Abstract
Physician –assisted suicide or euthanasia, which means terminating a person’s life, painlessly, with a ‘humane’ motive of putting an end to his suffering, has been going on for centuries. Though it is practiced widely, it is a highly debated issue and there is a lot of controversy surrounding it. In some countries, it is legalized, whereas it is still considered to be illegal in many other countries. However, today, most of the population, including the society as well as physicians, are in favor of this practice. If the benefits and harms of the practice are to be weighed, practicing euthanasia seems to be a optimal choice, is practical and rational, all provided there is no other way out for the dying individual and his physician.
Introduction
We all know physician assisted suicides (PAS) by a common term “Mercy Killing.” It means terminating a person’s life, painlessly, with a ‘humane’ motive of putting an end to his suffering. In medicine, PAS is more commonly termed as “Euthanasia” (Brogden, 2001).
Euthanasia is not a new phenomenon; in ancient days, it was practiced in countries like Greece and Rome to spare people of high social rank from prolonged pain and suffering. The Hippocratic Oath, which was written at that time, represented just a minority opinion among Greek physicians due to its stance against PAS (Brogden, 2001).
Issues in PAS
Though PAS is practiced widely, it is not legalized in many countries. The topic is highly debated and controversial. The debate and controversy surrounding PAS has been going on for long. It is considered to be a significant ethical and moral issue; some support, others do not (Norman, n.d.). What is debated even today is the moral limit of relieving a terminally ill individual of his suffering towards the end of his life, and where the responsibility of the treating physician lies (Norman, n.d.)? We all have this question in mind, particularly, when we see the populations aging and the diseases and disabilities of elderly presenting increasing challenges for the medical community as well as the individual’s family (Norman, n.d.).
Pros and Cons of PAS
Let us first have a look at why practicing PAS should be legalized!
The reason a dying patient would ask for help in ending his life may be because all is not well and he is facing some issue like illness - related poor experiences, changes in person’s sense of self, and fear of his future (Pearlman, 2005).
Illness - related experiences are plenty; it could be a feeling of weakness, tiredness, and discomfort. There may be symptoms that become unacceptable and unbearable to the patient such as dyspnea and fatigue; and as days go, such symptoms only become worse (Pearlman, 2005). The side effects of treatments and medications are an issue to many, particularly the treatments offered for cancer. Such symptoms only interfere with their overall quality of life, which goes on deteriorating day by day. Many patients also report intolerable and unbearable pain as a primary reason for wanting to end their lives (Pearlman, 2005). The terms used to describe pain by many patients are unbearable, consuming, unacceptable, or occupying etc. Some complain about the mind-altering effects of pain medications (Pearlman, 2005). Some other patients report loss of function, ranging from inability to eat, inability to socialize with friends, or inability to even use the bathroom or toilets on their own, thus necessitating to rely upon care takers for support (Pearlman, 2005). Many patients try to accommodate to functional losses as much as they can, till the losses become too great for them to handle any more (Pearlman, 2005).
Many patients express a concern on losing their personality. Their personality had defined them as certain individuals in good days of their life; and now that they have lost the personality, the personal dignity is jeopardized (Pearlman, 2005). Several patients also mention that they do not want to be remembered as ill and frail and helpless, while some others are not comfortable with the thought that someone else has to care for them and look after them. They take it to be an assault on their sense of self (Pearlman, 2005).
Some patients also fear for their future; if they live, in what condition will they live? Who will see them? Who will take care of them (Pearlman, 2005)? These are some good reasons why patients diagnosed with various diseases might not wish to live till the disease gives them a natural death, and may want to beg for death. However, the question in debate is should their physicians assist them in ending their lives?
After pain and suffering, what patients fear most is becoming a financial burden on their loved ones. Oregon is one of the few states where assisted dying is legal. Though pain and suffering are the reasons most commonly cited for PAS, in Oregon, in 66% of the cases, the reason for patients' requests was because they did not want to be a burden on their family or their care takers.
The latest NPR-Truven Health Analytics poll showed that most US citizens favored the idea of euthanasia for patients who are terminally ill and who have less than just 6 months to live (NPR, n.d.). In a survey in Canada in 1970, just 50% of Canadians said they were in favor of voluntary euthanasia, but by 2007, this number increased to 83% (Tiedemann, 2008). Physicians also held similar views. In 2003, 51% of specialists and 43% of general practitioners (GPs) supported the practice of euthanasia, (Euthanasie—sondage, 2003) while in 2009, the number jumped to 75%. The view is - shortening an intolerable life might fall within the continuum of ‘appropriate care’ (Boisvert, 2010).
Today, we have an understanding of the limits of palliative care. Recent few studies have shown that terminally ill patients are a lot concerned and tired of their suffering and pain (Heyland, 2006; Wilson, 2007). Surprisingly, in one of the studies on terminally ill cancer patients with a life expectancy of less than 6 months, 63% of them were in favor of euthanasia and 6% of them wanted it to be done as early as possible (Wilson, 2007). The surprise is that none of these patients had quoted pain as a reason; it is just that there was a marked deterioration in their physical and mental condition that deprived them of any autonomy (Wilson, 2007). The condition just stripped their life of any meaning. Therefore, the study demonstrated that even if the best possible palliative care is provided and patient is free of pain, it still cannot relieve them of their existential suffering. For such patients, management of pain does not give a meaning to their life, but what worries them often is “is it worth living, if life is reduced to death?” (Wilson, 2007)
It will not be wrong on the physician’s part to agree to the patient’s decision of dying considering the physical and mental suffering he is going through. Dr. Marcel Boisvert of McGrill University in Montreal, in his paper, rightly says that “when doctor leaves a dying patient’s bedside after spending an hour with him, he must understand that, that day the ailing patient faces 23 hours more of this kind of unbearable and intolerable existence; and he is anticipating the suffering the next day will bring” (Boisvert, 2010). Callahan D, in his research long back, argued that a physician needs to remain open to the patient’s wish because “the ‘sanctity of life’ has to be the sanctity of personhood, not merely the possession of a body” (Callahan, 1987). Providing access to euthanasia just wards off all the suffering the patient had been going through for days together. Dr. Boisvert wants to argue that we cannot impose our thoughts and beliefs on others, especially when there is a final wish of a dying person (Boisvert, 2010). Some time back, Jean-Louis Beaudoin rightly said “we can hold whatever personal opinions we have about euthanasia. Our personal opinions and feelings are primarily shaped by our moral and religious convictions” (Beaudoin, 2009). There is also scope to agree with Hubert Doucet’s opinion that he stated in his book entitled Mourir: approaches bioéthiques that “Dying with dignity, about which there has been so much debate in recent years, ought not to be conceived of as a gentle death. Rather, it ought to be conceived of as a death that respects the dying person’s personality and history” (Doucet, 1993). Thus, we know there are many who are in favor of legalizing euthanasia, and legalizing it for all the right reasons, primarily of providing a relief to the sufferer.
Taking all these points into consideration, legalizing euthanasia will do no harm to the dying person, but only help alleviate his suffering. It would be inhumane to make them watch suffer every day and make them endure the unbearable pain. The physicians should also take into consideration if the patient is suffering from an incurable disease where treatment would bring no benefit, nor improve their quality of life. The law should also take into consideration that ‘aid in death’ will be painless. It should be left up the patient to decide the value of life and death for him. Euthanasia is when the physician offers the means and medical device that aids someone to end his life by suicide (US Takes Oregon, 2004). It should be noted that the death is good in such cases since it is intended to be pain free. The physician’s role in assisting the patient to terminate his life is always with a good intention and is to always comfort the patient when hopes from further treatments have faded. When a pain - wracked patient begs for his death, his physician or other caregivers will likely pay heed to the ailing patient solely from a humanitarian instinct.
However, there are still many who are against the idea of assisting in death, for various reasons, primarily that it is considered to be ethically and morally incorrect. The debate and controversy surrounding euthanasia is because there is still a segment of society that has been against the idea of mercy killing. One argument refers way back to the Ten Commandments – “Thou shall not kill”. Killing a human being is considered to be morally abject (Keown, 2002). This argument stands very true for practicing clinicians who have taken the Hippocratic Oath, which explicitly forbids euthanasia (Keown, 2002). However, those who support the idea not to legalize it stick to very general ideas that lack reference and are not based on concrete experiences (Widdershoven, n.d.).
The Hippocratic Oath that a physician takes before beginning to start his profession as a doctor, forbids him from administering a deadly drug to his patient even when requested by the patient or simply for the noble reason of giving him a pain relief (Nova, n.d.). Though against the Hippocratic Oath, a physician feels forced to assist patients who beg for termination of life, but this should not lead to a situation wherein it becomes normal to kill people who are of no use to the society anymore (Widdershoven, n.d.)
During the past few decades, attempts were made to legalize PAS (US Takes Oregon, 2004). Oregon was the only state in US (US Takes Oregon, 2004), which legalized a form of PAS in 1997 followed by Washington and Montana (Norman, n.d.). Besides these three states of the USA, Netherlands and Belgium has passed laws permitting PAS (Norman, n.d.). In 1994, Oregon, under the Death with Dignity act, approved an initiative to enact PAS; and it became available for terminally ill patients in late 1997 (US Takes Oregon, 2004). The Washington Death with Dignity Act was approved in 2008; in Montana, it was made legal in 2009 (Norman, n.d.). Still, about forty five states have condemned PAS (Judiciary commission, 1998), whereas it is considered to be a crime in thirty six states (Eryn, 1999).
As we have read earlier, it is not only pain, but also suffering that prompts a terminally ill patient to take a decision not to live anymore. However, this can follow an argument that euthanasia does not truly address the suffering, rather just ignores it.
According to researcher Rene Leiva, one needs a little bit of humility to understand that there is mystery at the end of life that medicine does not know how to fix. Physicians just fall victims to current attempts for technological, quick-fix medical responses that have permeated our medical approach (Leiva, 2010). This also can be a valid point; therefore, taking this point into consideration, it is wise on a physician’s part to take a decision of agreeing to a patient’s last wish of death, only when there is absolutely no hope of satisfactory survival left.
For a terminally ill patient, not only death is certain, but so is physical pain and mental suffering. However, a big drawback of legalizing PAS will be that, patients will not be able to trust their doctors completely if doctors are given the rights to take their lives particularly in an environment where physicians are offered cost-saving incentives (Ardelt, 2003). Besides, it may also place undue moral and ethical burden on patient’s family and friends e.g., consider in a case where physician is absent at the time of suicide attempt and the patient has to ask for a family member’s help in the administration of lethal drug. Therefore, most religions also have condemned this act (Ardelt, 2003).
Another thing which everyone needs to think over is - Euthanasia can become a cost effective way of treating a terminally ill patient. No patient, so no cost.
In 1995, Markson described in his review the American Hospital Association’s recognition that, as many as six thousand deaths in the US per day are planned in some way or the other, either by the patients or their families or their physicians (Markson, 1995). Besides the physical pain and mental agony, there is also considerable medical cost to the patient and his family. Therefore, the decision to terminate a life can prove to be beneficial to all considering the economic costs, whereas in a decision to prolong a life, there is a direct and considerable economic cost (Chan, n.d.). Pain and suffering are considered to be negative cash flows; the benefit of PAS is to avoid the realization of negative cash flows.
Conclusion
For numerous reasons, the issue of legalization of PAS will always be in debate and will always be controversial. If there is a decision to prolong life, such decision will even impose emotional cost to both the patient and the family. Therefore, potential benefits from euthanasia appear to be greater than anything else, and the decision can be seen as a rational choice.
Considering euthanasia is optimal, provided there is a strong basis. In any case, before focusing on the individual’s right to choose a PAS, the field of medicine as well as the society should make sure that every individual has access to adequate healthcare facilities and long-term care that includes emotional, mental, physical, and spiritual care at the end of their lives.
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