Physician Assisted Suicide

Physician Assisted Suicide Summary Debate of whether physician-assisted suicide, PAS, should be made legal or it should be banned has become very hot in the last few years. Relieving the pain that the patient, who is deemed to be on the verge of dying, goes through is the main reason provided for the legalization of the PAS. Physician-assisted dying (PAD) has been a more preferable term since it is considered that the patient is conscious when seeking this service. Otherwise, other similar acts such as euthanasia are considered illegal in general. Legalization of PAD has only been done in a few states i.e. Oregon and Washington State while a few others are considering having such a law.

Doctors are caught in the dilemma of heeding to their Hippocratic Oath and the wish of the client. Some view that the autonomy to end life should not be left at the hands of the physicians.

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Whether legal or illegal, opponents of PAS view this act as outright killing, which is not acceptable. It is argued that states where the act is illegal, PAS is usually conducted underground hence legalizing it would allow for it be done in more dignified manner. The law must, however, be very clear and strict to avoid the "slippery slope". Regardless of which side of the debate one is in, it has become clear that physician-assisted dying is gaining more popularity among Americans. It is expected that more states will enact laws to regulate PAD. Nevertheless, the concerns raised by opponents of PAD must be considered while crafting such laws.

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Physician-Assisted Suicide Introduction Over the last few years the issue of physician-assisted suicide and whether or not it should be legalized has been debated in all levels of legislation in the country. Many have gone to the courts in an effort to seek a constitutional interpretation on what the constitutional stand is on the matter. But what exactly is physician-assisted suicide? Physician-assisted suicide is defined as the practice of doctors or any other medical practitioners giving patients who are mentally sound and terminally ill medical doses whose intention is to terminate the patient’s life with complete knowledge and agreement of the patient. This act is also known by another common widely used acronym, PAD which stands for physician aid-in-dying. This term was used more often after the enactment of the “Oregon Death with Dignity Act, 1996.” However, many people who are against this act do not see this act as “aiding in death” but rather as plain murder, hence the preference to refer to it as suicide (Schneider, 2000).

Similar Practices to Physician-assisted Suicide The physicians who support this act argue that although they are taking the life of another human being prematurely, they are actually helping to relieve the unbearable pain that terminal patient’s face. Therefore these practitioners argue that suicidal patients are not considered to be sane and have compromised decision making hence doctors and other health workers are ethically in order in holding the patient against their will and can even give them compulsory psychiatric treatment (Marcia, 2003). There is also a public misconception when it comes to use of the terms PAD and euthanasia. Although both involve the ending of a life prematurely, the difference is in how the lethal dose is taken. In PAD, the patient has the option of when he or she can ingest the drugs after the practitioner has given them the medicine. In most cases also, the

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person requiring the PAD is conscious. Euthanasia is considered in all states to be illegal because it is carried out by third parties who administer the drugs on behalf of the patient. In most cases the patient is not conscious and cannot make a sound decision on their own and therefore it is the party giving the medication who effectively decides whether or not to end the life of the patient.

Sometimes perfectly sane individuals may refuse to get treatment for their ailments even when they clearly need it in order to live. Patients may do these for various reasons among them that they may not want to drag their families into financial turmoil just so that they may access treatment for a condition that may be incurable. There are no requirements by law for doctors to force treatment to the patients in these cases (Marker & Hamlon, 2010). There is also the situation where a patient suffering from a terminal illness may choose to ingest pain medication to deal with the nerve-wrecking pain they are experiencing despite the risk of suffering the side effects. For instance, a patient suffering from lung cancer may choose to take medication that has the side effect of heart attack. In case they succumb to the heart attack, their usage of the drug can be justified even before the law because their main purpose in using the drug was to combat the lung cancer. Therefore the hastened death is acceptable collateral damage.

Another controversial medical practice that is closely associated with physician-aidedsuicide is palliative sedation. This practice involves terminal patients taking very heavy medication until they are unconscious. They do this so as to deal with unsolvable pain and unexplainable pain that conventional medication cannot deal with. During their sedation, doctors cannot use respirators, antibiotics and CPR. Thus at times the clinical management of pain using these means can be legally used. Hence when a patient dies during the treatment, the death is legally justifiably (Marcia, 2003).

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The ethical question of PAD The ethical question has been the major stumbling block both for both patients who want to access PADs and physicians willing to give patients these alternatives. It is no wonder that a number of states have sought to have legal policies enacted that clearly outline whether or not these physician-aided suicides (PAS) or even physician aid-in-dying (PAD) options should be permitted in the first place. In recent years, Washington State and the state of Oregon have enacted laws that legalize these practices; also the state of Montana has had a very liberal view on the matter. The laws aptly dubbed “Dignity with death acts” seek to regulate the practice to be within certain “acceptable” limits. Other states such as that of Massachusetts are also considering the introduction of similar laws (Rakowsky, 2011).

The belief that the practice is unethical comes from the argument that medical practitioners believe in the sanctity of life and usually take oaths to the same effect. Thus many argue that it is hypocritical for the very doctors and physicians to openly aide in the ending of any life, be it legally or otherwise. The result of this has been that many frown at those doctors who support PADs and PAS. But with all these ethical questions that have been raised, very few people especially those against the practice have so much taken the patient’s own consideration to mind.

The argument for supporting these practices is that it is indeed ethically permissible (Marcia, 2003). To proponents of PADs is that it becomes ethical if a patient chooses to avoid the unbearable pain and sufferings associated with terminal illness especially as death looms even closer. The physician is bound by the same ethics to alleviate that very pain and suffering that the patient is undergoing. Thus in aiding the death of the individual, the physician is in effect helping the patient and so his or her actions then become justifiable. However, the above

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argument is seen by opponents to the practice as a way of coloring the scope wide and believe that a doctor either aids in protecting life or helps in ending it and that there are no two ways about the matter. There should in effect, as regards life, not be any grey areas; instead just black and white.

Arguments in favor of physician aid-in-dying, PAD Among the arguments put forward that serve to make PAS ethically justifiable is the respect by the physician of the autonomy of the patients. It should be a personal decision when it comes to a person’s circumstances and time of death and as long as people are deemed to be competent before the eyes of the law, then the decision should indeed be up to them. Justice is also argued along these very lines; it is equivalent to denying a suffering patient their right to reject treatment that may prolong their inevitable deaths. It is therefore just to allow the suffering patients access to assisted death so as to hasten death.

Compassion is another reason cited (Marcia, 2003). Pain associated with terminal diseases is known to lay immeasurable suffering on the patient. With time they end up experiencing social, psychological and physical burdens resulting from loss of self control and independence that heavily weigh down on the patient. These results in heavy loss in dignity and therefore availing a PAD may be the only way left to assist them. PAD issues usually come down to state interests facing off against individual liberties; the state is seen as being hypocritical by arguing for preservation of life but generally want to look away when it comes to terminal illnesses. Therefore in order to guarantee for the wants of the patients, it is imperative that patient individual liberties take priority. Lastly, whether it can be proven legally or not, it has been argued that the practice of PAD has been going on in secret for a while. Therefore to

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safeguard the interests of both doctors and patients, legislation should be provided in order to make available better quality care for those who opt for PADs. Arguments against physician aid-in-dying, PAD There exists a very huge and vocal multitude of individuals, mostly those with very strong religious beliefs, who argue that the practice is not at all ethical and should not be allowed in the society. They believe that life is sacred and its sanctity should be preserved at all costs, hence the reason this lot is opposed to all ways of ending life including euthanasia, the death penalty, suicide and even PAD which they view as loosing respect for life’s sanctity. The other strong argument is that PAD is a result of plain killing by supporting the death of the individual medically and hence should not be justifiable. The same group, however, sees that the case of patients refusing treatment as justifiable since refusal of treatment is a valid choice available to the patient. Many are of the opinion that legalizing of PADs could be abused by various individuals, especially by the poor who may be lacking the finances to access better health care, to end up choosing assisted death for lack of other options. It would be difficult to stop health insurance providers and relatives of patients cutting costs by pushing PAD suggestions to the patients via coercion.

Due to the doctors’ code of ethics which had traditionally opposed any form of taking life, many opponents argue that the inclusion of PADs should not be used to compromise cherished traditions and ideals. As a result most of the major medical societies in the country such as the AMA are opposed to associating PAD as a medical practice because they fear tarnishing the public image and integrity of their beloved medical profession. Finally, there is also the fear that a patient may choose PAD after the rare but very probable possibility of a

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misdiagnosis. Therefore they argue that the state should safeguard against such possibilities by not legalizing the practice.

An example of PAD regulation: Oregon State law When on 27th October 1997 a legal notice was passed that allowed terminal patients the medical option to access physician-aided-suicide, medical physicians and proponents of the idea heralded this landmark ruling as a step in the right direction towards making the terminally sick a little bit more comfortable during their final moments on earth. The law was dubbed as the “Oregon Death with Dignity Act” (Eugene et al, 1999). What this law did in a nutshell was to give the Oregon Health Division, OHD, and the power to check for compliance to the new law by conducting statistical reports annually after collecting the necessary data about all the players legally participating or willing to undertake in the physician–aided-suicide, PAS. In a bid to understand the impact of the new law, a study for example about an identical case of patients would be conducted in order to see how the average Oregonian who is terminally ill, given the choice would take PAD and also others who despite the same turmoil would have opted not to apply for the option.

The act became law when it was put through in a referendum and those supporting it carried the day with a narrow majority vote of 51% to 49% in favor back in November 1994. The operation of the law was however not immediate and took nearly 3 years as a series of legal injunctions were filled by many disgruntled Oregonians. Such were the number of legal suits filled that petitioners even went to the Supreme Court of America. It was not until the 27th of October in 1997 when the 9th circuit Courts of Appeal finally allowed the law to come into effect.

On November of the same year, a Measure 51 was approved under the state law dubbed the “Oregon House Bill 2954” and was included in the ballot for the general election for a vote.

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When the results were announced, proponents for the act carried the day with just slightly over 60% of the cast vote on the day.

What this law does is that it gives terminally ill residents of the state of Oregon the legal right to access medication, and the lethal one at that, from their medical practitioners for purposes of self-administration. The law however does not oblige any doctors or health centers to comply with the Act. The jargon used by the law for this act is “death with dignity” as it is considered that if the patient strictly applies the law when taking his or her own life, then it is and should not, and rightly so, be referred to as suicide. In order to stop euthanasia, which the act still considers to be illegal and amounting to murder, the law requires that a terminal patient must apply for the lethal dosage personally by filling in a request form in order for the state to gauge whether or not the applicant meets the legal requirements for PAD. The requirements for the “service” are that: The patient must be an adult above 18 years old, reside in Oregon, to psychologically normal and in a position to make his or her own decisions as regards health care issues, and lastly should be a terminally ill individual and close to death by doctors prediction, by six months.

The law however does not end there as it also requires that lethal medicine should only be obtained from licensed medical practitioners. Before getting the drugs, verbal requests numbering two must be made to the doctor 15 days a part, followed by the handing over of written requests. The doctor must then ascertain if the patient’s diagnosis is correct. The prescribing physician is then by law required to make other alternatives known to the patient (Schneider, 2000). After having confirmed that the patient is indeed of sound mental judgement, the physician can then start the necessary paper work. Finally before handing over the medication the physician, although not required, must request the patient to notify family and

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friends of their decision. To ensure that criminal proceedings are not preferred against the physicians, they are required by the state to give the names of their medication recipients to the Oregon Health Department (OHD). Given that most of these patients do eventually die within the 6 months predicted by their doctor, some ultimately end up choosing not to take the medication or even do take them but end up dying from under-lying or opportunistic infections that may arise as side effects.

In order for the OHD to ensure complete adherence to the law, they have to counter check the physicians’ files of each patients case, and in addition to this confirm in the death certificate of the patient whether indeed it was the lethal drug that caused the death. In the case of any doubts and anomalies surrounding the death, the OHD may order an autopsy just to be sure of the cause of death. Statistics have shown that PADs ever since their legal acceptance in Oregon by 2004 accounted for just under a single death in every 1000 reported in the state. In 1998 the number of deaths resulting from physician aid-in-dying was 16, in 1999 it rose to 27 and then it was 21,21, 42 and then finally 37 deaths for the years 2000, 2001, 2002, 2003 and 2004 respectively (Dahl & Levy, 2005).

Increasing popularity of PAD The enactment of PAD laws in Oregon, Washington and Montana has triggered other states within the United States of America to draft legislations of their own to the same effect to introduce the practice. The state of Massachusetts was among the latest entrants, the state Attorney General Martha Coakley having already certified an initiative for a ballot to be held by November 2012. Proponents were given till 7th December 2011 to gather 68,911 signatures of support in order for the proposal to be subjected to a State ballot (Rakowski, 2011). During a medical ethics forum in Boston, proponents expressed the need for legislation by lamenting why

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in this day and age it was still illegal for doctors to offer PAD to sane patients who had zero chance of making any recovery. Their main motivation for supporting the proposal for most was that based on other states, particularly Oregon, the predicted horrors and fears of allowing for PAD that had been on numerous occasions quoted by opponents had not materialized. The argument was that those whom the law would most adversely affect would be mostly the minorities and the poverty stricken citizens. Evidence from the Oregon Department of Human Services, however, had showed that the huge majority of patients seeking the service were patients who were actually highly educated, rich and with good health covers (Dahl & Levy, 2005).

Conclusion From all the arguments that have been raised over the years concerning PAD, the one thing that comes out clearly is that there is indeed a need for real solutions. There is no denying that for patients suffering from terminal conditions and illnesses, they usually do face an uphill task in managing their pain and suffering. It is for these reasons that several states are now looking into legalizing PAD for those who might need it. The fear with legalizing these PADs is that in places that the option is available, patients who end up not choosing it end up feeling responsible and guilty for their suffering and pain.

The issue is no longer one about morality; that bridge was crossed the moment Washington, Oregon and Montana states legalized physician-assisted suicide through their respective “Death with Dignity Act” laws. It is now a political issue whereby proposed legislation is subjected to a plebiscite and the side that carries the day has its way. The fear by many opponents of the PAD issue is that the politicizing of the issue has resulted in widespread panic and that in a referendum the laws would end up getting the necessary support as citizens

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have a mortal fear of pain and would go to any length to avoid it in the future, including accepting laws that compromise their religious and moral beliefs. Opponents of aided deaths have however continued to hold on to their argument that the poor would be the greatest affected and that aided death should not just easily result in changes in traditional medical ethics and many other states rushing to adopting similar laws. Instead, the debate should continue at length to ensure that all possible angles and scenarios are clearly outlined and hammered out for the laws to function as intended if and when the United States of America as a whole decides to make it a universal federal law.

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Dahl, E. & Levy, N. (2005). The case for physician assisted suicide: how can it possibly be proven? Journal of Medical Ethics, 32(6), 335-338.

Eugene, A., Hedberg, K., Higginson, G. K. & Fleming, D. W. (1999). Oregon's Death with Dignity Act: The first years experience. Oregon Health Division. Center for Disease Prevention and Epidemiology.

Marcia, C. (2003). Physician-assisted suicide. Gastroenterology Nursing, 26(2), 55-59.

Marker, R. L. and Hamlon, K. (2010). Euthanasia and assisted suicide: Frequently asked questions: Patients Rights Council. Retrieved 26 April 2012 from http://www.patientsrightscouncil.org/site/frequently-asked-questions/ Rakowsky, J. (2011, December 11). When to help a patient die. Harvard Gazette. Retrieved 26 April 2012 from http://news.harvard.edu/gazette/story/2011/12/when-to-help-a-patientdie/ Schneider, C. E. (2000). Law at the end of life: The Supreme Court and assisted suicide. Ann Arbor, MI: University of Michigan Press.