Abstract
Physician-assisted suicide is one of the most controversial topics in healthcare today. Some people consider it morally incorrect because it degrades the value of human life while others consider it better than suffering a painful death. However, the requests for assisted suicide are some of the most difficult moments for healthcare professionals. In many cases, ethical dilemmas about the power over life and death will prevent the physician from participating, but compassion and respect for the patients’ self-determination sometimes encourage physicians to discuss alternative, legal options with the patients. Some ethical frameworks and laws are against physician assisted suicide, but the code of ethics clearly states that physicians and nurses are not allowed to make decisions instead of patients. With that in mind, the patients’ right self-determination ultimately allows them to make the decision based on their moral values and context.
Physician-assisted suicide (PAS) is an action in which the physician does not participate directly in ending the patient’s life, but the physician does provide the means to commit suicide in form of information or drugs. A study by Beck, Wallace, Starks, and Pearlman (1996) revealed that 12% of physicians receive requests for assisted suicide annually while 4% of them receive requests for euthanasia. Patients who want the physicians to help them end their life usually suffer from cancer, AIDS, neurological disorders, or other incurable disorders that significantly lower quality of life and make the patients dependent on others or their death inevitable (Beck et al., 1996). Although more people respect the ability of the patients to give up life when faced with a terminal illness, the issue is still controversial because ethical viewpoints are divided on the morality of assisted suicide.
PAS creates an ethical dilemma because it is contradictory to many religious and philosophical beliefs. During the Dark Ages, beliefs that suicide was a sin were prevalent because God was the only one who could create life and take it away (New York State Task Force on Life and the Law [NYSTF], 1994), and that belief is prevalent in many social groups today. While those beliefs are not grounded in science, personal beliefs and opinions have to be respected.
Unfortunately, the problem is perplexing because it is based on subjective evaluations and decision-making while most ethical frameworks consider truth objective and refuse to make exceptions. For example, Plato refuted the idea of suicide because the individual’s desire was irrelevant in contrast with the individual’s moral value or the objective truth (NYSTF, 1994). On the other hand, social trends that started favoring individual well-being over social compliance believed individuals had the right to end their life if desired. In the contemporary world, proponents of PAS argue that all people have the right to make decisions based on their system of values. Their arguments fall under relativism because they believe in individual convictions rather than objective truth.
The main dilemma in the controversy is the value of human life and the existence of universal moral truths. According to the opponents, PAS is not murder, but it is also not ethical because it reduces the value of human life. Furthermore, when somebody participates in the suicide, they consider it a social act, so various social norms and legal rules are at stake (NYSTF, 1994). From an ethical standpoint, the rights and duties are not completely clear when it comes to PAS. On one hand, people have the right to make their own choices as free beings. On the other hand, PAS opponents claim that a physician could not be granted rights to decide between life and death (NYSTF, 1994).
In Ancient Greece, suicide was regarded as an abandonment of duty because individuals would abandon their mandated responsibilities, both divine and social. In the late 20th century, the perception of PAS started to change. According to Samuel D. Williams, ending a life at the patients request by chloroform or other anesthetics should be a duty for all medical attendants because the patients have the right to end their suffering with a quick death (Euthanasia, 1873).
In essence, the main issue is failing to determine the context of suicide. While assisting a healthy individual to commit suicide would be unethical, the debate does not consider the patients’ condition and suffering. In fact, going against the patients’ will could be considered a form of suppression. The main problem surrounding the debate on PAS is its broadening to the questions of life’s meaning and the power over death. Those questions are irrelevant and too broad. The autonomy to decide between a long dying process and a quick death should be the focus of the debate instead.
In total, there can be three parties involved in the assisted suicide process. The physician is the person who makes the decision to help the patient or deny the request for assisted suicide. While most states prohibit PAS, the physicians have the authority to consult the patients and help them seek legal alternatives. Furthermore, physicians are obligated to relieve pain and suffering in dying patients and promote their dignity during the end-of-life stages. Because physicians might experience social pressure, ethical dilemmas, or legal issues in those circumstances, they should consult their colleagues before making any decisions for advising patients.
The patient can make requests based on their experience of pain or fear from the future uncertainty. They are the most important people involved in the issue, and their decisions are considered final because physicians are not allowed to enforce treatments. However, it is important to remember that patients do not think clearly when confronted with a terminal illness or immense suffering. That is why physicians are responsible for communicating with patients and consulting them prior to assisting suicide or advising alternatives.
Finally, the patient’s family also has a certain amount of influence when the patient requests PAS. If the patients are not able to express their desires and did not leave the family any instructions on their end-of-life care, their families can be empowered to act on their behalf. However, the patients’ request always supersedes their request if it was given in a lucid state of mind. The involvement of the family in the assisted suicide process can cause a conflict of interests, so their decision-making can be biased.
Because of its controversy and possible conflicts of interest, various laws were created to prevent physicians from assisting patients in committing suicide. Jack Kevorkian publicized it by helping approximately 44 patients take their lives, but the charges against him were dropped because there were no laws about physician-assisted suicide during the 1990s (Angell, 1997).
According to the Supreme Court, the Constitution does not list assisted suicide as a right, so states are allowed to create their own laws and positions on PAS. Although more than two-thirds of the US public currently supports physician-assisted suicide, it is legal only in Washington, Oregon, and Montana. However, the regulations in place are rigorous to keep the requests objective and prevent conflicts of interest in the process.
The solution to the issue is not clear because there are two ways to handle it, and according to the idea that humans have the freedom to believe in what they choose, both would be correct. One course of action is to ban PAS. That would be a solution in compliance with deontological ethics. Despite the idea of autonomy, deontological ethics does not view human freedom as absolute because actions are moral only when they are incompliance with the universal moral rules (NYSTF, 1994). Therefore, it is not correct to commit suicide or assist another person to commit it.
However, relativism or utilitarianism would not agree with deontological ethics Relativism does not consider truth objective or universal, and it is not possible to observe or evaluate situations outside of their contexts. Because of those characteristics, relativism might accept PAS in certain scenarios because suicide becomes a suitable option when suffering is the only alternative. Utilitarianism would consider maximizing happiness and reducing suffering the main objective of actions, so seeking PAS would be considered a way of avoiding unnecessary suffering.
Despite the ethical and legal limitations that surround PAS, there are various legal alternatives doctors can advise to patients. One example is refusing treatment or withdrawal from treatment. Physicians are not allowed to force patients into treatment and must accept the patients’ rights to refuse treatment. The same applies to food intake. Patients can hasten the dying process by refusing food, and doctors are not allowed to force-feed people who refuse to eat. Another legal alternative is medical sedation. When the patients are approaching the final days or hours of their lives, they can request end-of-life sedation, a procedure which uses drugs to induce a state that alleviates suffering from intolerable pain.
The nursing code of ethics does not allow illegal practices, but the aforementioned solutions are acceptable. For example, nurses are obligated to act on questionable practices and protect the well-being and safety of patients. If a co-worker engages in questionable practices, nurses are required to report those colleagues and avoid any action that may be considered illegal or immoral. According to that provision, nurses should not be allowed to participate in PAS.
Another provision states that nurses should respect the dignity of their patients and the patients’ right to self-determination. According to the code of ethics, patients have both the moral and legal right to decide whether or not they will participate in the treatment, and the nurses are not allowed to enforce any type of treatment on patients if they refuse. With that in mind, it is possible to notice that PAS is acceptable in certain scenarios when nurses are required to respect the patients’ decisions to refuse treatments against medical advice. In that case, they are legally protected and the patients carry the responsibility for their own decisions.
The morality of PAS remains controversial, and the subject will be brought up continuously before any resolution can be made. PAS will certainly remain controversial because death itself is a sensitive topic, and the religious and philosophical doctrines responsible for defining suicide as an immoral act are still prevalent. Laws cannot change how people perceive morality and religious beliefs, so the only way people are going to unanimously accept PAS will be when they agree on universal moral norms and duties. Until then, every patient will have the right to refuse treatments and practice their individual moral values.
References
Angell, M. (1997). The Supreme Court and physician-assisted suicide: The ultimate right. The New England Journal of Medicine, 336(1): 50–53. doi:10.1056/NEJM199701023360108
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), 919-925. doi:10.1001/jama.1996.03530360029034
Euthanasia. (1873). Popular Science Monthly, 3, 90-96. Retrieved from http://www.biodiversitylibrary.org/item/18310#page/1/mode/1up
New York State Task Force on Life and the Law. (1994). When death is sought: Assisted suicide and euthanasia in the medical context. Retrieved from http://www.health.ny.gov/ regulations/task_force/reports_publications/when_death_is_sought/
