Starting in the 21st century an intense debate began to arise with respect to the determination of death. Despite legal and ethical consensus that death may be decided by either neurological criteria or traditional cardio-pulmonary criteria. Physician-Assisted Suicide has been one of the most complex, emotionally charged, and controversial issues in the healthcare arena. The question of whether terminally ill patients are entitled to a physician’s aid to end their suffering has been met with controversy on both fronts. Questions such as does a person have an inherent right to autonomy and free thinking, when does the welfare of the individual supersede their own judgment or wishes, when is it permissible and when is it not, to the more religious moral and existential questions. Research studies published in multiple medical journals have confirmed, a small percentage of healthcare professionals, including physicians, that have admitted to having hastened a patient’s death. Societies around the globe, are deeply divided on the question of whether PAD may be legal, and if so to what degree. Recently published surveys show two-thirds of the United States population approve of PAD as a choice for terminally ill patients. Furthermore, there has been consistent evidence of secret Physician-Assisted deaths being done in countries where is it prohibited and illegal. The Hippocratic Oath of do no harm, promote beneficence, and respect individual autonomy is taken very seriously by most persons in the medical profession. Moreover, the Hippocratic Oath does not explicitly state but does suggest, Physician-Assisted death lies outside the prevue of a physician’s professional responsibilities; and as such, leaves no legal obligation to honor such request from patients. In the 21st century, however, the world has seen a much-needed cultural shift and stance on the issue of Physician-Assisted suicide. Increasingly, more Americans have begun to take interest in end-of-life measures and contemplate those crucial decisions, for example, what it means to have a good death. The Hastings Center Report Essays Has Physician-Assisted Death Become the Good Death by Franklin G. Miller, Physician-Assisted Death by Timothy E. Quill ; Bernard Sussman, Physician-Assisted Death in the United States: Are the Existing Last Resorts Enough by Timothy Quill, and Physician-Assisted Suicide: A Conservative Critique of Intervention by Daniel Lee tackle the hot-button issue all from different lenses and perspectives. All four essays have one common theme that leaves one puzzled, one cannot say definitively what would or should be in the best interest of an individual who is terminally ill unless put in the same position. The preceding essay I will tackle the issue of Physician-Assisted suicide from an unbiased analytical perspective using the scholarly essays as a reference point to evaluate all sides, pulling information from other sources to further delineate my position. In presenting the facts as they are, including the moral and religious dissensions as I see them, my hope is to present an argument for Physician-Assisted death as an individual’s rights issue, not one for the courts or church to decide.
To begin an educated discussion on the issue of Physician-Assisted suicide, one needs to understand what is it. PAS is described as the voluntary termination of one’s own life by the administration of a lethal substance with the direct or indirect aid of a physician. In the United States, and in most jurisdictions within the United States PAD is prohibited with specific statutory provisions or judicial application of more general statutes. Pain and suffering though complex problems are prima facie treatable. One must ask, however, to what extent does palliative and hospice care give relief from pain and suffering. An argument could be made, the amount of pain and suffering one can endure is subjective and different from person to person. Moreover, what does one do as a physician or family member when palliative care no longer works? For example, consider a patient with advanced bladder cancer and is nearing death. This patient must make tradeoffs between adequate pain management and sedation, he or she reaches a point when just being out of pain is the goal. When do last resort options become acceptable? How much pain is too much pain? This I believe is the million-dollar question plagued by the medical professionals and the community. Physician-assisted suicide and Death with Dignity laws have tried to address such issues by allowing terminally ill patients to hasten an inevitable and unavoidable death. The United States Supreme Court cases Washington v Glucksberg and Quill v Vacco challenged the constitutionality of the prohibitions on Physician-assisted suicide. Although the Federal courts found no constitutionally-based right to PAD, it did suggest that such matters should be decided in the laboratory of the states. Society must, therefore, decide when Physician-Assisted Suicide is and is not ethical and permissible, as the issues of moral and legal permissibility are closely linked. Those in favor of Physician-assisted suicide have cited as an argument, the Principle of Double Effect or passive euthanasia, which places a great deal of respect for individual autonomy, and a patient’s right to refuse life-saving equipment, or if already connected to such machines having them withdrawn. The PDE does not, however, allow a physician to give an individual who wishes to die a medication that would directly and knowingly cause their death. For example, a patient who wants to die may be given an injection of morphine to alleviate pain with the foreseeable result that they will die. The key, to the PDE in this example, is that the physician does not intend to cause the death of the patient. This could be counter balanced with active euthanasia, which describes a person who wishes to end their life, and who is given a medication to alleviate pain with the intended result that they will die. In this example, it is both immoral and illegal because it is considered direct Physician-Assisted death. Supporters of the PAS argument, additionally, hold that by recognizing the rights of competent people to choose the timing and manner of their death, when faced with terminal illness by default allows for a death with dignity and should be honored. Those who are against Physician-assisted suicide may argue, Physician-Assisted death can never be morally and ethical as it contradicts the traditional duty of the physician to preserve life and to do no harm. Which, coincidentally, coincides with the Hippocratic Oath taken by all medical professional and inherently understood by most traditional religious beliefs. Furthermore, critics of the right to die argument assert, that PAS if legalized may lead to potential abuses as social forces would condone the practice. Lee for example, in his essay, argues in favor of medical paternalism, that we always ought to intervene to prevent self-destructive behavior. Critics contend, that clear compromises like terminal sedation are both repugnant and can be abused, since full formal consent may not be sought. They also argue, on the grounds of equity, saying that it is unfair that patients who depend on dialysis or a respirator can achieve a comparatively easy death when they choose, by simply ending life-sustaining supports. Which in some states like Washington, Oregon, Montana, and Vermont is fully legal under certain circumstances. What’s more, how can it seem fair, when patients who are not dependent on life-supports are not able to choose when they die but must wait until the inevitable end. While these arguments continue, increasingly the terminally ill cry out in agony for the right to end their suffering. If, however, proponents and critics alike, could work together, and collectively adopt a compromised point of view this may allow for a more narrowed focus on improving pain control, accelerating research, and broadening the education of physicians.
Issues of end-of-life treatments, refusal, and withdrawal of some forms of medical treatment at the end-of-life may be the least discussed topic with patients, doctors, and families, yet, may be the most important discussion needed to be had. This may be because in the 21st century when an individual is diagnosed with a terminal illness, current practices by physicians and hospitals is to initially resist giving such treatments. A formula known as the QALY was devised by health care economist to quantify the actual value of person’s life, weighted against the number of resources it would cost to keep an individual alive and pain-free. Furthermore, this formula gave physicians and hospitals, a reference point for setting priorities to certain patients and further delineated who should and should not receive costly treatments. However, in certain instances standard health insurance contracts, as well as Medicare and Medicaid policies, give payers the right to refuse to cover such treatments considered not medically necessary. As a result, patients may lack the resources to pay for such end-of-life measures. Which then leaves health care providers and physicians in a difficult position of either treating without getting paid or refuse care because of the inability to pay. Even still, many health care providers acquiesce in the face of family or political pressures. This difficult balancing act is unlikely to change, unless one, proponents and opponents alike, can agree collectively on issues of end-of-life care and Physician-Assisted death, and two this consensus should be embodied through legislation, that sets forth, medical treatments that will be paid for by private and government health insurance.
According to the American Institute of Medicine, most Americans do not have proper access to long-term palliative care and unfortunately a third die in pain that could have been prevented. With the advancement in medical technology, developments in neuroscience over the past century, coupled with the understanding of pain control, the process of dying has been complicated. And therefore, a movement has begun to push state-of-the-art palliative care as the standard of care for any end of life suffering. More importantly, these advances in medical technology and treatments have given ways to save patients’ lives. With many welcoming these advancements in pain control, there are those who argue, current laws and policies constrict the freedom of a dying person from choosing the time and manner that they wish to die. In the 21st century no longer can a patient or their family members assume that his or her physician has their best medical interests at heart. As today, many physicians are being urged, to consider the cost to society of a patient’s care, and judge whether a patient is worthy of such expense. As a result, many unlucky patients, and their families, who are seeking comfort, authentic compassion, and informed consent at the end of life are left feeling hopeless and lost. It is therefore important, one does not forget these patients and their families who themselves have a stake in the Physician-Assisted suicide debate. It is these individuals and their loved ones whose lives hang in the balance. When an individual is told that an illness is terminal, many questions begin to appear and answers to these questions come, not with the never-ending doctor’s appointments, treatments or tests that consume the individual and their family members but in the comfort of solitude. final life questions, have a very personal and spiritual nature.
A small proportion of Americans have written advance directives, such as living wills, and medical powers of attorney. Their usefulness however, has long been questioned by the medical professionals who must draw guidance from them. Critics have argued, advance directives tend to be either too general or too specific to shed light on, what a patient would, or would not want in the event they can no longer make those decisions for themselves. Furthermore, studies show that close family members do not always know or have correct knowledge of what a patient would want. The best directives seem to be those that appoint a health care proxy, but even their effectiveness is open to question. With that said, despite their limitations, it is better to have an advance directive than not to have one as medical revolutions have changed the experience of death.
In recent years, final life questions have demanded society reinvestigate its position on end-of-life measures, and increase the debate about the morality and permissibility of PAD. In doing so, society must prepare itself, to understand both sides of the debate. A crucial point must be acknowledged, for the debate to traverse in a positive fashion. Cultures and moral beliefs differ from geographic area to geographic area. With that said, the question then arises to what extent is this moral or immoral. Physician-assisted suicide, on the one hand, is considered unethical by many faith traditions who adhere to a stricter moral understanding of life’s final journey. Specifically, most religious traditions consider PAS immoral and unethical, as it directly aids a patient in committing suicide and goes against Gods teachings and plan for humankind. There are exceptions, however, to this general rule, for example, Catholic Health Care ethics follow the natural law theory which holds that when the burden of life-sustaining extraordinary care such as a ventilator is greater than the benefit it provides, such care may be withdrawn (Hunnell, 2012). These actions are not seen as causing the death of the patient but allowing the patient to die from his or her underlying illness. The American Baptist and Southern Baptist Convention differ in their points of view about aided dying. The American Baptist, have adopted an advocacy policy, that calls for increased emphasis on the caring or palliative goals of medicine which preserve the dignity and minimize the suffering of the individual and respect personal choice for the end of life care. The Southern Baptist, however, view end-of-life choices violates the sanctity of human life and therefore preservation should be sought at all cost. Modern medical technology, however, not only has found a way to prolong life but has opened the door and demanded that faith leaders actively reconsider their beliefs. As leaders of faith lend their voices to the Physician-Assisted suicide debate, they must also find ways to explore and express how morality and religious views inform end-of-life care.
Justice demands that each person is treated rightly as they deserve according to what is owed to them or due to them. The concepts of justice are closely linked to normative ethics such as human rights and fairness. In clinical practice however, these decisions are made daily and as such demand the strictest of standards. Medical futility comes into place at what point does one conclude that the individual’s life is better off alive or dead. What many doctors do not realize is the importance of the process of decision making. Without giving enough weight that the clinical decisions are final and do not consider spiritual, cultural needs. Arguments for and against medically assisted death no longer center on just the ethics and the morality of suicide. Instead, the argument should shift to how much pain a patient should be expected to endure before drastic end-of-life measures may be taken. Moreover, one must ask how far God’s love reaches into the midst of suffering.
To conclude, I read a very lengthy New York Times article, which follows John Shields, who was diagnosed with a hereditary terminal form of amyloidosis. The article follows Mr. Shields and his very public journey to a Physician-Assisted suicide. Mr. Shields stressed the importance of having control over the terms of his death. Expressing that it made him feel empowered over the disease rather than crippled by it. Mr. Shields further, believed that dying openly and without fear could be his most meaningful legacy. That statement alone, I feel resonates with most Americans and persons around the globe, who suffer from terminal illness. I believe as they do it should be about choice and giving full informed consent, laying on the cards on the table and allowing the patient and the family an opportunity to make the decision about what is best for them. Finally, where does one draw the line in the sand, when a family member is diagnosed with a terminal ill disease or your son or daughter is diagnosed with a terminal hereditary disease? What does one do when the person they carry in their heart can no longer recognize their face or their touch.
Annotated Bibliography
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