Physician Assisted Suicide

Physician-Assisted Suicide: The Right to Die
Abstract
More and more patients in and end-of-life phase are expressing a desire for physician-assisted suicide (PAS) as an option that allows them to die with dignity and forego the pain and suffering associated with their disease and deteriorating condition. Yet in most states in the U.S., physician-assisted suicide remains illegal. The policy of this paper would be for lawmakers to be encouraged to pass a bill that makes PAS legal at the federal level. By having the right to die, patients can choose to end suffering in a way sanctioned by society and law with the help of providers who view it as an ethically sound approach to quality care.
Policy Problem
Physician-assisted suicide (PAS) is an issue that touches on quality of life factors. PAS is a process by which a physician makes available to the patient the means for the patient to terminate his or her life at his or her choosing. While the American Medical Association (AMA, 2018) has stated that PAS is “fundamentally incompatible with the physician’s role as healer,” Zukowski (2014) writing for Johns-Hopkins argues that patients should have the option or right to die so that they can close out their lives with dignity and quality in a manner of their choosing. There are numerous social, economic, ethical, political and legal factors surrounding this issue that must be addressed in order for a policy of promoting PAS to be effectively developed and implemented. This paper will examine those factors, list the goals of such a policy, identify options and alternatives, and nursing implications for promoting PAS.
Background
Social factors. If a person suffering from a terminal disease wants to end his or her life rather than suffer from a deteriorating quality of life for which there is no help, proponents of euthanasia feel a person should have the right to physician-assisted suicide in such cases. Opponents of PAS argue that this goes against the essence of the Hippocratic Oath, that suicide is a sign of mental illness according to the DSM-V, and that a desire to end life should be treated rather than indulged. Nonetheless, in 7 states in the U.S., PAS is legal, as well as in countries like Canada, Netherlands, Colombia, Belgium and Luxembourg (Emanuel, Onwuteaka-Philipsen, Urwin & Cohen, 2016).
Economic factors. PAS can reduce the amount of time and resources required to provide care for individuals in an end-of-life phase (Smith, 2017). Thus, PAS could reduce the amount of federal money spent via Medicare on patients, which could shore up funds for others. Zukowski (2014) notes that “approximately 25% of Medicare costs are to treat 5% of Medicare users to cover end-of-life care.” On the other hand, Jones and Paton (2015) have shown that in states where PAS has been legalized, suicide rates have climbed—a point which could have a negative economic drag on society if it should persist. Additionally, in states like Oregon where PAS is legal, there are a number of procedural processes that patients must who request PAS services must undergo—such as referral from physicians and a psychological evaluation (Death with Dignity Act, 1994).
Ethical factors. Herx (2015) argues that PAS “and euthanasia go against the very core of the palliative care approach and have no place within palliative care” (p. 82). This sentiment coincides with the argument that PAS is antithetical to the Hippocratic Oath. However, as Kamisar (1998) has noted, an individual who is faced with a terminal illness may have good personal reasons for wanting to go the route of PAS and out of respect for personal choice, these reasons should not be ignored.
Political factors. Politicy makers at the governmental level are impacted by ethical, economic and social factors, but as Clark (2014) points out, “the history of assisted suicide made it almost inevitable that by default, it would become an object of direct democracy” (p. 84). In other words, the issue is not one that will go away with time; on the contrary, as ethical perspectives shift towards upholding civil rights, PSA will continue to gain support from advocacy groups promoting quality of life and dying with dignity objectives. For the time being, PAS has found support among a handful of states in the U.S.
Legal factors. The Supreme Court ruled in Washington v. Glucksberg (1997) that PAS is not protected by the U.S. Constitution. However, some states have passed their own laws regarding PAS. PAS is legal in Oregon, Washington, California, Colorado, Hawaii, Vermont and Montana as well as the District of Columbia (Emanuel et al., 2016). Meanwhile, in 36 states, PAS is illegal; in the other states, PAS is a gray area (Euthanasia, 2018).
Stakeholders
Stakeholders who are impacted by this issue include patients, patient families, physicians, nurses, health care organizations, state, local and federal lawmakers, taxpayers and medical organizations and associations, insurers, and the health care industry as a whole.
Policy Goals & Objectives
A review of the literature shows that PAS is meeting with increasing social acceptance around the world (Emanuel et al., 2016; Frey & Hans, 2016). As the moral and ethical foundations upon which the modern view of life is situated shifts more towards preserving quality and maintaining dignity rather than ensuring longevity, health care providers face the inevitable decision about how to handle PAS requests (Clark, 2014). Some states have already taken action to give patients the right to request physician assisted suicide (Death with Dignity Act, 1994). While palliative may still be considered an option for those who have no interest in PAS, patients who prefer the option of choosing the time and manner of their own death are increasing in number (Jones & Paton, 2015). Much of the medical community remains opposed to PAS (Huxtable & Mullock, 2015); however, in order to meet the needs and wishes of patients, the medical community should at least adopt a neutral perspective on PAS so that if the patient does desire it, he or she can be matched with a physician willing to provide the requisite services.
For these reasons, it is important that health care providers push U.S. legislators to provide states with the option of granting patients who prefer PAS to the right to obtain this service. The goal of this policy is to achieve legalization of PAS at the federal level. The objective of this policy are to promote PAS among the health care community in a positive manner so that health care providers can more accurately reflect the rising demand in modern society for PAS services among patients entering into an end-of-life phase seeking to die with dignity while they still have some quality of life left. This objective will be pursued by educating health care providers about the benefits of PAS and encouraging them to urge their organizations and associations to lobby legislators to address the need for PAS among today’s population in a favorable way.
Another objective is to provide the necessary evidence that shows why there is a need for PAS legalization. As Mason, Leavitt and Chaffee (2006) state, one of the main barriers to “crafting policy is that there can be a lack of clarity about the evidence that is needed” (p. 69). By providing stakeholders with the information needed to make the right decision for legalizing PAS at the federal level, this policy objective facilitates the overall goal in a significant way.
Using the Longest’s Policy Cycle Model, three phases are identified by the policy maker: “a policy formulation phase, an implementation phase, and a policy modification phase” (Mason et al., 2006, p. 65). Moreover, the Longest Model holds that policy formulation dependents substantially on legislators and that “it is in this phase that nurses can serve as a knowledge source to legislators in helping frame the problem and bringing nursing stories and patient narratives to illustrate how health problems play out with individual constituents/populations” (Mason et al., 2006, p. 65). For this reason, another objective of this policy is for nurses’ stories about patients seeking or desiring PAS to be gathered together that they might be presented to U.S. lawmakers so that an appropriate bill could be introduced to Congress based on these stories which will help to modify the existing decision handed down by the U.S. Supreme Court in the 1990s. That decision represented the first window of opportunity for federal law to acknowledge the patient’s right to die. Since then, the right to die has only been implemented in a handful of states because of the Supreme Court’s decision in Washington v. Glucksberg. Now it is time for modification of that position to take place, based on the stories and experiences that nurses have obtained first hand in dealing with end-of-life patients who desired PAS but had no recourse to it because of the laws in their state.
Evaluations of Options & Alternatives
Nurses all over the U.S. have encountered end-of-life patients who have sought PAS services instead of palliative care services out of a desire to exercise their right to die with dignity and while they still possessed a modicum of quality of life. These stories can serve as a the support needed to move lawmakers to approach the issue of PAS at the federal level and introduce a bill to Congress that would address the needs of these patients in a more humane way by making it legal for them to obtain PAS services no matter where they live. The bill could include protocols for nurses and physicians who are opposed to delivering PAS services, allowing them to exercise their own conscientious objections and refer the patient to a different provider.
Alternatives to this policy would be for the current system to remain in place, which limits the ability of patients in the end-of-life phase to apply for right to die services. Currently, there is also a great deal of disparity between what patients and society would like (PAS services) and what the medical community is willing to provide (most health care associations are opposed to PAS).
Another alternative is to make it a state issue and allow states to determine whether PAS should be legal in their jurisdiction—but this does has its own limitations as well. It does not resolve the issue at the federal level, which can make many health care providers nursing fearing prosecution at the federal level should they engage in PAS only later to be sued by a family member.
A third alternative is to go the opposite way and to abolish all PAS services at the federal level so that no one anywhere in the U.S. may obtain these services. This would go against the current trend, however, and block the desires of many patients in society who would like to have access to PAS if they should find themselves in a situation in the end-of-life phase where dying with dignity presents itself as the most favorable option at that time.
Cost
The cost of pursuing the policy of promoting PAS so that a federal law could be passed that allows physicians to provide this service in every state of the country is minimal. The aim would be to obtain evidence, both statistical and anecdotal, quantitative and qualitative, of the need for PAS services. The outcome of legalizing PAS at the federal level would be that it saves millions of dollars spent on Medicare for end-of-life patients (Zukowski, 2014; Smith, 2017). This cost-saving aspect of PAS is the biggest pro among all the options. The con is that costs may arise in other areas, such as if suicide rates increase in the community, which can drag on the economy overall.
The cost of keeping the current system in place would be that a quarter of all Medicare funds would continue to go to end-of-life patients who do not have a PAS option (Zukowski, 2014). There is also a social cost to keeping the current system in place: as social needs change over time, institutions and government legislators must be attentive to these changes. The con of keeping the current situation unchanged is that it does nothing to address the needs of today’s patients.
The cost of pursuing the state-issue option is that tension remains in the health care community about whether providers should or should not support PAS or adopt a neutral stance at best towards it. Leaving it as a state issue prevents organizations and associations from acting in unison to provide patients with the best care possible; similarly, abolishing PAS outright would continue to be a drain on Medicare resources, which is a major con for the federal government which is already deeply in debt.
Quality of Care
The option for legalizing PAS presents the best approach to quality of care. Quality of care is an important part of nursing—but so too is quality of life (Welch, Schwartz & Woloshin, 2011) and the former should not be pursued without regard for the latter. After all, quality care can best be measured by the extent to which it improves the patient’s quality of life. If quality of life can only deteriorate for end-of-life patients, access to PAS could present some patients with the best quality care for a person in their situation. It is ultimately a decision that has to be made by the patient, and the option of having that decision is one that should be allowed. Nurses and physicians who believe that quality of care is intimately tied to quality of life should view PAS as a reasonable option for end-of-life patients, even if they do not support it from an ethical position. Not everyone shares the same ethical outlook in the modern era, and in a society that values freedom of choice, PAS should at least be presented as one option among many in the health care community.
By encouraging nurses and physicians to tell their own stories so that anecdotal evidence can be accumulated to support the statistical evidence reported by various researchers over the past few years showing a rising demand for and acceptance of PAS, this approach to promoting PAS services would help the policy to achieve its objectives and goals while advocating for a realistic approach to quality of care that is tied distinctly to the concept of advocating quality of life concerns, such as the right of patients to die with dignity.
The current system does not promote quality of care in its fullest sense since it does not legally approve PAS at the federal level and thus does not take into consideration the subjective aspect of quality of life and how it ties into quality care. This is the biggest con of the current system, and the other alternatives—state-by-state basis and total ban on PAS—would only continue to reflect this con.
Protection of Patient & Provider Autonomy
The option that best promotes the protection of patient and provider autonomy is the policy to legalize PAS at the federal level. This would give the patient the right to choose to die in an end-of-life scenario and it would also give a health care provider the autonomy to decide whether or not providing PAS aligned with his or her own ethical position. Both stakeholders have to be respected, so the policy should only give patients the option of obtaining a provider willing to give PAS services; it should not require providers to provide PAS if it violates their ethical position. If there is a lack of clarity on this part in the legislation, it could be a major con going forward.
To leave the current system in place, the protection of patient and provider autonomy would be too lopsided. Currently, it favors providers who are opposed to PAS. The current system does not promote the right of patients to obtain PAS if they desire it. The state-by-state option and the total abolishment option would not be any better.
Political Feasibility
The legalizing of PAS at the federal level is politically feasible if the right lawmaker supports the bill and enough nurses and physicians provide anecdotal evidence to give the bill the emotional and social backing it would need to get through Congress. The biggest pro for this option in terms of political feasibility is that it is highly realistic and could be obtained in the near future with the right administration in place.
The current system is not as politically feasible, as it does not respect the current social trends, and a state-by-state basis or total abolishment of PAS would not either and would only cause tension and confusion just as the medical marijuana issue has done over the past few years.
Best Option
The best option to be recommended here would be for PAS to be passed at the federal level so that patient rights can be respected and the right to die be allowed as an option to patients no matter where they live in the U.S. This policy would not oblige providers to give PAS services if it went against their ethical position, but it would allow patients the right to be matched with a physician who was willing to give these services. This would help to enhance quality of care, protect patient and provider autonomy and give the best chance of political feasibility.
Nursing Implications
Nurses would have to recognize that though patients have the option to select PAS services, this does not mean that health care providers have to provide these services. It is to be expected that some providers will be willing to provide these services and every staff should have some of these providers on board so that there is no personal conflict of interest involved in the dispensation of quality care to patients. However, were PAS to be federally legalized, issues could still arise; nurses may feel pressured into violating their own personal and professional ethics by assisting in a facility that offers PAS services in a situation that they could say is akin to working in an abortion facility. To address this issue, PAS services may need to be provided only in designated facilities where nurses who support this approach to care can willingly apply to work, just as others apply to work in facilities that provide abortion facilities. Legalization does not mean that every facility must offer the service, only that the service be offered by some facilities.
Conclusion
Patients in an end-of-life scenario should have the right to choose to die at a time of their own choosing in order to end their days with a higher quality of life. Though some in the medical community may not agree with this position, the trend in society is for acceptance of PAS, and in a liberty-loving society, this right should be accepted as well. PAS should therefore be federally legalized and the goal of this policy would be to educate stakeholders as to why it should be legalized at the federal level by collecting statistical and anecdotal evidence to show the need for PAS as at least an option for patients in end-of-life phases.

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