosseini 203).
The earliest PAS resistance, which accounts for survival of the Hippocratic Oath to the present day, is suicide condemnation by religious movements in the first century and more specifically, Christianity and Judaism. These movements argued that whether to take one’s life or that of others undermines sanctity of human life (Dowbiggin 13).
However, despite long term and strong controversy surrounding PAS, the relevance of the practice in modern medical did not attract a lot of attention in the US until the late 1980’s when a campaign for PAS as a just cause was began by Dr. Jack Kevorkian. The doctor met a lot of resistance from United States justice system and American Medical Association.
Dr. Kevorkian was later arrested and jailed for administering a lethal injection to a patient as well as videotaping the death of the patient (Hosseini 203). He was accused of murder and even though AMA opposes PAS to date, the issue has remained an ethical dilemma with significant implications for medical practitioners.
PAS and Medical Ethics
Medical practitioners are subject to the code of ethics of conduct relevant to their field of practice. The adherence to specific norms and virtues is additionally a major requirement for any medical practitioner (Ornstein 28). Additionally, high value placed on human life is indeed a huge demand on health professionals and physicians as it requires them to adhere to medical ethics. This is based on the fact that medical errors come with severe implications on the quality of life of a patient and can cause death. PAS also affects patients and physicians directly and it falls in medical ethics realms.
Unfortunately, the code of ethics of AMA does not clearly provide clear guidance in regards to the role of physicians in the practice. Newer versions of AMA code also emphasize little on virtues such as patience, promptness, piety and sobriety (Hosseini 206). AMA opposes the practice without developing any concrete arguments against it. AMA instead claims that PAS erodes integrity of physicians and medical practice as a whole.
Unassisted and assisted suicides all fall in realm of ethics based on the fact that anyone who helps another to commit suicide or needs help to do so belongs to the community. The society in other words has a great duty towards those who want to commit suicide because of different issues that affect their social lives including substance abuse, sickness, poverty and other problems that often serve as suicidal motives.
As a matter of fact, suicidal social aspect explains the tolerance of assisted suicide in Roman and ancient Greek societies. They allowed people and convicts with devastating conditions to commit suicide as opposed to dying miserably (Dowbiggin 9). Modern institutions including legal systems, healthcare system and religious bodies have similarly assumed different roles towards suicide intervention.
An attempt to develop argument against or for PAS on medical grounds also necessitates appreciation of different ethical principles that are applicable to the practice. They include justice, patient autonomy and non-malefic. Additionally, the principle of autonomy recognizes patient’s rights to make decisions based on their health and it does not exclude settling of suicide as an ideal death alternative.
According to Sneddon, there are forms of autonomy including deep autonomy and shallow autonomy (392). Shallow autonomy is freedom to make decisions and it does not involve pertinent issues of life and existence. Deep autonomy on the other refers to complete control of personal life or self-rule. It also includes choosing a purpose for life, planning it, self-evaluation, reflecting and aligning the goals of an individual with different moral values.
Respect for deep autonomy is one of the major motives for seeking the consent of a patient in medical ethics (Sneddon 392). The global recognition of a patient’s autonomy justifies PAS as long as the patient requesting the procedure is capable of making a rational decision. Such capability includes ability of a patient to understand alternatives at his or her disposal as well as the consequences of the alternatives and the intention of pursuing the selected alternative.
The right of an individual to settle extends to all alternatives given as long as it doesn’t harm others. Choosing PAS as a way to end suffering and pain does not harm other people or contradict goals set by medical practitioners including fostering autonomy and self-determination.
There are also people that argue that PAS should not be legalized under any circumstance because it is very inconsistent with healing purposes of medical practice. By considering such an argument, the purpose of healing should always be considered. Health-giving does always capture all goals of medical practice based on the fact that there are practices offered for preventive measures, palliative care and contraceptive use for example does not qualify the ambiguity of healing practices (Martin, Mauron, and Hurst 56).
It is essential to note that medical ethics permit medical practitioners and more specifically physicians to offer contraceptives as a means of controlling fertility. Even so, fertility is not a disease and the use of contraceptives is not to cure fertility or heal. Therefore, accepting the role of a physician to offer contraceptives cannot only be considered a way of fulfilling other medical goals including fostering the autonomy of an individual on whether to become pregnant or not.
Similarly, the role of a physician in offering preventive medical care as well as palliative care is not disputed. It is in pursuant of medical practices that do not necessarily culminate in healing (Martin, Mauron, and Hurst 56). This clearly demonstrates that the purpose of medical practices go beyond healing but includes practices that reflect respect of a patient’s autonomy, values and priorities in the event where healing is impossible.
Patients with terminal illnesses in the US who settle for last resorts reflect the dire need to respect the autonomy of a patient. For instance, a patient always has the right to discontinue his or her life supporting therapy as long as he is aware of the consequences of taking such a step which in most cases include death (Quill 59). It is essential to note that nothing can be done on the body of a patient without the patient’s consent.
This means that a patient cannot be forced to remain on a life supporting machine regardless of his or her intention to die. The guarantee that such a treatment will keep the patient alive and the surety that the patient will die if he or she decides to quit treatment.
Fasting is another last resort and the patient may decide to expedite death process by refusing to drink or eat. In such a case, a physician cannot use any other form of food administration or force the patient to eat without consent of the patient (Quill 60). While the patient can settle for voluntary fasting as an easy way to die, without involving the physician, the physician will be needed to manage symptoms of last fasting stages. Additionally, physicians are allowed to relieve patients suffering through the use of palliative sedation in the event of terminal illness as long as the patient is aware of the initiation.
The intention of palliative sedation is to relief different symptoms and where the relief cannot be achieved unless sedation is used to the stage of unconsciousness (Quill 60). Artificial feeding process can also be withdrawn to enhance sedation especially if it is clear that only unconscious sedation will help relieve the symptoms. It is imperative to note that continuous sedation is acceptable even if it leads to unconsciousness as long as the patient has capability to consent and agrees to the process.
Compared to other last resort options in the US, PAS does not violate the purpose of respecting self-determination and autonomy of a patient in the end of medical or life care. As a matter of fact, PAS can accomplish its objectives by offering personalized attention compared to other options. For instance, if a patient suffering from a terminal illness decides to die freely and consciously in the presence of loved ones, PAS would be an ideal option compared to sedation based on the fact that in the latter, a patient is defined of consciousness especially in the last stages of dying (Martin, Mauron and Hurst 56).
Additionally, PAS allows a patient to stop the process in the event of change of mind. For instance, a patient may decide not to be administered specific medication avoiding death even if it is in the last stage of the process. On the other hand, continuous sedation to unconscious state denies the patient an opportunity to change their decisions once the process has begun.
What’s more, continuous sedation occurs often in clinical settings that are unfriendly and unfamiliar to the patient. It is beyond the control of a patient compared to PAS that occurs in a relaxed and friendly setting allowing the patient to control and choose preferences to the entire process.
PAS according to different case studies helps to eliminate concerns over the negative impact of the impact of PAS on medical practice. To begin with, information from Oregon where PAS is legally practiced demonstrates how the procedure is associated with enhancing Palliative care compared to claims in other states that it deteriorates Palliative care (Quill 61)
Oregon is one of the leading states with high number of home deaths, hospice referrals, use of life supporting machines and opioid prescriptions. Additionally, physicians in the state have increased their participation in training programs covering palliative care because of their recognition that the training will help them to help those considering PAS better.
All physicians must recognize that palliative care is not replaced by PAS for dying patients. Instead, patients must have the right to access standard palliative care and it would only be applicable in the event where standard care has failed.
The other factor against PAS legalization is that it will accelerate the abuse of the uninsured, minors, the elderly, racial minorities, the disabled and those with low education. Battin et al. investigated this claim by collecting information from Netherlands and Oregon where PAS is legal.
After making a comparison of the data collected over 15yrs of PAS practice, researchers found out that there is no disproportionate rise in the PAS use against vulnerable groups except for those living with HIV/AIDs (Battin et al. 594). Gil also found out on the same issue that contrary to popular claims that vulnerable groups are more likely to seek PAS, majority of those who make the request have health insurance, are members of the majority groups and are well educated (Gill 28).
Out of 208 citizens in Oregon who sought PAS between 1998 and 2004, only two did not have health covers. This is an indication that those who seek PAS do not do so necessarily because they are vulnerable (Dieterle 133).
Terminal nature of many diseases and their implications on self-rule of an individual including loss of dignity, loss of control and decline in the meaning of life because of physical incapacitation are some of the main reasons for seeking PAS (Lachman 123).
The Physicians Role: Relieving suffering versus Hastening Death
A physician’s role in hospice and palliative care is to relieve suffering. The physician plays a crucial role of ensuring that his or actions as well as inactions are just in last resort practices especially in the event of death. End of life process acceptance often depends on whether the process is carried out to hasten death or to relief suffering (Quill 62).
Processes that are designed to hasten death include PAS and euthanasia and they face a lot of resistance compared to the processes that are designed to relieve suffering (which can result in death as an unintended consequence) for example if palliative sedation is accepted.
The rule is considered double effect as it applies to different degrees to last resort and available alternatives. For instance, increasing dosage to relief pain or cause death is proportionate to palliative sedation as it may result in unintended consequences such as unconsciousness and death, of which, a physician is always aware even before administering the treatment.
In the two scenarios, the purity of a physician’s intention is imperative in justifying his or her actions morally (Quill 63). However, the discontinuation of life support, avoiding drinks and eating as well as PAS is very difficult to justify unless in the event where a patient consents, rather than the action or inaction is always a primary consideration.
The physician may also discontinue life support therapy and allow nature to take its cause. Even so, discontinuing life support treatment without a patient’s consent or surrogates is considered active involvement in expediting death (Quill 62). This also means that the consent of a patient plays a very critical role in determining whether to discontinue life support treatment or not. Similarly, stopping drinking or eating by a patient cannot force a physician to help the patient to do so because there are different means of food and drink administration as well as nutrition that also require the approval of a patient because of the respect of human sanctity. The same scenario also arises in PAS practice.
The intention of a physician in the process is also considered irrelevant despite the fact that his or her role in evaluating the request and informing the patient is very crucial. Once the physician has clearly determined that the patient requesting PAS is capable of making wise and informed decisions on the process, the physician will solely rely on the intent and will of the patient to determine the next course of action including assisting the patient to hasten death.
The intention of the physician in other words to prescribe lethal medication does not matter as long as the patient is capable of making the request for medication within available safeguards. Therefore, PAS should always be recognized as formal alternatives in ending of a patient’s life based on the request of a patient as opposed to the intention of a physician.
Even though a lot of emphasis has been placed the will of a patient, the consent of a physician is also imperative. A physician is obliged to assist a patient end his or her life if the patient fulfills all PAS requirements (Lachman 124). Physicians who also feel that engaging in the process violates their conscience and values can refrain completely from PAS practice without facing any legal implication.
By doing so, PAS practice does not violate freedom of individuals, their will, autonomy as well as values of patients as well as the physician.
The Benefits of Legalizing PAS
Presently, only states in the US have legalized PAS and they include Washington, Montana and Oregon. However, PAS secret practice is widespread. Even before the debate on whether to legalize the practice or not, PAS also gained a lot of publicity in late 1980s and it was already work in secret.
For instance, Dr. Kevorkian assisted more than 100 patients to due and when he admitted doing so, he was only reproached for offering active euthanasia to one patient (Quill and Greenlaw 137). The gaps in palliative care however seem to necessitate PAS practice. Excellent palliative care on the other hand includes offering advanced procedures to help manage pain, signs/symptoms and to provide psychological support.
Even so, available palliative treatment options fail to provide desired outcomes for some patients based on different individual experience as well as varying degrees of suffering in its physical, psychological, existential and social forms. Quill and Greenlaw found out that PAS accounts between 1 to 2 percent of deaths in the United States where the practice is illegal. This is much higher than in Oregon where PAS is legal (137).
The situation also calls for improvement of palliative care to help reduce the need for PAS and its legalization to minimize the abuse of the practice. When a sick person requests PAS, a physician will have to evaluate the patient first to ensure that he or she has received standard care. This is important as it helps to ensure PAS does not serve as a quick alternative to hospice or palliative care.
The only way to track the conduct of a physician following the request of a patient for PAS is to legalize the process because even under given conditions, the physician does not report their PAS practices for fear of prosecution. Additionally, legalizing the practice will allow physicians to consult other psychiatrists, physicians and family members concerning the matter including the need for consent and patient evaluation.
When PAS is conducted secretly, only the patient and the physician are involved in the process and therefore, it is very difficult to ascertain whether the values, rights, will and interests of the patient are fully considered (Quill 63). What’s more, recognizing the practice as a last formal resort medical practice had offered the benefit of offering statewide training initiatives for physicians to help them prepare to handle all PAS requests effectively.
Many physicians who have practiced PAS secretly lack quality and sufficient training that is required to evaluate the necessity of the decision and this increases the likelihood of unnecessary PAS (Gill 39). Openness is also beneficial to patients and currently, many patients who may need the process find it very hard to freely express themselves before a physician. This is based on the fact that a physician may view them as suicidal.
As a result, physicians often miss the opportunity to address all underlying sufferings that a patient goes through. Therefore, free exchange of information between patients and physicians concerning the practice is very crucial because it ensures a patient is well protected and evaluated effectively to enhance palliative care.
Legalizing PAS is the most ideal way to ensure the practice is considered in safe ways that do not compromise medical practices such as respect of the autonomy of a patient, human dignity and the commitment to provide quality care till end of life. Physician assisted suicide is under the realm of acceptable practices medically that have nothing to do with treatment but are very essential in ensuring that a patient meets his or her healthcare needs.
The legalization of the process is also the first step towards appreciating the need to enhance palliative care because people seek PAS as a last option. Openness about the legalization of the process will also help to increase understanding of the issue to enhance opportunities to help minimize the need for PAS.
Battin, Margaret P., Agnes van der Heide, Linda Ganzini, Gerrit van der Wal, and Bregje D. Onwuteaka Philpsen. “Legal Physician-assisted Dying in Oregon and the Netherlands: Evidence Concerning the Impact on Patients in “Vulnerable” Groups.” Journal of Medical Ethics 33(2007): 591-597.
This study used the case studies of PAS in Oregon and the Netherlands to demonstrate that PAS does not increase the risk of death in patients belonging to various vulnerable groups such as ethnic minorities, the elderly and the poor.
Dieterle, J.M. “Physician Assisted Suicide: A New Look At the Arguments.” Bioethics 21.3 (2007): 127-139. Academic Search Premier. Web. 3 Dec. 2013.
The author of this article uses data from the PAS practices in Oregon to discredit arguments against the legalization of PAS.
Dowbiggin, Ian R. A Concise History of Euthanasia: Life, Death, God, and Medicine. Lanham: Rowman & Littlefield, 2007. Print.
Chapter 1 of this book provides a brief historical overview of assisted suicide focusing of ancient Greek and Roman cultures.
Gill, Michael B. “Is The Legalization Of Physician-Assisted Suicide Compatible With Good End-Of-Life Care?.” Journal Of Applied Philosophy 26.1 (2009): 27-45. Academic Search Premier. Web. 3 Dec. 2013.
Gill examines some of the anti-PAS arguments and demonstrates that the legalization of PAS does not contradict the principles of palliative care.
Hosseini, Hengameh M. “Ethics, the Illegality of Physician Assisted Suicide in the United States, and the Role and Ordeal of Dr. Jack Kevorkian before His Death.” Review of European Studies 4.5 (2012): 203-209. Academic Search Premier. Web. 3 Dec. 2013.
This study emphasizes the significance of PAS debate to various groups including physicians, researchers and legal experts and highlights the key arguments raised.
Lachman, Vicki. “Physician-Assisted Suicide: Compassionate Liberation Or Murder?.” MEDSURG Nursing 19.2 (2010): 121-125. Academic Search Premier. Web. 3 Dec. 2013.
This study points out the key issues in PAS that nurses should know and how they can respond to patients requesting for PAS.
Martin, Angela K., Alex Mauron, and Samia A. Hurst. “Assisted Suicide is Compatible with Medical Ethos.” American Journal of Bioethics 11.6 (2011): 55-57. Academic Search Premier. Web. 3 Dec. 2013.
The authors argue that although PAS is not about healing, it falls within the goals of medical practice concerned with respect for personal liberty rather than healing.
Ornstein, Allan C, Daniel U. Levine, Gerald L. Gutek, and David E. Vocke. Foundations of Education. New York, NY: Cengage Learning, 2014. Print.
Chapter 2 of this book identifies ethical standards as a necessary component of any profession.
Prokopetz, Julian J. Z. and Lisa Soleymani Lehmann. “Redefining Physicians’ Role in Assisted Dying.” The New England Journal of Medicine 367.2(2012): 97-99.
The authors recognize that PAS presents additional physician duties such as evaluation and prescription, which should be clearly defined to protect the physician from engaging in activities that might undermine his or her ability to offer excellent care .
Quill, Timothy E. “Physicians Should ‘Assist in Suicide’ When it is Appropriate.” Journal Of Law, Medicine & Ethics 40.1 (2012): 57-65. Academic Search Premier. Web. 3 Dec. 2013.
Quill identifies circumstances in which physicians should assist patients in need of PAS and explains the potential benefits of legalizing PAS.
Quill, Timothy E. and Jane Greenlaw. “Physician-assisted Death.” The Hastings Center Bioethics Briefing Book. Garrison, NY: The Hastings Center, 2008.
Chapter 30 of this book examines the physician-assisted death debate and the possibility of its legalization.
Sneddon, Andrew. “Equality, Justice, and Paternalism: Recentreing Debate about Physician-Assisted Suicide.” Journal of Applied Philosophy 23.4 (2006): 387-404. Academic Search Premier. Web. 3 Dec. 2013.
The author examines the PAS debate from the perspective of equality and makes an argument for PAS based on equality principles.
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