There are few debates as controversial to the medical community as that of the right to die, or the right to have an assisted suicide. This sample research paper addresses the primary legal and ethical dimensions of that debate and, specifically, focuses on the role of physicians in the assisted suicide controversy.
Legality of physician-assisted suicide in Oregon
In 1990, Dr. Jack Kevorkian thrust the subject of assisted suicide into the public’s consciousness. This quickly became a prominent legal and ethical issue in the United States, and is still hotly debated today. Nurses and physicians face problems when making ethics decisions, but they look to their primary oath - do no harm. The prominent role of physicians is to cause wellness in their patients and, barring that, to cause comfort. This is widely understood, but not often discussed. Sometimes the hope of getting well fades away, leaving comfort as a patient’s only option. And sometimes even comfort cannot be found.
Assisting in suicide has never been considered a part of “providing comfort.” Sometimes deaths of patients occur due to the high amounts of morphine and other drugs required to manage pain, but they are unintended. But what is the right thing to do when a doctor’s pain-wracked patient begs them to help them die? Those working in and around the healthcare field must understand the legal and ethical implications of issues arising for patients at the end of life. (Darr 2007).
In 1994, Dr. Goodwin and other like-minded activists petitioned for a ballot measure that would ultimately lead to the Death with Dignity Act. During that time he spoke before the Oregon Medical Association (O.M.A.), which resulted in the O.M.A. releasing a neutral stance on the measure. This position was a critical advantage to the ballot measure’s narrow win.
“I think that had the OMA not taken that position in ’94, the law would not have passed. It only passed 51% to 49%,” said Dr. Stevens, vice president of the Physicians for Compassionate Care Education Foundation, a Yakima, Washington—a group that opposes physician-assisted suicide.
The O.M.A. later backed a failed 1997 effort to repeal the Death with Dignity Act and reaffirmed that pro-repeal position in 2005.
The American Medical Association policy “strongly opposes any bill to legalize physician-assisted suicide” because the practice is “fundamentally inconsistent with the physician’s role as healer.” (O’Reily 2012)
Importance of pain management
Some argue that the passage of physician-assisted suicide into law led to a greater effort on the part of health care and hospice care teams to ensure adequate pain control. A task force to improve the care of terminally ill Oregonians was established to bring greater awareness to the question of pain management by using potentially addictive opioid pain medications immediately after the act was signed into law. The task force issued an influential report in 1998 that practitioners still rely on a decade later.
New pain management protocols were developed and adopted by health care institutions, and physicians no longer had to face the gray and dangerous legal consequences for “suspicious” over-use of conventional pain medicines in dealing with pain, which gave them more autonomy in the management of that pain with their patients. After the passage of the Death with Dignity Act, there was a lower-than-expected number of patients requesting lethal drugs. This may due to these improvements in the quality of pain management. (Campbell 2007).
The number of patients asking for physician-assisted suicide
A 1-year study determined patients still want the right to die on their own terms.
- 12% of physicians received one or more requests for physician-assisted suicide
- 4% received one or more requests for euthanasia
These physicians provided 207 case descriptions. The top three diagnoses associated with requests were:
- Cancer
- Neurological disease
- AIDS
The patient concerns most often perceived by physicians were worries about loss of control, being a burden, being dependent on others for personal care, and loss of dignity—all non-physical concerns. Physicians provided assistance more often to patients with physical symptoms, and physicians infrequently sought advice from colleagues. Of 156 patients who requested physician-assisted suicide:
- 38 (24%) received prescriptions
- 21 of these died as a result
The question of how to ensure quality in the evaluation of patient requests for physician-assisted death is raised, since this practice was illegal in during the time the study took place, thus resulting in clandestine prescriptions and a lack of consultation with colleagues (Back, 1996).
The most common reason patients seek to end their lives is not pain, but a loss of dignity.
Chronic illness patients and the elderly are often described as a compassion fatigue on caregivers such as nurses and hospice workers. This causes the patient to regret their illness and choose not to be a burden. Whether it stems from the emotional discomfort of being a burden on one’s family, or from more physical means—severe body wasting, intractable vomiting, urinary and bowel incontinence, immobility. The loss of autonomy and function, creating total dependence and a constant feeling of sickness are recognized as more important than pain in the desire for hastened death.
These things that make people feel as if they are no longer a part of the world are the main causes for unrelieved misery and desperation. Life is a precious gift, and no sane person wants to part with it. But there are some circumstances where life loses its value. This is the crux of the argument. A great many people believe that a competent person who has thoughtfully considered his or her own situation and finds that unrelieved suffering outweighs the value of continued life shouldn't have to starve to death or find other drastic and violent solutions when more merciful means exist.
Physicians get caught in the cross hairs on this issue because it is mainly a moral one, and those doctors who fulfill what they perceive to be their humane responsibilities to their patients are forced by legislative prohibition into covert actions, constantly working under the threat of incarceration. (Rogatz 2001)
Sufferers of depression
However, there are others that argue that patients who seek out physician-assisted suicide are merely people who suffer from chronic depression, and these sufferers should be treated with non-lethal means:
Patients themselves say that the primary motive is not to escape physical pain but psychological distress; the main drivers are depression, hopelessness and fear of loss of autonomy and control.
Dutch researchers, for a report published in 2005, followed 138 terminally ill cancer patients and found that depressed patients were four times more likely to request euthanasia or physician-assisted suicide. Nearly half of those who requested euthanasia were depressed.
In this light, physician-assisted suicide looks less like a good death in the face of unremitting pain and more like plain old suicide. (Emanuel 2012)
Beyond the examination of whether or not a moral imperative exists to deny physician-assisted suicide, the way assisted suicide is practiced is troubling. One of the main points of controversy in the Death with Dignity law is that there is now monitoring or control once the prescription for lethal drugs is written. Physicians are not required to be present when the drugs are taken. In 2005, for example, physicians were present a mere 23% of the time.
No one knows what happens to lethal agents that are not used by patients who originally request them, though Oregon’s reports make it clear that some patients died of other causes. The drugs could be stored over time in private homes or workplaces, with no oversight to protect public safety (Golden 2010). There is a terrifying lack of control here when it comes to these supposedly “controlled substances.” One wonders why the law was written in such as way as to allow suicidal patients who suffer from other forms of mental illness unfettered access to lethal medication. Perhaps it is a way to dodge impassioned anger and protests since it removes location—and thus an area or place to symbolize—from the act.
An excerpt from the Death with Dignity law shows a certain care in attempting to respect the personal moralistic choices of the physicians who carry out the request:
"No professional organization or association, or health care provider, may subject a person to censure, discipline, suspension, loss of license, loss of privileges, loss of membership or other penalty for participating or refusing to participate in good faith compliance with ORS 127.800 to 127.897." (Oregon.gov 1997)
And here is a passage that attempts to protect the rights of the dying so that there is no question of coercion or enforcement:
"NOTE: One witness shall not be a relative (by blood, marriage or adoption) of the person signing this request, shall not be entitled to any portion of the person's estate upon death and shall not own, operate or be employed at a health care facility where the person is a patient or resident. If the patient is an inpatient at a health care facility, one of the witnesses shall be an individual designated by the facility." (Oregon.gov 1997)
But the law, despite its good intentions, does not address the aforementioned dispersal of lethal substances, nor the issue of treating despressives versus killing them.
Terminal illness and healthcare connections to assisted suicide
In 2008, Linda Marker reports of an insidious way the outward intentions of this law are twisted to abuse sufferers of terminal illnesses.
64-year old Barbara Wagner was informed that her cancer, which had been in remission for two years, had returned. Her doctor gave her a prescription that would likely slow the cancer's growth and extend her life.
She was relieved by the news and also by the fact that she had universal healthcare coverage through the Oregon Health Plan. It didn't take long for her hopes to be dashed though.
Barbara Wagner was notified by letter that the Oregon Health Plan wouldn't cover her prescription, but that it would cover assisted suicide.
Marker also notes that the administering doctors are the ones who fill out the reports that describe whether or not the administering of the suicide followed the law—and we all know how well self-regulation has worked for varying industries in the past.
Also, according to American Medical News, Oregon officials in charge of issuing the reports have conceded that "there's no way to know if additional deaths went unreported."
Beyond that, the request for the lethal prescription can be phoned in. Sure, by law the patient needs a witness to sign the form, but a faxed or mailed copy is acceptable—and that completely castrates the law's safeguards set in place to protect the patient from coercion. And despite there being a required psychological evaluation before the patient’s request is approved, there are loopholes that are generously taken advantage of.
The darker side of physician-assisted suicide
According to an official 2008 report from the state of Oregon, not one patient who died after taking the lethal drugs was referred for counseling prior to being given the prescription. And then, of course, there is the unpleasantness of the next of kin notification. It is up to the patient whether or not they notify their family of their decision. While this may or may not be moralistically defensible, it is unquestioningly disturbing for those who must find out about the patient’s passing in shocking ways that they are unprepared for. (Marker 2008)
Focusing on the minutiae of the wrongheaded legislative choices and implementations surrounding this law, and other laws like it, will always be valuable because it is imperative to ensure the best possible solutions are worked out and seen applied wherever possible. But it becomes easy to flip flop onto both sides of this issue because of the hair-thin wire it balances on. The Hippocratic Oath says: “do no harm.” And human nature, when not perverted and bent, is to see living things do well.
But, as stated before, when one’s choices of wellness consist of living in extremely substandard conditions brought on by terminal illness, or ending that delicate thing called life that so many find intrinsic beauty in and seek to preserve—when one’s choices consist of only those two options, the correct way becomes obfuscated with confusion.
The US Bishops, in Living the Gospel of Life, bring up an interesting point. They write:
"Abortion and euthanasia have become preeminent threats to human dignity because they directly attack life itself, the most fundamental human good and the condition for all others… All direct attacks on innocent human life, such as abortion and euthanasia, strike at the house's foundation.
These directly and immediately violate the human person's most fundamental right -- the right to life. Neglect of these issues is the equivalent of building our house on sand. Such attacks cannot help but lull the social conscience in ways ultimately destructive of other human rights." (Pavone 2005)
Opposition by the church
Mandating an advocacy for the causation of death is simply dark. It is the absolute undoing of a person. If life is to be considered precious, and if doctors are to do no harm, would not the snuffing out of life be the biggest harm a doctor could do? This is especially relevant in the face of the fact that most requests are from patients in distress, not pain. Distress calls are usually answered, not drowned. The bishops’ view of Christian ethics is furthered with the following quote from The Pope:
"To claim the right to abortion, infanticide, and euthanasia, and to recognize that right in law, means to attribute to human freedom a perverse and evil significance: that of an absolute power over others and against others. This is the death of true freedom" (Pavone 2005).
Of course, atheists and agnostics will roll their eyes in the face of this quote, but consider this: pro assisted suicide advocates mention that doctors will no longer have to sneak around in granting requests. They also say that pain treatment has gotten much better, and that pain, for the most part, has nothing to do with assisted suicide requests. So what are the merits of having the Death with Dignity law in any form?
Father Pavone notes that Mother Teresa "assisted" many people "in dying" and "helped" many people "to die." She was present to them, assuring them that they would not die alone. She helped them find the courage to face death, the conviction that their dignity had not been lost, and the serenity borne of receiving love from people and from God. This is the legitimate meaning of death with dignity and of helping people to die. Physicians and care practitioners should work to emulate this example—and most of them do, actually.
References
Back, A. L. & Wallace, J. I. & Starks, H. E. & Pearlman, R. A.. (1996).
Physician-Assisted Suicide and Euthanasia in Washington State: Patient Requests and Physician Responses. JAMA. 275(12). Retrieved from: http://jama.jamanetwork.com/article.aspx?articleid=399087
Campbell, C. S.. (2008) Ten Years of “Death With Dignity”. The New Atlantis. No. 22. Retrieved from: http://www.thenewatlantis.com/publications/ten-years-of-death-with-dignity
Darr, K.. (2007). Physician-Assisted Suicide: Legal and Ethical Considerations. Journal of Health Law. Volume 40(No. 1). Retrieved from http://www.healthlawyers.org/Publications/Journal/Documents/Vol%2040%20Issue%201/Physician-Assisted%20Suicide-%20Legal%20and%20Ethical%20Considerations.pdf
Emanuel, E. J. (2012). Four Myths About Doctor-Assisted Suicide. The New York Times. Retrieved from: http://opinionator.blogs.nytimes.com/2012/10/27/four-myths-about-doctor-assisted-suicide/
Golden, M. & Zoanni. T. (2010). Killing Us Softly: The Dangers of Legalizing Assisted Suicide. Disability and Health Journal. 3(16-30). Retrieved from: http://dredf.org/PIIS1.pdf
Marker, R. L. (2008). Oregon’s Suidical Approach to Health Care. American Thinker. Retrieved from: http://www.americanthinker.com/2008/09/oregons_suicidal_approach_to_h.html
Oregon.gov. (1997). Oregon Revised Statute. Retrieved from: http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Pages/ors.aspx
O’Reilly, K. B.. (2012). Family Physician who Supported Assisted Suicide Dies with Doctor’s Aid. American Medical News. Retrieved from http://www.ama-assn.org/amednews/2012/03/19/prse0323.htm
Pavone, Fr. F. (2005). Reflections on Euthanasia and Assisted Suicide. Priests For Life. Retrieved from: http://www.priestsforlife.org/euthanasia/euthanasiaqanda.htm
Rogatz, P.. (2001). The Virtues of Physician-Assisted Suicide. The Humanist. Retrieved from: http://www.thehumanist.org/humanist/articles/rogatz.htm