Ethical Dilemma of Assisted Suicide

Ethical Dilemma of Assisted Suicide

"In the care of patients with terminal illness, arguably the singular purpose should be safe, effective treatment and relief of pain and suffering," yet it is within this context that a heated debate about assisted suicide exists (Goslin 2006 p 2). Overall, the public seems to support the individual's right to choose. This has been deeply ingrained within American culture in the presence of staunch individualism. It is also present within debates exploring how to handle the end stages of life for terminally ill patients who are in great suffering. The current research shows an environment where the public supports such measures; yet, overwhelmingly, physicians tend not to show the same type of support for the practice. Ethical considerations are also a major part of the debate; with religious beliefs and morality tend to influence support as well. Essentially, assisted suicide is an issue that is very controversial, and one which will continue to spur debate for generations to come.

Assisted Suicide

Physician-assisted suicide (PAS) occurs when a terminally ill patient requests the actions of their physicians in helping them end their life prematurely, before whatever condition or illness can actually cause their death. Essentially, PAS is different from withdrawal of life support and terminal sedation because it allows the individual to have an active choice in the matter of when and where they actually die (Curlin et al. 2008).

PAS is a practice that is widely debated as a hot bed controversial issue, yet has found some support in legislation around the world. Some European countries allow for assisted suicide in extreme cases. One notable example of this is in the Netherlands, which allows for assisted suicide to end "intolerable suffering" (Hendin & Foley 2008 p 124). This statute is protected under The Dutch Euthanasia Act, which allows for the possibility of assisted suicide when individuals meet the extensive list of criteria (Buiting et al. 2009). Here, the research states that it is also "granting physicians full immunity and then surveying them with questionnaires and interviews," (Hendin & Foley 2008 p 143). This essentially part of how the practice is observed and regulated within the Dutch environment and assures that cases of assisted suicide and euthanasia were properly reported and accounted for. Such restrictions also focus on making sure physicians are responsible for taking all the necessary precautions. Similar legislative practices exist also Belgium (Buiting et al., 2009). In this country, there are stipulations which also make assisted suicide possible, under the most extreme of cases (Chambaere et al. 2011). Although technically still illegal in the UK, England has adopted legislation that has decriminalized the act of suicide with The Suicide Act in 1961 in the UK (Curtice & Field 2010). This piece of legislation states that "the act of suicide itself is not a criminal offense," (Curtice & Field 2010 p 187). It therefore allows individuals to go abroad and enter into care in another country that allows PAS practices, because of the fact that assisted suicide is still illegal in the UK itself.

The United States has also had a long history of dealing with this controversial issue. In 1997, the United States Supreme Court "ruled that there was no right to assisted suicide in the Constitution but implied that states have the right to decide for themselves whether to permit or prohibit physician-assisted suicide," (Hendin & Foley 2008 p 121)

Since the 1990s, over nineteen states have tried to legalized measures of assisted suicide (Gorsuch 2009). Many of these have proven unsuccessful, and instead, most states actually have standing bans on PAS practices for terminally ill patients. Most recently, Washington passed legislation adopting PAS practices in extreme cases in 2008 (Buiting et al. 2009). The most notable case, however, is Oregon's Death with Dignity Act (Hendin & Foley 2008). This act allows for assisted suicide under the care of physicians under very specific circumstances. Terminally ill patients who have a diagnosis of living less than six months have the right to request PAS if desired under this state statute. The act also provides the physician the capability to prescribe medication in lethal doses so that individual can make the decision on their own in terms of when and where they want to die. In fact, Oregon was the first state in the United States to pass legislation supporting patients' rights to assisted suicide. Still, there are many restrictions and specifications of the law. Two witnesses must be present to witness the request, who are not family or physicians, and there must be a second opinion of the patients' case by another physician. The entire process involves physicians, patients, and family members in crucial decisions in the end-of-life stages for terminally ill patients. According to the research, the Act focuses on "ensuring that patients are competent to make end-of-life decisions for themselves," (Hendin & Foley 2008 p 122). It also protects doctors from liability in the process. 456 patients received prescriptions that would allow them to pass, and 292 of them actually went along with the procedures for assisted suicide under Oregon State law (Hendin & Foley 2008). Yet, this has been challenged by the federal government, In fact, in 2001, then President George W. Bush signed orders refusing to allow Oregon doctors to use federally regulated medications in PAS strategies for those patients who had decided to use practices of assisted suicide.

In many cases, PAS is frowned upon because of the legal issues that revolve around it as well. Fortunately, for suffering patients, there are little consequences for their choice in asking for assistance in dying. This creates a situation where a patient is not reprimanded for asking about the possibility of PAS in his or her individual circumstances, therefore keeping the practice possible in the minds of many patients who cannot endure their suffering any longer. There are no legal ramifications for the patients who essentially are seeking assistance in their death; although, there is the potential for physicians to face legal troubles when assisting patients in their choice to die (Gorsuch 2009). Often times, physicians caught performing PAS are demonized in the press, with public trials and professional embarrassment. In this regard, physicians are often restricted by legal ramifications, but also matters of professional ethics as well. Here, the research states that "Professional ethics codes declare physician-assisted suicide to be fundamentally 'inconsistent with the physician's role as a healer,'" (Gostin 2006 p 2). Thus, many regions still inflict legal restrictions on PAS, with the potential for criminal charges. There is the example of Switzerland, which treats assisted suicide cases as unnatural deaths, therefore subject to full forensic investigations (Wagner et al. 2011).

Opinions

Physician-assisted suicide is still a very controversial matter. Essentially, it is a hotbed issue that has supporters on both sides of it. There are those within the public who support it, and those who do not. Physicians also are divided in terms of their support or opposition to the practices associated with PAS.

Overall, several studies have shown that the majority of the public is in favor for allowing assisted suicide to occur in extreme cases. The public still shows mixed feelings on the matter, but several studies have shown a majority actually supporting legislation favoring PAS practices. Seale (2009), was a UK study that found that "Most polls find a majority of the general public are in favor of allowing euthanasia, with regular church goers, nonwhites, non-UK nationals, disabled people and those with less formal education being more likely to be opposed," (Seale 2009 p 1). This study focused on the public in the UK, but still shows clear consistencies with potential public opinions here in the United States.

Yet, the opinions of physicians stand in contrast to popular public beliefs on the subject. Here, the research "suggests support for the view that greater experience of the end-of-life care results in greater opposition to medically assisting dying," (Seale 2009 p 2). In fact, Seale's 2009 study only found 31% were supportive of allowing assisted suicide in the UK (Seale 2009). Studies exploring physician's opinions here in the United States also found similar results. One study (Curlin et al. 2008) found that only 18% of American physicians supported the right for individuals to opt out with the use of assisted suicide. This study also confirmed the previous work conducted in the UK by exposing the fact that the more experience and exposure physicians have with terminally ill patients, the less likely they were to support PAS and similar measures. This is a very interesting concept, considering that common sense would assume the more terminally ill patients one would be exposed to would actually increase the support for PAS measures in order to end their suffering. However, the research clearly shows that is not the case in actual reality. The study here shows this may be because physicians often have a much different interpretation of what a "good death" is (Curlin et al. 2008). Here, the research shows that physicians believe that pain management, preparation for death, and involvement with others is what constitutes a "good death" in medical practices. This often leads a large percentage of physicians to support religious beliefs during the last stages of life, so that the patient prepares and accepts what is coming. Patients, on the other hand view a "good death" differently, seeing it as a greater individual decision capability. Another study conducted here in the United States was Craig et al. (2009) the explored specifically the beliefs and opinions of physicians in Vermont. Here, about 38% believed that PAS should be legalized, a much higher percentage than national averages. According to the findings of this study, it was the main staple of autonomy that created a situation where physicians were willing to support the legalization of PAS practices. Thus, patient autonomy and individual choice still weigh heavily in terms of evaluating physicians opinions regarding the matter.

Ethics

The ethics revolving around PAS are complicated. They focus on very different moral perspectives throughout modern medical history. Suicide itself was once an acceptable and honorable death in certain circumstances within Greek and Roman societies. It was essentially seen as the "preservation of one's honor," (Rubin 2009 p 771). However, this view of suicide has morphed into a deplorable concept in more modern Christian societies, where morality of honor was replaced with the concept that those who committed suicide are punishable by God (Rubin 2009). Religious affiliations have long impacted how people view death, and suicide as well. According to the research, "Different faiths have different perspectives on end-of-life care," (Curlin et al. 2008 p 114). Many of these religious affiliations see assisted suicide in an unethical light, because it essentially places the power over life and death within the hands of physicians and patients, and out of the hands of God or another deity. Most often, those who oppose assisted suicide practices are those with strong or conservative religious beliefs (Seale 2009).

Yet, there are those who see the lack of PAS practices as unethical as well. In this view, it is the individual choice which should be honored, therefore making the practice ethical in certain circumstances. Bans and a lack of support structure for PAS are essentially taking the autonomy out of crucial end-of-life decisions. Here, the research suggests that "The most commonly stated legal rationale for arguing that the Constitution protects people's ability to obtain assistance in ending their lives is the so-called right to die, which is grounded on either substantive due process or the right of privacy, the penumbra of the first eight amendments," (Rubin 2009 p 766). It is within this context that one can see the clear differences from euthanasia. Physician-assisted suicide relies on the choice of the individual which is the most important part of the situation. Essentially, it is "killing those who wish to die but cannot kill themselves," (Gorsuch 2009 p 6). Whereas, euthanasia tends to carry with it much less of the autonomous decision making that is associated with assisted suicide. The fact that the individuals themselves are making the decision is what is key here. Within this argument, it is acceptable for individuals to make such decisions regarding their own lives, and "this does not bother society," (Mitchell 2009 p 1086).

For those who believe in supporting the right for individuals to be able to choose assisted suicide if need be, it is unethical for a physician to disagree with that choice. Although the research shows that the majority of physicians disapprove of PAS measures, they would have to follow the best regiment of care for their patients. In cases where the patient is terminally ill and in extreme suffering, it would be unethical for a doctor to automatically dismiss requests for PAS. Here, the research suggests "that patients may have the right to discontinue care even when they have a suicidal intent to die, and doctors not only may intentionally assist such killings, but may have a duty to do so," (Gorsuch 2009 p 182). Assisted suicide practices stop unbearable suffering, which is essentially the primary duty of the physician to begin with (Wagner et al. 2011).

Many would believe that assisted suicide would have a negative impact on the family and friends of terminally ill patients. However, the research reflects the opposite. In fact, there are a number of instances where family and friends support the individual's right to choose their own fate, and when to end their own suffering. Moreover, one 2011 study (Wagner et al.) showed how treating assisted suicide cases like murders can actually have a negative impact of the survivors of the individual who had chosen death. The study recorded increased incidents of Post Traumatic Stress Disorder in family members and friends of those who choose to enact measures of assisted suicide (Wagner et al. 2011). This shows that when an assisted suicide takes place, it is actually counterproductive to follow up with a criminal investigation, which is the typical response in regions like the United States or Switzerland. Essentially, many who support a family member's decision to use PAS are only further tormented with the constant reminder of their lost loved ones during an impending investigation after death. It is within this context that supports many to believe that PAS should be legalized in extreme cases as to not only allow the individual to have a greater choice, but also to ensure that family members are not further aggravated by legal proceedings after the event if it does still occur.