Physician-assisted suicide: ethical and legal considerations

Right-to-Die Opinion

Order ID: Right-to-Die Opinion

Suicide is a very emotionally and morally charged subject to many people. The reason for the discord and divergence of opinions comes from the different perspectives and directions. Some of these motives and viewpoints are based on morality beliefs, religion or a combination of the two. Others are based more on humanity, empathy and the belief that suicide can be a solution to end misery and chronic pain. Some hold that taking one's own life is selfish, immoral and damaging to family and friends. Others hold that such a decision should reside with the individual in question alone. While there is no single answer that will placate all pundits, scholars and ethicists, the right to die should be allowed under the care of a physician and provided that the necessary conditions are met.

Analysis

Perhaps one of the more strident views about suicide emanates from the Christian church, with the Catholic sects usually being some of the more aggressive on the subject. Indeed, Catholics often hold that suicide is a mortal sin and that it results in a person going straight to Hell. Not all Christian sects believe that, however. Suicide is generally held to be a sin in the Christian faith because it is a form of murder to many and ending one's life is also often seen as an affront to God who, per Christian belief and the Bible, created man in his own image. Obviously, this strain of beliefs is geared towards the Christian definition and construct of morality. This is the same moral code that discourages premarital sex, having children out of wedlock, divorce and other perceived transgressions that are immoral or unacceptable under the Christian belief but are not illegal under the law in American or other societies. That being said, this has not always been the case as there were indeed laws against such acts but that has been relaxed or ignored more over the years. Suicide has even been criminalized in many parts of Western society including the United States. However, many of those laws have been stricken or are not enforced.

However, suicide as a moral failing and cop-out is not limited to Christian or other religious ideology to put it lightly. Indeed, some people take some rather rigid and hardline stances when it comes to the subject. Many of these sort of people refer to suicide as "selfish" and harmful to others. Indeed, a person speaking of or actually committing suicide can leave a huge void and cause major distress to coworkers, friends and family members. To be sure, many people considering suicide are doing so for reasons that can or do override and usurp those and other concerns. For example, the terminally ill or those that feel they have no escape from the misery and degradation they feel they face view suicide as the one and only sure-fire solution to escape their pain. This would be a common theme with people that, other than the terminally ill, would include people that are bullied, those that are in extreme distress to a relationship turning sour with a partner and so forth. Suicide is obviously not the only potential solution in situations like this but it seems that way, or it is at least the best option, for people that try or succeed in killing themselves.

However, there is another major perspective relating to suicide and that would be people that feel that everyone's life is their own to live or take and thus they should be allowed to end their life if they see fit to do so. There are some people that espouse this in the United States but it is not allowed under the law in the United States. However, Europe and other more liberal or progressive parts of the world are another story. Even so, there is certainly no part of the world that is monolithically for or against the right to die but majorities one way or another are the norm. Other places still have a fairly even divide on the subject in the court of public opinion. One major complicating factor to all of this, and indeed something that is true of the law in general, would be the role of doctors, nurses and other medical professionals as it relates to suicide. Many people within the bioethics and medical realms cite the credo "do no harm" but others take a more moderate to liberal view and assert that while enabling and helping a person commit suicide is wrong, the act itself is up to the person engaging in it. Regardless, medical professionals and personnel delving into the moral and religious decisions and feelings of patients is a very slippery slope and is something that should be avoided at all costs. This does not mean that doctors and nurses should oblige the right to die for someone that wants it but foisting religious and moral views on patients and families of the same is also less than wise (Beauchamp & Childress, 2013). Even private corporations like Hobby Lobby have caught hell (pardon the pun) for doing so and the stakes (and consequences) are even higher when speaking of educational and medical institutions. The Jesuit university that denied any form of birth control to all students including popular figure Sandra Fluke stands out as an example.

Scholarly literature is rife with material relating to suicide and its related subjects. These corollary subjects including assisted suicide, euthanasia, who should have a right to die, who should not and so forth. There is also material about desired or actual changes to the law in the United State and other parts of the world. First up will be a bit of a shift back to the medical/suicide dichotomy because this would be one of more contentious arenas where suicide is discussed due to the seemingly contrarian viewpoints between those that desire the right to die and the medical professionals whose usually goal is the opposite, or at least to minimize pain and suffering. To that end, there are directors and living wills where people state in advance and up front that they do not wish to be resuscitated. However, there are other forms of suicide that are not nearly as overt yet involved medical care or lack thereof. Some cancer patients who feel the fight is no longer worth it will stop treatment and/or go to hospice. Similarly, people that should be hospitalized will try to leave the hospital or refuse treatment or medications. However, the major line that has to be danced around is that people that want to die and how the medical professionals react and strategize based on that fact. Medical technology has gotten to the point where a body can technically be alive due to the wonders of medicine even if the brain function of the patient is dead and gone. While some hold that doing any and all medical treatment is a moral and professional imperative, the idea of being kept alive only by a machine along with a loss of privacy and/or dignity is a bridge too far for a lot of people. If brain function is gone, then the decision could generally be made to end care but if there is any chance of a patient recovering and they are stable, the likelihood of this is extremely rare as it would generally be viewed to be illegal and/or unethical to do so. Even when terminating future care is an option, if not an obvious one, making such a decision for people that are incapacitated and for which no advanced directive exists can be extreme troubling and caustic if immediate family members differ about how to proceed. A real-world example of this maelstrom in full swing was the Terry Schiavo case. Schiavo was technical conscious but was in a persisted vegetative state and it was deemed that she had no chance of recovering or getting back even her basis motor functions and speech. However, there is another major example in the past of the United States that can be spoken of and that would be Karen Ann Quinlan back in 1983. That situation was a little different but not by much. In the Quinlan case, the matter was more of a legal matter as the family wanted to discontinue care but the doctors refused to do so out of concern of legal and criminal liability (Ball, 2006).

The legal fray started to swing towards the right to die movement more than a decade before the Schiavo situation when Oregon introduced right-to-die legislation in 1994. It was passed via ballot initiative but was not fully enacted into law until 1997. However, while the Supreme Court upheld the law since there was no contradictory federal law usurping the state's rights to enact such a law, future Attorney General John Ashcroft made it clear to doctors in Oregon and elsewhere that any doctor prescribing level II medications for the purpose of suicide were violating federal law and thus could have their right to prescribe medication stripped and/or face prosecution for the death of any patients that they helped die. The law was further reduced in scope and usability when certain types of doctors and/or from certain departments were precluded from ever participating in a physician-assisted suicide. Other scholarly research has held that nurses should be flatly banned from ever participating in the practice even if the agree on a personal moral or religious basis. That being said, nurses can be a listening ear and a hand to hold. Indeed, part of nursing is being a soothing and helping presence even when death of any form or cause is basically assured. Nurses can help assist in deciding whether a person wanting to die and/or making decisions about medical care are lucid and able to make such decisions. Indeed, people that do not have such standing can be stripped of the ability to make such decisions if a court renders and verifies this status to be the case (Ball, 2006).

The author will now come back to the Oregon law mentioned in the last paragraph. The list of people eligible to choose to end their life was kept fairly tight upon the law's passing. People who wanted to receive a lethal dose of drugs have to be 18 years old, must be a resident of Oregon, must be lucid and able to make such a decision under psychological/psychiatric standards, must confirm the request verbally directly to a doctor on two different occasions no less than fifteen days apart and there have to be two witnesses that sign off on the declarations. The witnesses cannot be family members nor can the witnesses be affiliated with any healthcare facility or organization. As of 2009, only 242 patients had taken advantage of the law and ended their life via its framework. However, the chorus about the law after its implementation as far from monolithic. For example, psychologies are involved in the process for the mental acuity assessment dimension. While nearly four out of five respondents to an official survey were fine with the involvement of psychologists in the process, the other fifth were vehemently against such involvement and felt it was an endangerment to the profession and ethics of psychology. At the same time, four fifths of the psychologists surveyed would absolutely go through the framework in place if they decided to go that route in the future. The discord about the subject, despite the widespread support, emanated from the structure of such a program rather than the general right to die if one so chooses and wants to (Westefield et al., 2009).

Even though nurses are banned from being a part of the process other than for comfort and consolation, physicians are no less prone to be conflicted and unprepared. Many physicians that have had right-to-die chats with patients felt unprepared, apprehensive and extremely uncomfortable with engaging in the process. The same pool of doctors were surveyed about the framework and some very divergent opinions were found. Almost a third found that writing an intentionally lethal prescription is "immoral and unethical." About a tenth of doctors surveyed were neutral on the subject and the other sixty percent or so were not morally conflicted or hesitant about the subject. However, drilling deeper with the questions finds some more facts and figures that are interesting to say the least. For example, roughly a fifth of a broad survey of regular people found that suicide assisted by physicians is never allowed. Similar to before, another seventy-one percent thought it was alright to allow for suicide if certain criteria were met, such as those mandated by the Oregon right-to-die law. This is consistent with the numbers mentioned already (Westefield et al., 2009).

However, the opinions offered about the questions thereafter had a varying amount of responses significant enough to be counted, that meaning a score of 5, 6 or 7 on a Likert scale, were quite eyebrow-raising. For example, only 43 people thought that physician-assisted suicide should never be allowed but 147 people answered in the affirmative about certain criteria being met. When it comes to age restrictions, roughly two thirds thought there should be age restrictions. Less than half supported the act for a family member. Less than a third said they would personally consider the act if it was their life in question. The family member question was answered significantly by 87 people and the personal choice question was from 64 total people. The highest significant response rate, 157 people in total, came regarding the environment in which the person opting to die may receive a lethal dose. It was confirmed with that question that the process should be carried out with a doctor present or in an authorized facility like a hospital or similar location. Lastly, there was a 46% rate for the idea that only terminally ill people should be allowed to use the right-to-die option and only 45% said they would vote for a right-to-die law if it were on the ballot in their home state (Westefield, 2009).

There are actually three overall perspectives that are involved with what is being discussed in this report. Those three perspectives and viewpoints are right-to-life, right-to-die and assisted suicide. This prism brings to life another real-world test case by the name of Diane Pretty. She was a 42-year-old woman in the advanced stages of motor-neuron disease. More or less, the disease was going to lead to a long and painful death over a fairly long time horizon including gradual paralysis, loss of muscle function and loss of respiratory function. Rather than endure a long-term and agonizing disease that would certainly kill her at some point, she considered ending her life. She took her case to the European Court of Human Rights and asserted that the Suicide Act and the Human Rights Act directly contradicted each other. She said that the "right to life" in the Human Rights Act concurrently implied a right to die, that the Suicide Act's forbidding of assisted suicide forced her to suffer greatly, that her private life included the right to decide when she had enough of all of her struggles and that the Suicide Act's ban on physician-assisted suicide was condoning discrimination against her. The European Court of Human Rights ruled against her stating that protecting human life at all costs was the moral and legal imperative of the medical community. This obviously ran counter to Pretty's feeling that the government had no right to assert such a rule and that she should have the right to die peacefully and at a time of her choosing rather than going to perpetual agony for an elongated period of time. Indeed, she felt the outcome was not in doubt but she wanted to control the timing of it. The Netherlands and Belgium have taken different stances in recent years but the United Kingdom has been more stubborn on the subject (Chetwynd, 2004).

One major buzz phrase in this discussion is "dying with dignity." While this may seem like a black and white subject to some, many hold the opposite to be the case. Indeed, imploring someone to define "dignity" and lack thereof can illuminate and clarify why this is the case. To prove the point, one can look at the disabled. To avoid questions about mental acuity and competence, one can look at people that are paralyzed, otherwise bound to wheelchairs or suffering from a disease that reduces a person's quality of life. Indeed, human history (albeit thankfully not recent in most cases) has treated the disabled like a liability and they would tend to be either killed or relegated to an asylum for all of their life. Indeed, improper treatment of the disabled up to and including active eugenics has been a problem over the history of mankind. One question that comes up quite easily when looking at the disabled is whether they should have the right to die if they so choose. People with physical deformity, nerve or pain issues and so forth may come to the conclusion that they are sick and tired of living such an existence. However, unless their condition is terminal and/or their life is in immediate danger, the odds of most people supporting suicide as a voluntary option is not all that high. People that feel suicide is a choice that anyone can and should be able to make irrespective of the circumstances might support the idea of the disabled beign able to make such a choice. However, the consistently held standards of chronic pain and suffering and/or a terminal illness are not remotely met in the case of most disabled people no matter how miserable they rare. Much the same thing could be said for the forlorn, the depressed, the bullied and the destitute that are not facing any sort of illness yet want to die because of what they feel life has become or will be for them. Indeed, culture, perspectives and prisms can have a demonstrative and significant effect on how someone defines "dignity" and whether any given person who wants to die should be given the right to do so. The problem with dynamic is that there will always be disagreement and discord involved and the presence of religion, politics and other ideology-driven paradigms are not going away yet they feed these debates to no end. There are indeed some people who hold themselves to be moral relativists and thus will not hold anyone else's choices against them. However, suicide can and does harm the mental state and well-being of others and thus this begs the question whether suicide should be allowed even if it seems like the best or only option to reasonably choose (Behuniak, 2011; Hendry et al., 2013).