Ethical issues in counseling patients considering euthanasia

Against Euthanasia

Death has always been shrouded in mystery, the constant litanies of myth, science, curiosity, magic, fear, and of course, religion. Just as myths have always wound down to the pragmatic, the real, and core accurate factual reporting - summarily losing the romantic, whimsical, and magical elements - so has the inevitability of human death.

Death is the central theme to life, vitality, order of society, and even powers - through the use of fossil fuels - our industry! When one, therefore, examines death objectively, he or she finds that death is a catalytic contract propelling the core beliefs and motivations of a group of people.

This evaluation seeks to isolate one aspect of death - euthanasia and a person's right to choose the time, place, and circumstance of their death without interference from legal, moral, religious, family, or other groups of social or punitive nature - and defend the sanctity of life in all circumstances.

The New Civil War

The right to die - with all its legal, moral, value-based, human-dignity, religious, and personal freedom issues attached - is rapidly becoming the new, internalized civil war for the entire human race. As proponents and opponents of euthanasia polarize their positions more and more definitively, the morality of the situation rises to the top of the list of 'reasonings'.

While some groups would structure suicide of terminally ill and abortion into this stew pot of emotional reactions, this paper will deal solely with the emergent nature, unethical nature, and negative social impact of euthanasia.

The word euthanasia originates from the Greek, "eu" = goodly or well, and "thanatos" = death - a good death. Until the late 19th century, the application of the word and attendant function was simply that - one who experienced a painless, quiet, and "good death."

It is important to make a clear distinction at this point; suicide - irrational, with defined planning and 'rationality', or the forced taking of another life, for any cause, is not euthanasia.

Thesis Statement

It is illegal, immoral, and unethical to take a human life, regardless the condition in which the patient finds himself or herself. With today's palliative measures, pain management technology, and medical intervention, the pain receptors in patient brains can be silenced without death.

All life is valuable; dying is a process of learning for the patient and their support system while edifying those remaining behind. To shorten that process is not for man to decide - the resulting act of euthanasia is murder, not self-defense.

Literature Supporting Thesis

It has been said that most people in North America die what may be classified a bad death, i.e., in pain, their desires concerning treatment go unheard and unaddressed, often after spending an average of 10 days or more in an intensive care unit. Following is a breakdown of reasoning for the partial legitimacy to this statement and proposed corrections to the problem, always maintaining that suicide - assisted or otherwise - is wrong.

Pain and the Medical Profession

Pain is a physical response to stimulus recorded in the brain. Numerous chemical and medical palliative treatments are available to curtail or even eliminate the receptors in the brain, which register pain. So, why do terminally ill patients suffer from any pain whatsoever?

Legal ramifications to triplicate prescription writing and the use of Schedule I and II drugs are severe and may cause excessive scrutiny by the DEA and other federal and local agencies.

Citizens, chemical use and abuse by physicians, and a growing -seemingly unending - war against such use inundate the American legal system with high rates of drug abuse and misuse. The black and white perceptions of this "war on drugs" in America today stem from this abuse and hold a hard line on misusing chemicals for recreational use. This author has no argument with this position, however the gray areas become problematic. For the terminally ill patient, there is no such issue as drug abuse. Addiction is a non-issue for these people, but the legal ramifications have never been clearly identified.

Physicians have personal abhorrence - based on personal ethics, beliefs, and medical school training - to contributing to drug dependency in their patients and often work within this set of personal guidelines. The terminally ill patient, therefore, suffers being under medicated as a result.

Medical schools spend a great deal of time and effort to teach future physicians that drugs, while a very necessary function of American medical care, are potentially dangerous to their careers and personal well-being. Addiction theory and prevention medicine is not studied nearly as intently as how to protect his or her practice from being sued, the doctor being implicated in criminal and civil lawsuits, and medical malpractice's increasing costs. As a result, the ramifications for the physician are such that the fear of overmedicating the patient, being sued by family members, and the criminal and legal issues create 'dead space' for the patient.

Some patients and their physicians are concerned about the possible side effects of pain medication, including addiction. Patients and physicians are acutely aware of the extremely addictive properties of drugs such as morphine and heroin. But what is less known is that these drugs' addictive properties are primarily seen among healthy people who are not in pain. They become addicted when they use these drugs illegally for the feeling of euphoria that they generate. If a person who is in severe pain properly uses these narcotics for the relief of pain, they do not feel euphoria; they do not become addicted; they simply have relief from intense pain.

Wide ranges of people are in need of such medication; including individuals who are suffering from advanced cancer, untreatable back pain, and limb amputations. Unfortunately, most physicians are not trained in the use of opioid therapy for the relief of intense chronic pain.

Even worse, the members of some state medical boards are also unaware of the need for this use of narcotics. When they review physicians in their jurisdiction who specialize in the relief of pain, all they see is "over subscription" of controlled substances. There is intense pressure placed on physicians to prescribe lower quantities of these narcotics, thus causing their patients to live in continuous pain.

Some boards have revoked the medical licenses of physicians specializing in this field. Each time this happens, the pain management of dozens of patients is terminated. Without narcotics, the desire for euthanasia, suicide, and other end-of-life decision-making is brought to the forefront of the patient's thinking; with narcotics, they can lead productive lives relatively free of pain.

The money trail is a factor in whom and how much care is provided. While America's free enterprise system necessitates the funding to develop new and emergent drugs and medical therapies yet the cost can be prohibitive for those needing them most.

In 1994, David E. Joranson, of the Pain Research Group, at the University of Wisconsin Medical School wrote: "Access to professional services, prescription drugs, and medical equipment is critical to obtaining effective pain management and to restoring quality of life. The U.S. is one of the few countries in the world where access to these products and services is based on the ability of a person to pay for them, either through personal resources or third-party private or government health insurance."

It is currently estimated that approximately 41 million Americans have no health insurance. By 2005, this number is expected to grow to over 44 million and historically seems to continue to increase at about 1 million a year. Additionally, there are the uncounted millions of people who have limited insurance and cannot afford to pay the extra costs associated with their illness.

According to the industry-respected Kaiser Survey of Family Health Experiences, in those who are uninsured with unmet needs (i.e., delaying or going without care or medication needed for management of the medical problem) 27% report problems at job or school, 30% report that their health has worsened, and 77% report they were sick longer or were forced to tolerate unnecessary pain.

Many people over the age of 65 have less ability to pay for prescription drugs because they are on fixed and low incomes. Yet these are the individuals who are most likely to need pain medication due to age-related degenerative diseases like arthritis and terminal illnesses like cancer.

Some pharmaceutical manufacturers have limited programs to make their medication available to indigent patients, but the costs for pain medication is increasingly prohibitive to the large group of people who need it and pharmaceutical companies do not implement country-wide programs or announcements of 'gifting' their products to those who cannot afford them.

In October, 1999 the federal Pain Relief Promotion Act (PRPA) was passed by the House of Representatives by a vote of 271 to 156.

If the bill had passed the Senate and been signed into law by the President, it would have:

prevented the use of federally regulated drugs in cases of physician-assisted suicides, prohibited the U.S. Attorney General from allowing exceptions, and its effect would have overruled the Oregonian Death With Dignity law, which permits physicians to assist terminally ill people in committing suicide

The constitutionality of such a Federal law was highly doubtful. The U.S. Supreme Court decision of 1997 implied that states could pass laws, which permit physician - assisted suicide, and that individuals would then have a right to take advantage of these laws if they wish. The Federal Government would hardly be able to prevent such access. The law stalled in Congress and has not been revived at this writing.

If the law had been passed, it would have had a profound effect on the management of pain: from a positive aspect, patients currently unmedicated or severely under medicated might experience some pain relief... To a degree. The law would have permitted doctors to prescribe narcotics for pain relief, even if the drugs had side effects, which would shorten the patient's life.

Has this law passed, this very routine method of pain control would have been legalized and perhaps free physicians - currently leaving their terminal or chronically pain-ridden patients in agony - to use prescriptive medications to assist with pain management.

Fear for being charged with murder - if prescribed medications shorten the patient's life by even a few days - prevents many doctors from prescribing even minimal levels of pain narcotics. If this bill were ever passed, these same doctors would be protected from criminal charges in the ethical and reasonable care of their patients.

The downside to passing this bill, however, would mean that physicians would be afraid to give adequate narcotics at all. If the dosage was misjudged - human errors ensue - and the patient died, the doctor could be charged under the act and end up with a 20-year jail sentence for murder.

Any doctor prescribing a narcotic - justified or otherwise - would have a troop of DEA investigators watching every move made, evaluating each dose and attempting to assess the doctor's intention.

The natural, human tendency will be for most doctors to err on the side of their own safety and refuse to prescribe adequate levels of medication to control their patient's pain. In this way, the physician will be able to make certain that the patient's death is not unnaturally accelerated and attract the DEA's attention.

Study after study demonstrates that doctors typically under-treat pain by using mild, ineffective medications when opiates would be appropriate in pain management. The reasons most doctors give for this under management are fear of scrutiny or discipline from state and federal authorities.

Over and over, studies have shown that patients experiencing chronic and/or intractable pain want to die because of under treatment for the pain. With good medical care, however, the pain is almost always manageable and these same people regain their desire to live. With the addiction conundrum not a factor, even mental acuity is rarely impaired.

Euthanasia's Legal Position Today

The Netherlands is currently the only country in the world where euthanasia is openly practiced. Although not specifically permitted by law, Dutch judiciary recognizes a standard defense from doctors who have adhered strictly to official guidelines, which through logical progression is specifically permitted by law (i.e., official guidelines provide the vehicle upon which a physician may euthanize a patient; were euthanasia unacceptable in form, guidelines would never have been developed at all). The State Commission on euthanasia defines Dutch law as the "termination of life by a doctor at the express wish of a patient. The request to the doctor must be voluntary, explicit, and carefully considered, and it must have been made repeatedly. Moreover, the patient's suffering must be unbearable and without any prospect of improvement."

On October 27, 1997, Oregon adopted a legal medical option for terminally ill Oregon residents. At present, only the state of Oregon has a statute permitting doctor-assisted/physician-assisted suicide (DAS/PAS) and then only within very narrowly prescribed circumstances, i.e., for a terminally ill patient.

In the November 1998 elections, voters in Michigan defeated a ballot measure to legalize doctor-assisted suicide.

Earlier in the last decade, voters in California and Washington State defeated similar ballot measures.

A bill similar to Oregon's PAS law died in the Maine Legislature's Judiciary Committee in February 2000 and the issue before Maine voters as a referendum in the November 2000 election was narrowly defeated by some 51% of those voting [315,031 for; 332,280 against].

Such legislative measures - although often introduced - often die within committee hearings and seldom reach the floor of the full legislative body.

An example of such proposed legislation is California's Death With Dignity Act, proposed in early 999. Permissive DAS legislation is overshadowed by measures prohibiting DAS under penalty of law.

During the 2002 legislative session in Hawaii, several legislative observers believed that proceedings might finally yield enabling legislation either a bill to legalize DAS or a ballot initiative for voters - both, however, failed.

The Appendix compiles a summary of reports summaries on different states seeking to gain legal sanctions when permitting or prohibiting doctor-assisted suicide for 2003 legislative sessions.

In the remainder of the states outside Oregon, DAS/PAS is subsumed under assisted suicide. Thirty-nine states have a statute prohibiting assisted suicide.

Six states - Alabama, Idaho, Massachusetts, Nevada, Vermont, and West Virginia - prohibit assisted suicide through application of common law.

In spring 1999, Maryland was the latest state by statute to outlaw assisted suicide.

Four states - North Carolina, Ohio, Utah, and Wyoming - have neither a statute nor common law, which prohibits assisted suicide.

If the Pain Relief Promotion Act of 1999, passed by the House, received in the Senate on November 19, 1999, and referred to the Committee on Judiciary, becomes the law of the land, the legal and political landscape surrounding doctor assisted suicide will once again be markedly altered.

On November 6, 2001, U.S. Attorney General Ashcroft blocked Oregon's assisted-suicide law authorizing federal drug agents to punish doctors who prescribe federally controlled drugs to help terminally ill patients die. The action was suspended two days later by a temporary restraining order pending a hearing on a permanent injunction to be heard within 10 days. That restraining order was extended on November 20 for five months at which time arguments will be heard. However, on April 17, 2002 a federal judge that the U.S. Justice Department lacks the authority to overturn an Oregon law allowing physician-assisted suicides.

Subsequently, on September 23, 2002, the Justice Department asked the 9th U.S. Circuit Court of Appeals to strike down Oregon's assisted-suicide law as counter to a U.S. drug law, the Controlled Substances Act. As of this writing, the case is waiting for a date for oral argument in this continuing emotional debate.

United States Supreme Court Decisions

On January 8, 1997, the Supreme Court heard the issue of whether assisted suicide is protected by the Constitution, and whether criminal penalties for those who aid in assisted suicide violate the 14th Amendment's Due Process Clause. On June 26, 1997, with a vote of 9 to 0, the Court found no constitutional right to die with the help of a physician and upheld state bans on assisted suicide.

Conclusions

The issue of euthanasia is a prickly one for both sides; the pro-euthanasia side believes it to be a fundamental human right to choose when, where, and how to die. Michel de Montaigne (1533-1592) was the first major European dissenter. Arguing that suicide should be considered a matter of personal, human fundamental rights, he defended it as the only rational option in some circumstances. In A Defense of Legal Suicide, he wrote: Death is a remedy against all evils: it is a most assured haven, never to be feared, and often to be sought: All comes to one period, whether man makes an end of himself, or whether he endure it; whether he run before his day, or whether he expect it: whence soever it come, it is ever his own, where ever the thread be broken, it is all there, it's the end of the web. The voluntariest death is the fairest. Life dependeth on the will of others, death on ours."

This argument, while flawed, is a strong emotional one, promising peace in suicide and something most terminally ill patients lose early in the disease process - control.

The case for euthanasia is seriously flawed, however. The act of suicide violates a person's natural will to live, harms other people, and is a gift a man or woman doesn't own - life is given by God and is to be taken by God.

Consider this portion of the Hippocratic Oath: the moral and ethical agreement into which physicians enter upon being trained and licensed to practice medicine:

will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them.

I will not give poison to anyone though asked to do so, nor will I suggest such a plan. Similarly I will not give a pessary [i.e., a potion meant to cause abortion] to a woman to cause abortion. But in purity and in holiness I will guard my life and my art."