Physician Assisted Suicide in Patients With Unbearable Suffering or the Terminally Ill
One of the most hotly debated issues today is physician-assisted suicide. Recently, California became the fifth state to legalize physician-assisted suicide, and there is an increasing likelihood that other states will follow suit in the foreseeable future. The purpose of this study is to determine if the factors chosen have any bearing on those who choose to end their life with physician assisted suicide. In support of this purpose, the objectives of this study were as follows: (a) to research scholarly articles regarding physician-assisted suicide and gather pertinent information into a comprehensive profile; (b) to research whether unbearable suffering is the dominant motive to request physician-assisted suicide; (c) to research whether the race and level of education of the patient are contributing factors when physician-assisted suicide is requested; and, (d) to research whether the type of terminal illness the patient has been diagnosed with is a factor when requesting physician assisted suicide.
Table 1. Part One: Survey demographic data
Table 2. Part Two: Likert-scaled statement results
Table 3. Survey response percentages
Table 4. Custom survey instrument design steps
List of Figures
Figure 1. Dr. Jack Kevorkian's Volkswagen microbus containing his
"death machine"
Figure 2. U.S. population pyramid
Figure 3. Current legislative status of physician-assisted suicide in the U.S.
Figure 4. Responses to the statement, "I believe that unbearable suffering
is the dominant motive for most people requesting physician-assisted
suicide"
Figure 5. Responses to the statement, "Physicians have a moral obligation
to relieve patients' unbearable suffering"
Figure 6. Responses to the statement, "Physicians shouldn't play God by helping people die"
Figure 7. Responses to the statement, "The type of diagnosed terminal
illness has a major impact on the decision to seek physician-assisted
suicide"
Figure 8. Responses to the statement, "Members of low-income minority
groups are more likely to want physician-assisted suicide compared
to more affluent white Americans"
Figure 9. Responses to the statement, "Legalizing euthanasia would
leave vulnerable people without sufficient legal protection"
Figure 10. Responses to the statement, "Legalizing euthanasia would send the message that the lives of the sick and disabled are less valuable"
Figure 11. Responses to the statement, "Legalizing euthanasia would
establish clearer guidelines for doctors to deal with end-of-life
decisions"
Figure 12. Responses to the statement, "Legalizing euthanasia would give
people who are suffering an opportunity to ease their pain"
Figure 13. Responses to the statement, "When a person has a disease that
cannot be cured and is living in severe pain, doctors should be
allowed by law to assist the patient to commit suicide if the patient
requests it"
Chapter One: Introduction
Background of Study
In 2015, California became the fifth U.S. state to legalize physician-assisted suicide, and so-called "death-with-dignity" legislation has become one of the most hotly debated issues in recent years. Even as the debate ensues, though, the trend is clear and more than a dozen states have already introduced death-with-dignity legislation or have committed to do so by year's end (Slew of states to consider aid-in-dying bills, 2016). While a majority of Americans continue to approve of physician-assisted suicide under certain circumstances, opponents charge that the practice places too much power in the hands of physicians who may misuse or abuse it, especially for minorities or lower-income patients. Other critics charge that family members may exploit these laws to rid themselves of the elderly or infirm who demand enormous amounts of personal care. Against this backdrop, identifying the primary motives for requesting physician-assisted suicide, determining whether patients' race and educational levels plays a role in this decision and what types of terminal illnesses are most frequently a factor when requesting physician-assisted suicide has assumed new important and relevance as discussed further below.
Statement of the Problem
Physician-assisted suicide is an up-and-coming cause of death in patients with unbearable suffering and the terminally ill. In 2015, California passed the End of Life Option Act (AB 15) which allows California residents who are terminally ill or have unbearable suffering to request a prescription for medications meant to hasten death. This can take place either as a physician-assisted suicide in which the physician provides the necessary means for the patient to perform the act themselves or as euthanasia which is when the physician performs the act on the patient. Many critics, though, maintain that a problem exists with legalizing physician-assisted suicide because of the potential for abuse by family members of the elderly. For instance, Dore (2011) argues that, "Legalization of assisted suicide is a recipe for elder abuse. It devalues people with disabilities. Legalizing assisted suicide would violate official state policy preventing suicide" (p. 82). During a period in history when the United States is experiencing especially rapid growth in its elderly population, these are especially salient arguments that have important implications for all stakeholders.
Conversely, proponents of physician-assisted suicide maintain that it is a humane and compassionate way to help people relieve their suffering, especially due to terminal conditions that will claim their lives anyway. Moreover, death-with-dignity advocates argue in support of individual autonomy and counter that everyone has a fundamental right to determine the time and manner of their own deaths under certain circumstances. These diametrically opposed views about this timely and important issue make additional research needed as described below.
Purpose and Objective of the Study
The purpose of this study was to determine if the factors chosen have any bearing on those who choose to end their life with physician assisted suicide. In support of this purpose, the objectives of this study were as follows:
1. To research scholarly articles regarding physician-assisted suicide and gather pertinent information into a comprehensive profile;
2. To research whether unbearable suffering is the dominant motive to request physician-assisted suicide;
3. To research whether the race and level of education of the patient are contributing factors when physician-assisted suicide is requested; and,
4. To research whether the type of terminal illness the patient has been diagnosed with is a factor when requesting physician assisted suicide.
Rationale of the Study
It is reasonable to posit that the overwhelming majority of Americans would prefer that no one should be forced to consider suicide, with or without physician assistance, as a viable alternative, and innovations in pain management in recent years have improved the quality of life for those with terminal illnesses (Rogatz, 2011). As Rogatz emphasizes, though, "There are some patients who experience terrible suffering that can't be relieved by any of the therapeutic or palliative techniques medicine and nursing have to offer, and some of those patients desperately seek deliverance" (2011, p. 32). It is also reasonable to posit that the overwhelming majority of Americans prefer that no one should be forced to experience "terrible suffering." Therefore, studies of this type can provide valuable insights concerning the antecedents to physician-assisted suicide that can help guide death-with-dignity policymaking efforts in the future.
Definition of Terms
Death with dignity. Although no universal definition exists, Hillyard and Dombrink (2001) generally define this term the death-with-dignity movement as an effort to "define and safeguard the right of patients to orchestrate their own deaths according to their own morality" (p. 8).
Euthanasia: From the Greek for "happy death," this term refers to situations wherein physicians act directly to end a patient's life (Hosseini, 2012). According to the definition provided by Black's Law Dictionary (1990), euthanasia is "the act or practice of painlessly putting to death persons suffering from incurable and distressing diseases as an act of mercy" (p. 554).
Palliative care: The definition provided by the World Health Organization states palliative care is "an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness" [achieved] "through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual" (cited in Lau & O'Connor, 2012, p. 56).
Physician-assisted suicide: The American Medical Association (AMA) defines physician-assisted suicide as follows: "Physician-assisted suicide occurs when a physician facilitates a patient's death by providing the necessary means and/or information to enable the patient to perform the life-ending act (e.g., the physician provides sleeping pills and information about the lethal dose, while aware that the patient may commit suicide)" (cited in Dore, 2011, p. 82).
Suicide: The legal definition of this act provided by Black's Law Dictionary (1990) states that suicide is "self-destruction; the deliberate termination of one's own life" (p. 1434).
Limitations of Study
The findings that emerged from this study were limited in scope by the relatively small number (n=67) of responses collected from the administration of the custom survey instrument shown at Appendix B and the inability to follow up the survey with face-to-face or telephonic interviews. In addition, there is always a potential for researcher bias when selected peer-reviewed and scholarly sources for inclusion in a study of virtually any type (Karimov, Brengman & Van Hove, 2011). Therefore, special effort was made to select relevant secondary resources that reflected varied sides of each of the issues of interest.
Theoretical Framework
Over the past several decades, there has been a growing body of scholarship devoted to the moral and legal implications of withholding medical treatment for patients in certain circumstances as well as physician-assisted suicide and euthanasia (Hosseini, 2012). A growing consensus has emerged from this body of scholarship that otherwise competent American adults have a fundamental right to make their own decisions concerning what type and amount of medical care they receive, including the right to make decisions that could cause their deaths (Hosseini, 2012).
Research Hypotheses
1. Unbearable suffering is considered a significant motive to request physician-assisted suicide (Boudreau & Somerville, 2013);
2. There is a significant difference in patients who have a higher education requesting physician assisted suicide than patients who have not completed high school or college;
3. There is a significant difference in patients requesting physician assisted suicide dependent upon the type of diagnosed terminal illness; and,
4. The elderly of any race or financial condition suffering from terminal illnesses who rely on family members for caregiving are more likely to seek physician-assisted suicide compared to those in tertiary or long-term care facilities.
Expected Outcomes
There were three basic outcomes expected to result from this study as follows:
1. Less educated patients are more likely to seek and receive physician-assisted suicide interventions;
2. People who suffer from extremely painful terminal illnesses will be more likely to prefer physician-assisted suicide; and,
3. There are income-related differences in the percentages of patients seeking physician-assisted suicide.
Chapter II: Literature Review
Background and Overview
The so-called "right to die" movement is certainly not a new phenomenon, but rather represents an ongoing debate over the precise role of physicians in helping people end suffering that dates to the turn of the 20th century (Hillyard & Dombrink, 2001). For instance, Fenigsen and Fenigson (2012) report that, "Historically, the American ['right-to-die'] movement has always promoted active euthanasia, lethal injections administered by physicians, with (or, sometimes, without) consent of the patient" (p. 304). Some salient examples of these efforts include the American Euthanasia Society's sponsorship of a bill in New York State in 1938 that would have legalized voluntary active euthanasia, and several initiatives to legalize some form of physician-assisted suicide between the 1940s and 1950s including those by W. G. Lennox, Dr. Foster Kennedy, Rev. Joseph Fletcher, Dr. Abraham Wolbarst and the Hemlock Society (Fenigsen & Fenigsen, 2012).
More recently, though, this debate has become more formalized and intensive by virtue of fundamental changes in American society concerning individual rights across a broad spectrum of issues. In this regard, Hillyard and Dombrink report that, "Historically speaking, the right-to-die movement resonates with other rights oriented movements of the 1960s and the 1970s" (2001, p. 8). Since that time, the right-to-die movement has been alternatively supported by these "rights" movements in the 1970s and subsequently challenged by more conservative politicians during the 1980s (Hillyard & Dombrink, 2001).
While it is clear that the advocates of death-with-dignity have not achieved their whole goals of legalizing the practice nationwide, their vocal demands have served as a catalyst for more intensive scrutiny of physician-assisted suicide. In this regard, Hillyard and Dombrink conclude that, "Ultimately, the death with dignity movement has succeeded in tapping into the discourse from each of these social movements and their attendant arenas of debate to frame its grievances, press its claims, and seek support for the movement" (2001, pp. 8-9).
This debate became even more heated during the early 1990s following the highly publicized efforts by Dr. Jack Kevorkian who performed the first physician-assisted suicide in the United States (Fins, 1999). In this regard, Fins (1999) reports that, "This story could be said to have begun in June 1990, when we read that the retired pathologist had helped a 54-year-old woman with a presumptive diagnosis of Alzheimer's disease to end her life" (p. 81). Following a final tennis game and penning an explanatory message to her family concerning her rationale in support of her decision to terminate her life despite her non-terminal condition, the patient, Janet Adkins, entered Dr. Kevorkian's infamous Volkswagen microbus (see Figure 1 below) where she was connected to his so-called "suicide machine" and received a lethal injection of a combination of medications (Fins, 1999). According to Wolfson (1998), "[Adkins] was in many ways typical of the victims that would follow: female, not terminally ill, and killed not long after her first meeting with Kevorkian" (p. 51).
Figure 1. Dr. Jack Kevorkian's Volkswagen microbus containing his "death machine"
Source: http://www.lifenews.com/wp-content/uploads/2015/08/jackkevorkian3.jpg
Following Adkin's death, Dr. Kevorkian was tried and convicted for second-degree murder when he assisted another patient, Thomas Youk, with his suicide (Fins, 1999). Eventually, Dr. Kevorkian received a 10-to-25-year sentence on April 13, 1999 for this conviction following three acquittals and a mistrial for which he served 8 years before being paroled with the stipulation that he abstain from providing life-ending assistance to anyone or to promote the act (Fins, 1999). According to one physician, "It could be argued that we have made remarkable progress since Kevorkian's first assisted suicide" (Fins, 1999, p. 81). While Fins qualifies this assertion by pointing out the Dr. Kevorkian was not individual responsible for this progress, his actions and the media attention they attracted did serve as a springboard for more thoughtful debate among state and national policymakers over physician-assisted suicide (Fins, 1999).
Besides the high-profile efforts by Dr. Kevorkian, there were other factors involved in the intensified debate over physician-assisted suicide that took place in the 1990s, including most especially the 1995 publication of the comprehensive "Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment" (SUPPORT) sponsored by the Robert Wood Johnson Foundation (Fins, 1999). According to Bauer-Maglin and Perry (2010), "The $28 million "Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment" is considered definitive because it surveyed 9,105 seriously ill patients in detail, including following about half of the group until death" (p. 181). The SUPPORT study considered a wide range of factors in its analysis, including the expenditure of life savings to provide hospital care for terminally ill patients, the pain experiences of dying patients, and the amount of time spent on artificial life support systems (Bauer-Maglin & Perry, 2010).
The results that emerged from the SUPPORT study included the finding that unacceptably high percentages of terminally ill patients were not received adequate pain management and their preferences for end-of-life care were either unsolicited or ignored (Fins, 1999). The increased media coverage that followed the publication of the SUPPORT study included numerous reports of terminally ill patients being unaware of advance directives, that doctors were failing to provide adequate pain management support for dying patients and that even when patients' had stipulated advance directives for end-of-life care, their physicians were unaware of them (Fins, 1999). As a result, Fins (1999) reports that, "SUPPORTS conclusions, which were sometimes accurately described and sometimes misrepresented in the professional and lay press, helped to further a desire for the legalization of physician-assisted suicide that had begun in earnest with Timothy Quill's 1991 New England Journal of Medicine account of how he helped his patient 'Diane' end her life" (p. 82).
The publication of Quill's study in a mainstream juried journal together with the publicity attended to Dr. Kevorkian's conviction and public statements in support of physician-assisted suicide resulted in calls from medical ethicists and leading physicians to develop formal regulatory guidelines (Fins, 1999). While many analysts interpreted the SUPPORT findings as clear evidence of deficiencies in medical care, others viewed these findings as legitimate rationale in support of legalizing physician-assisted suicide across the country. As Fins (1999) puts it, "After all, if things were this bad in American hospitals, then patients must be given an ability to control the timing and manner of their deaths" (1999, p. 82). Notwithstanding the fatalistic nature of this rationale, it became increasingly clear that some type of legislation was needed to help terminally ill patients avoid unnecessary suffering.
At the state level, efforts to legislate regulatory guidelines for physician-assisted suicide were spurred by New York Governor Mario Cuomo's Force on Life and the Law commission that investigated the pros and cons and concluded that legalizing the practice was not in the public's best interests (Fins, 1999). In addition, state laws that prohibited physician-assisted suicides were increasingly challenged in federal courts across the country, with an early precedential case (Compassion in Dying v. Washington, I994) in the State of Washington rejecting state law against physician-assisted suicide, holding that "if women had the right to make important intimate choices about questions such as abortion, then dying patients-invoking a comparable liberty interest-had a similar right to determine how they died" (cited in Fins, 1999, p. 82).
Conversely, a federal district court in a New York state case (Quill v. Koppel, I994) upheld the state's laws against physician-assisted suicide, arguing that these was were not unconstitutional (Fins, 1999). These conflicting decisions were subsequently appealed to Circuit Courts of Appeal with competent jurisdiction, with the Ninth Circuit Court overturning the decision in the State of Washington, thereby upholding the state's law against physician-assisted suicide (Fins, 1999). The urgency and complexity of these cases, though, ultimately resulted in these cases being heard en banc by the entire Ninth Circuit Court of Appeals which held in an eight-to-three decision that there was a fundamental constitutional right to physician-assisted suicide (Fins, 1999). In this latter decision by the court, Judge Stephen Reinhardt, expressing the majority opinion, cited the equal protection clause of the 14th Amendment to the U.S. Constitution, and emphasized that, "A competent, terminally ill adult, having lived nearly the full measure of his life, has a strong liberty interest in choosing a dignified and humane death rather than being reduced to a state of helplessness, diapered, sedated, incompetent" (cited in Fins, 1999, p. 82).
Likewise, the Second Circuit Court of Appeals in New York reversed the holding by the district court and ruled that the state's laws against physician-assisted suicide were in fact unconstitutional, also citing the equal protection clause of the 14th Amendment. According to Fins, "The judges argued that if terminally ill patients had the right to have life-sustaining therapies withdrawn in order to die, then patients who were not sustained by such measures were denied an equal opportunity under the law to end their lives, given the prohibition on physician-assisted suicide" (1999, p. 82). The U.S. Supreme Court agreed to hear the respective Circuit Courts of Appeal decisions to finally resolve these issues at the national level. In January 1997, the Supreme Court considered both of these seminal cases and held that U.S. citizens did not have a constitutional right to physician-assisted suicide in the case Vacco v. Quill (I997) (Fins, 1999).
Concomitant with the Supreme Court's decision in the Vacco v. Quill case, a number of states were considering various physician-assisted suicide legislation that would legalize the practice and Oregon became the first state to do so in November 1997 (Fins, 1999). Pursuant to the Death with Dignity Act passed on Oregon, physicians were authorized to prescribe lethal dosages of medications in those cases where terminally ill patients made repeated and voluntary requests for life-ending assistance (Fins, 1999). As noted in the introductory chapter, since that time, several other states have joined Oregon in legalized physician-assisted suicide in some form, making the need to distinguish physician-assisted suicide from euthanasia as discussed further below.
Physician-Assisted Suicide vs. Euthanasia
Proponents of physician-assisted suicide frequently attempt to differentiate the practice from active euthanasia; however, both practices share many of the same objections (Dixon, 1998). In this regard, Dixon emphasizes that, "Both can lead to abuse, both implicate the physician in the death of a patient, and both violate whatever objections there are to killing. Their moral similarity derives from the similar roles of the physician" (1998, p. 25). The Hippocratic Oath that is administered to all physicians in the United States counsels them to "abstain from doing harm" (rather than "first, do no harm" as popularly believed). In addition, according to one physician, "The classical version of the Hippocratic Oath in medicine has various requirements for physicians. Among those, the physician is required to state that: 'I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to that effect'" (cited in Hosseini, 2012, p. 203). On its face, this proscription against helping even terminally ill people would appear to obviate the arguments in support of physician-assisted suicide, but the issue reaches far deeper than this classical version indicates. Indeed, even the ancient Greeks were divided on whether some people should be allowed to die of their own volition and whether they should be permitted to receive assistance in doing so (Hosseini, 2012).
Today, the debate over the legalization of physician-assisted suicide typically excludes euthanasia as defined in the introductory chapter, but the two practices are sufficiently conflated in their respective objectives to warrant their consideration together. In this regard, Gorsuch (2006) advises that:
Though an analytical distinction exists between assisted suicide and euthanasia, there is a great deal they share in common, and those who support legalizing one tend to support legalizing the other for the same or similar reasons -- whether it be out of a sense that fairness requires killing those who wish to die but who cannot kill themselves, a desire to promote individual autonomy whether it is expressed in terms of a desire to kill oneself or have another do so, or a sense that the actions serve a similar social utility in allowing patients to avoid needless suffering. (p. 6)
Nevertheless, many proponents of physician-assisted suicide, particularly in the United States, have attempted to develop a distinction between the physician-assisted suicide and euthanasia through legislation that legalizes the former but not the latter. Perhaps this reluctance to include both practices is a lingering legacy of the horror stories that were caused by Dr. Kevorkian's "deathmobile," but the fact remains that even Oregon's law specifically legalizes physician-assisted suicide and not euthanasia (Gorsuch, 2006). As Gorsuch ponders, though, "Is there really any meaningful moral distinction that can be drawn between assisted suicide and euthanasia? If not, what is at work here?" (2006, p. 6).
"What is at work" is the notion that even people who should be allowed to take their own lives (with physician assistance) should be in final control of the circumstances of their death without the active involvement of anyone else, including trained medical professionals who are in the best possible position to render such assistance. In both physician-assisted suicides and euthanasia situations, though, there is a conscious decision on the part of an individual to seek life-ending treatment and a conscious decision on the part of the treating physician to provide it, making the legal distinction between the two practices less meaningful (Gorsuch, 2006). In the Netherlands, both practices are legal based on the rationale that "they are considered to be identical because intentionally and effectively they both involve actively assisting death" (cited in Gorsuch, 2006, p. 6).
Moreover, many physicians concur that there is little or no real difference between physician-assisted suicide and euthanasia beyond the strictly mechanical act of actively helping someone consume whatever lethal medications have already been prescribed. For example, one physician, Dr. John Keown, queries: "What, for example, is the supposed difference between a doctor handing a lethal pill to a patient; placing the pill on the patient's tongue; and dropping it down the patient's throat" (cited in Gorsuch, 2006, p. 6). Consequently, even seemingly progressive states that have enacted laws allowing physician-assisted suicide are actually excluding some patients who would otherwise be able to avail themselves of these laws if they were physical able to do so. As Gorsuch points out, "Thinking that physician-assisted suicide is the entire answer...is a fantasy. There will always be patients who cannot drink, or are semiconscious, or prefer that a physician perform this act" (2006, p. 6).
It is noteworthy that other countries that have legalized physician-assisted suicide have not drawn any legal distinctions between the practice and euthanasia based in large part on the foregoing rationale. For instance, Gorsuch adds that, "The distinction between the practices is made almost exclusively in American debate -- the Dutch and most others who have contemplated legalization see little reason to distinguish between the practices" (p. 6). It is also noteworthy that the rationale in support of continuing this distinction between physician-assisted suicide and euthanasia is likely attributable, at least in part, to efforts by proponents of the former to challenge existing laws that prohibit the practice when the opportunity presents itself (Gorsuch). This assertion is supported by the fact that the Euthanasia Society of America and other similar advocacy groups only came into existence during the late 1970s and 1980s as the legal challenges to physician-assisted suicide were becoming more commonplace (Gorsuch, 2006). Notwithstanding these legal distinctions between physician-assisted suicide and euthanasia in the United States, the arguments in support of the former share a number of features in common as discussed further below.
Arguments in Support of Physician-Assisted Suicide
As noted above, right-to-die advocates have been judicious in selecting which laws to challenges and when to challenge them depending on a number of prevailing social and political factors, but the arguments in support of physician-assisted suicide have typically focused on patient autonomy and the need to prevent unnecessary suffering. For instance, according to one medical ethicist, "Physician-assisted suicide isn't about physicians becoming killers. It's about patients whose suffering we can't relieve and about not turning away from them when they ask for help" (Hosseini, 2012, p. 204). Certainly, some medical doctors who have spent their entire careers trying to keep people from dying may be reluctant to engage in any type of practice that hastens death, but many other physicians have made it clear that they not only support physician-assisted suicide as a humane and compassionate intervention, they would be willing to do so personally as well (Rogatz, 2011). For example, one physician who support physician assisted suicide writes:
The role of physicians is not simply to preserve life, but also to apply expertise and skills to help improve their patients' health or alleviate their suffering. The latter includes providing comfort and support to dying patients. Such patients may, after careful consideration, come to the conclusion that in their particular situation, asking a physician for assistance in suicide best reflects their interests and preferences. (Biller-Andorno, 2013, p. 1451)
Notwithstanding the several arguments against physician-assisted suicide (discussed further below), Rogatz (2011) and like-minded authorities believe these arguments are more than countered by two fundamental arguments in support of the practice, with the first relating to patient autonomy and the second relating to the need to relieve unbearable suffering. In this regard, Rogatz (2011) notes that, "[American] society recognizes the competent patient's right to autonomy -- to decide what will or won't be done to his or her body. There is almost universal agreement that a competent adult has the right to self-determination, including the right to have life-sustaining treatment withheld or withdrawn" (p. 32).
In addition, many right-to-die proponents point out that although suicide was against the law throughout the U.S. in the past, there are currently no laws against committing suicide in the country today (Rogatz, 2011). Nevertheless, except in the handful of states that have legalized physician-assisted suicide, it is still a crime in 44 states for anyone to facilitate an act of suicide by another (Rogatz, 2011). This situation places citizens in these states at a distinct disadvantage when it comes to end-of-life decisions in the face of unbearable suffering. For instance, as Rogatz points out, "If patients seek such help, it is cruel to leave them to fend for themselves, weighing options that are both traumatic and uncertain, when humane assistance could be made available" (2011, p. 33).
There are also some powerful but pragmatic arguments in support of physician-assisted suicide. For instance, Smith (2003) emphasizes that, "It takes only about forty dollars for the drugs used in an assisted suicide. But it could take $40,000 (or more) to provide the medical care and mental health support necessary to alleviate an ill or disabled person's suicidal desire" (p. 32). Many Americans would likely agree that although it is impossible to place a price tag on human life, the human costs of providing terminally ill patients with palliative care that merely prolongs their suffering -- especially against their will -- far outweigh economic considerations. As Derek Humphry, founder of the Hemlock Society puts it, "[Assisted suicide could result in the saving of] hundreds of billions of dollars" [that] "could benefit those patients who not only can be cured but who want to live" (cited in Smith, 2003, p. 32).
Yet other advocates of physician-assisted suicide argue that "the line has already been crossed" in terms of de facto practice because Americans are already empowered to dictate their preferences through advance directives that prohibit the use of heroic life-saving measures to prolong their lives. In this regard, Hull (2003) points out that, "The fact that physicians must, at the insistence of the competent patient or the incompetent patient's duly appointed surrogate, withdraw life-sustaining technology shows that physicians can assist patient suicides and can perform euthanasia on those fortunate enough to be dependent on machines" (p. 36). In this context, "fortunate enough" of course refers only to the financial ability of patients to afford these life-sustaining interventions rather than their expressed preferences for such measures, but the issue does serve to underscore the inequity in current laws against physician-assisted suicide that place certain demographic groups at a disadvantage compared to their more affluent counterparts.
As noted above, many courts have relied on the equal protection provisions of the Fourteenth Amendment to justify the legalization of physician-assisted suicide for just this reason. This point is also made by Hull (2003) who argues that, "It becomes a matter of simple justice -- equal protection before the law -- to permit the same privileges to other terminal patients. That the U.S. Supreme Court has ruled against this argument did not dissuade the citizens of the State of Oregon from embracing it" (p. 37). These are powerful arguments in support of physician-assisted suicide, but there are other -- even more compelling reasons as well.
Notwithstanding anything in the Hippocratic Oath or current laws against physician-assisted suicide to the contrary, most Americans and practitioners alike agree that all physicians share an overarching responsibility to relieve unnecessary suffering whenever possible. For example, Rogatz (2011) notes that, "The physician's obligations are many but, when cure is impossible and palliation has failed to achieve its objectives, there is always a residual obligation to relieve suffering" (2011, p. 32). Unfortunately, this "residual obligation" remains the most contentious issue for many physicians since acting outside or against the law can easily result in malpractice or malfeasance litigation (Rogatz, 2011).
This is also one of the key reasons why proponents argue that physician-assisted suicide should be legalized -- to eliminate the subjectivity involved in evaluating the worth of human life versus unbearable suffering. According to Rogatz, "Ultimately, if the physician has exhausted all reasonable palliative measures, it is the patient -- and only the patient -- who can judge whether death is harmful or a good to be sought" (p. 32). The former executive editor of the New England Journal of Medicine, Marcia Angell, weighed in on this very issue by stating:
The highest ethical imperative of doctors should be to provide care in whatever way best serves patients' interests, in accord with each patient's wishes, not with a theoretical commitment to preserve life no matter what the cost in suffering.... The greatest harm we can do is to consign a desperate patient to unbearable suffering -- or force the patient to seek out a stranger like Dr. Kevorkian (cited in Rogatz, 2011, p. 32).
In reality, then, many of the arguments in support of physician-assisted suicide serve to underscore the limitations, inabilities and outright failures of the medical profession to adequately care for the terminally ill, especially those who are experiencing unbearable suffering, due in large part to fears about being labeled unethical "pill pushers." For instance, Hull (2003) points out that, "Far too many patients spend their last days without adequate palliation of pain. Physicians sensitive to their cries hesitate to order adequate narcotics, for fear of scrutiny by state health departments and federal drug agents" (p. 37). These are especially important issues when it comes to terminal conditions such as pancreatic cancer that can cause inordinate amounts of pain and suffering (Ikeda & Tomizawa, 2015).
Moreover, far too many physicians tend to refuse to accept the fact that their patients are simply going to die because this acceptance would run contrary to their professional standards and goals to maintain life as long as possible regardless of what this means to the terminally ill (Hull, 2003)..Taken together, then, it is clear that even the arguments in support of physician-assisted suicide are multifaceted, so it is not surprising that there are also a number of different arguments against the practice as discussed further below.
Arguments against Physician-Assisted Suicide
On June 30, 2016, the State of New Mexico joined a number of other states in rejecting lawsuits that challenge their laws against physician-assisted suicide (Hanson, 2016). In the case, Morris v. Brandenburg, right-to-die advocates argued that physician-assisted suicide was a fundamental right and that any state laws against the practice were invalidated absent a compelling reason from the state to the contrary (Hanson, 2016). The New Mexico Supreme Court's unanimous decision held that not only was there no such fundamental right under the state's constitution, the state had a number of reasons for prohibiting the practice even if such a right existed pursuant to the Fourteenth Amendment to the U.S. Constitution, including the following:
1. The need to protect "the integrity and ethics of the medical profession";
2. The need to protect "vulnerable groups -- including the poor, the elderly, and disabled persons -- from the risk of subtle coercion and undue influence in end-of-life situations, including pressures associated with the substantial financial burden of end-of-life health care costs"; and,
3. The need to protect "against voluntary or involuntary euthanasia because if physician aid in dying is a constitutional right, it must be made available to everyone, even when a duly appointed surrogate makes the decision, and even when the patient is unable to self-administer the life-ending medication" (cited in Hanson, 2016, p. 15).
These are powerful arguments, certainly, but opponents of physician-assisted suicide tend to conflate the practice with the type of grisly euthanasia practiced by Dr. Kevorkian rather than the protocols that are followed in states where the practice is legal. Nevertheless, many opponents of physician-assisted suicide agree that while right-to-die advocates make some good arguments, they are insufficient to counter the compelling arguments against the practice. In this regard, Levy (2008) maintains that, "While the policy arguments for physician-assisted suicide are strong they are not strong enough. They are counteracted by even stronger policy arguments against physician-assisted suicide" (p. 81).
The seeming conflation of physician-assisted suicide and euthanasia is also cited by Levy (2008) as being one of the constraints to the enactment of laws approving the practice in many states. For instance, Levy (2008) adds that, "Importantly, the latter arguments apply with greater force to physician-assisted suicide than to withdrawal of lifesaving medical treatment or palliative but death-hastening treatment" (Levy, 2008).
Some of the other, more compelling arguments against physician-assisted suicide include the following:
1. Many severely compromised individuals, in their depression, loneliness, loss of normal life, and despair, have asked their physicians to assist them in dying. Yet later (after physicians resisted their requests and others awakened them to alternative opportunities) they have returned to meaningful lives.
2. Medicine would be transformed for the worse if doctors could legally help patients end their lives. The public would become distrustful, wondering whether physicians were truly committed to saving lives, or if they would stop striving as soon as it became inconvenient.
3. Euthanasia and physician-assisted suicide are incompatible with our obligations to respect the human spirit and human life.
4. The longstanding and time-honored doctrine of double effect permits administering pain-relieving drugs that have the effect of shortening life, provided the intent of the physician is the relief of the pain and not the (foreseen) death of the patient (Smith, 2003, p. 33).
Each of these arguments, on its face, makes a good case for maintaining existing prohibitions against physician-assisted suicide in those states where such laws are currently on the books and for reexamining the laws of states where the practice has already been legalized, but there are other, equally compelling arguments against physician-assisted suicide as well, including those described by Levy (2008). According to Levy, one of the more persuasive arguments against legalizing physician-assisted suicide is that it would put serious financial pressure on terminally ill patients, especially those who are poor, to choose this option rather than the option of lifesaving medical treatment" (p. 83).
This assertion is based on the very real potential for Medicaid and Medicare authorities, viatical settlement organizations (these organizations purchase the all or part of a life insurance policy for less than its death benefit which is paid when the seller dies), managed health care plans and health and life insurance companies to more frequently counsel patients against receiving medical treatment if physician-assisted suicides were legally available in order to reduce costs and optimize their profits (Levy, 2008).
Clearly, the current situation is untenable from a humanitarian perspective because the outcome is based solely on financial issues rather than the human aspects that are involved, and less affluent Americans should not be compelled to seek physician-assisted suicide simply because it is a cheaper alternative, especially when it is merely cheaper for third parties that have a vested interest in hastening their deaths for two fundamental reasons. In this regard, Levy (2008) advises that the first reason is that, "Financial considerations are simply the wrong kind of basis for decisions that have such significant non-financial (i.e., personal, inter-personal, and spiritual/religious) significance and ramifications" (p. 84).
The second reason cited by Levy (2008) concerns the vulnerability of the less affluent terminally ill who may experience enormous pressure to accept physician-assisted suicide compared to their more affluent counterparts. Moreover, Levy emphasizes that, "This financial pressure will only be compounded by psychological pressure as well. Too many terminally ill patients wish to die because they feel -- or worse, have been made to feel -- like annoying nuisances to their families and doctors" (p. 84). Consequently, the fear exists that these patients would be especially vulnerable to "subtle coercion" from others to opt for physician-assisted suicide if the practice was legal in their states (Levy, 2008). Therefore, by keeping the practice illegal, patients in these circumstances will not feel pressured or obligated to take the most cost-effective course of action simply because it is not legally available (Levy, 2008).
Finally, the so-called "slippery slope argument" maintains that to the extent that physician-assisted suicide is made readily available is likely the extent to which the American public's views about physicians will change for the worse, causing widespread sociological and psychological problems (Levy, 2008). This point is also made by Fenigsen and Fenigsen (2012) who emphasize that, "If a category of persons is entitled to assistance in committing suicide, the courts may -- or will have to -- adjudge the same right to paralyzed patients unable to take the poison, and to unconscious persons and minors represented by guardians" (p. 306). Therefore, and as noted above, the slippery slope argument also maintains that the equal protection clause of the Fourteenth Amendment to the U.S. Constitution will ultimately be applied to the legalization of voluntary and even involuntary euthanasia if physician-assisted suicide is legalized (Fenigsen & Fenigsen, 2012). In addition, if physician-assisted suicide is legalized nationwide, the physicians who become "instruments of death" will come to consider the practice as "not so bad" and even as a "necessary evil" (Levy, 2008, p. 83).
There is also fear that legalized physician-assisted suicide could lead to the same types of eugenics that were practiced in ancient Sparta as well as the United States in the early 20th century and Nazi Germany during the mid-20th century. In this regard, Levy (2008) cautions that, "Some more opportunistic (and malevolent) physicians might come to regard physician-assisted suicide as an all-too-convenient means of 'weeding out' the 'weakest' or 'least desirable' members of society" (p. 83). Harking back to the gruesome practices used by Dr. "Death" Kevorkian whose first "patient" suffered from a non-terminal case of Alzheimer's disease, critics of physician-assisted suicide also argue that as the practice becomes more commonplace, more and more physicians will use this opportunity to coerce terminally and even non-terminal patients to accept their final solution.
Current Public Opinion about Physician-Assisted Suicide in the United States
The results of a series of national surveys indicate that a majority of American are in favor of physician-assisted suicides as shown in the series of tables at Appendix A. These national surveys also reflect a growing approval rate for physician-assisted suicide. For example, the responses to a Gallup survey question, "When a person has a disease that cannot be cured, do you think doctors should be allowed by law to end the patient's life by some painless means if the patient and his or her family request it?" showed 68% of Americans viewed the practice as being morally acceptable in May 2008 compared to 70% in May 2013. It is especially noteworthy that this question included requests by family members as well as the patient. These responses seem to indicate that most Americans consider it morally accepted to intervene on loved ones' behalf if and when they become unable to make the decision for themselves.
Likewise, the responses to the Gallup survey question, "When a person has a disease that cannot be cured and is living in severe pain, do you think doctors should or should not be allowed by law to assist the patient to commit suicide if the patient requests it?" showed that nearly two-thirds (62%) of Americans believe that doctors should be allowed to assist the patient commit suicide in May 2008 but 68% believed this in May 2015. These approval ratings are a far cry from June 1947 Gallup survey when not even half (49%) of the American public viewed" doctor-assisted suicide as morally acceptable" (Slew of states to consider aid-in-dying bills, 2016).
The most recent results of other nationwide polls reflect similar attitudes about physician-assisted suicide among the general American population. For instance, a majority (70%) of respondents to an Angus Reid Public Opinion poll conducted February 4-5, 2010 said they agreed that "Legalizing euthanasia would give people who are suffering an opportunity to ease their pain," but more than half (52%) also believed that legalizing the practice would also "leave vulnerable people without sufficient legal protection" (Slew of states to consider aid-in-dying bills, 2016).
The results of a CBS News/New York Times survey conducted in 2005 and 2006 also identified increasing approval levels among the American public concerning physician-assisted suicide. For example, the responses to the question, "If a person has a disease that will ultimately destroy their mind or body and they want to take their own life, should a doctor be allowed to assist the person in taking their own life, or not?," showed that in 2005, 54% of Americans believed that physician-assisted suicide should be allowed while 56% approved in 2006 (Slew of states to consider aid-in-dying bills, 2016).
Finally, the results of a Pew Research Center poll conducted March 2001 through July 2005 also identified stronger support for physician-assisted suicide but by a smaller margin than the foregoing surveys, with 46% of the respondents approving versus 45% who disapproved (9% reported being unsure about the issue) (Slew of states to consider aid-in-dying bills, 2016).
Taken together, it is clear that while physician-assisted suicide is a complex and contentious issue, the practice enjoys growing support from a broad-based sample of Americans who have become more familiar with modern life-ending interventions and the grisly episodes committed by Dr. Kevorkian become less salient. The review of the literature and these survey findings also confirm that both advocates and opponents of physician-assisted suicide concede that each camp has valid points but both believe their counter-arguments should prevail.
Chapter III: Methodology
Chapter Introduction
As reported in the introductory chapter, the purpose and objectives of this study were as follow:
1. To research whether unbearable suffering is the dominant motive to request physician-assisted suicide;
2. To research whether the race and level of education of the patient are contributing factors when physician-assisted suicide is requested; and,
3. To research whether the type of terminal illness the patient has been diagnosed with is a factor when requesting physician assisted suicide.
This chapter describes the data collection procedures that were used to achieve the above-stated research purpose and objectives. The first section of this chapter provides a demographic breakdown of the United States to determine the percentage of elderly individuals who may be especially affected by right-to-die legislation and a political map of states where physician-assisted suicide is already legal and those considering such legislation.
The second section presents the results of a custom survey of a convenience sample of American respondents (n=67) concerning their views about physician-assisted suicide.
Data Collection Procedures
The data used in section one below was collected from current U.S. population statistics maintained by the CIA World Factbook and the data for the map and current legislative status of physician-assisted suicide laws in the U.S. were derived from a study entitled, "Slew of states to consider aid-in-dying bills" (2016). The data used in section two below was collected from a total of 67 respondents who completed a custom online survey maintained at Surveymonkey in time for their responses to be included in the data analysis. The results of the custom survey are presented in tabular and graphic formats, and interpreted in a narrative fashion in the data analysis chapter that follows.
Setting
The survey was administered online to a convenience sample recruited using face-to-face and email invitations containing a link to the survey hosted at Surveymonkey.
Description of the Subjects
The subjects in this study were comprised of individuals, including friends, family members, classmates, coworkers and associates known to the author as well as those who were referred by these individuals for participation in the online custom survey. The subjects were contacted directly in person, by telephone or by email. Face-to-face and telephonic solicitations that were successful were followed up with a link to the online survey and all email solicitations also contained a link.
Description of the Research Instrument
A proforma copy of the two-section research instrument used in this study is shown at Appendix B. The custom survey instrument shown at Appendix B was developed following the guidance provided by Neuman (2003) to ensure that no double-barreled or ambiguous questions were included in the survey as shown in Table __ below.
Table 4
Custom survey instrument design steps
Step
Description
Step No. 1
Decide on type of survey.
Write survey questions.
Decide on response categories.
Design layout.
Step No. 2
Plan how to record data.
Step No. 3
Decide on target population.
Get sampling frame.
Decide on sample size.
Select sample.
Step No. 4
Locate respondents.
Administer survey.
Carefully record data.
Step No. 5
Enter data into computers.
Recheck all data.
Perform statistical analysis on data.
Step No. 6
Describe methods and findings in research report.
Presenting findings to other for critique and evaluation.
Source: Neuman, 2003 p. 268
In addition, the custom survey instrument was designed by following the steps advocated by Wallen and Fraenkel (2001) for this purpose as follows:
1. Be sure to be clear as to what variable or variables are to be assessed. Much time and effort can be wasted by definitions that are too ambiguous. If more than one variable is involved, be sure to keep both their meanings and specific items distinct. In general, a particular item or question should be used for only one variable.
2. Review existing instruments that are similar in intent in order to decide on item format and to obtain ideas on specific items.
3. Decide on format. Although it is sometimes appropriate to mix multiple-choice, true-false, matching, rating, and open-ended items, doing so complicates scoring and is usually undesirable.
4. Begin compiling and/or writing items. Be sure that each has logical validity -- that is, that the item is consistent with the definition of the variable. Try to ensure that vocabulary is appropriate for the intended respondents.
5. Have colleagues review the items for content validity. Supply colleagues with a copy of your definition and a description of the intended respondents. Be sure they evaluate format as well as content.
6. Revise items on the basis of colleague feedback. At this point, try to have about twice as many items as you intend to use in the final formy (Wallen & Fraenkel, 2001, p. 122).
Finally, the draft survey instrument was reviewed by several classmates, family members and coworkers to ensure that it appeared to collect the type of data desired that they readily understood the questions in order to ensure face validity (Neuman, 2003).
Procedures
The primary data collected from the online surveys was transferred to an Excel worksheet and frequency analyses and percentages were calculated. All respondents were guaranteed their anonymity and the original survey data was destroyed upon completion of the data analysis.
Chapter IV: Results
Section One: Current Demographic Breakdown of the United States and Status of Physician-Assisted Suicide Legislation
Part One: Demographic Breakdown
At present, more than 25% of the American population is aged 55 years and over, and nearly 13% (12.85%) of these are aged 65 years and older (U.S. population, 2016). Even the very elderly categories have experienced significant increases in recent years as shown in Figure 2 below.
Figure 2. U.S. population pyramid
Source: https://www.cia.gov/library/publications/the-world-factbook/graphics/ population/US_popgraph%202016.bmp
Moreover, the demographic composition of the American population has become far more diverse in recent years, and whites no longer account for a majority of the population in many regions of the country (U.S. population, 2016).
Part Two: Current Status of Physician-Assisted Suicide Legislation
As shown in Figure 3 below, at present, physician-assisted suicide is legal in Oregon, Washington, Vermont, Montana, New Mexico (Bernalillo County only). The states that are considering aid-in-dying legislation are California, Colorado, Florida, Indiana, Iowa, Maryland, Minnesota, Missouri, New Hampshire, New York, Nevada, Pennsylvania, Wisconsin and Wyoming.
Figure 3. Current legislative status of physician-assisted suicide in the U.S.
Source: https://www.lexisnexis.com/Communities/cfs-file.ashx/__key/communityserver-blogs-components-weblogfiles/00-00-00-00-22/3005.Deathdigmap.jpg
Section Two: Survey Results
As shown in Table __ below, there were a total of five African-American, 43 Caucasian, and nine Asian-American respondents who completed the custom survey in time for their results to be included in the data analysis. Four respondents self-reported "some high school," 33 reported earning a high school diploma or GED, 19 reported having some college, four reported having earned an associate's degree, five reported earning a bachelor's degree and one each respondents reported having earned advanced degrees.
Table 1
Part One: Survey demographic data
Gender
33 Male
34 Female
Race
5 African-American
43 Caucasian
10 Hispanic
0 Pacific Islander
9 Asian-American
0 Native American
0 Other
Education
4 Some high school
33 High school diploma/GED
19 Some college
4 Associate's degree
5 Bachelor's degree
1 Master's degree or other advanced degree
1 Phd or other doctoral degree
The responses to the series of Likert-scaled statements and their respective percentages are provided in Tables 2 and 3 below.
Table 2
Part Two: Likert-scaled statement results
Likert-Scaled Statements
SD
D
NA
A
SA
I believe that unbearable suffering is the dominant motive for most people requesting physician-assisted suicide.
3
4
4
23
33
Physicians have a moral obligation to relieve patients' unbearable suffering.
1
2
5
25
34
Physicians shouldn't play God by helping people die.
15
17
9
14
12
The type of diagnosed terminal illness has a major impact on the decision to seek physician-assisted suicide.
4
3
7
27
26
Members of low-income minority groups are more likely to want physician-assisted suicide compared to more affluent white Americans.
14
18
7
15
13
Legalizing euthanasia would leave vulnerable people without sufficient legal protection
5
7
6
22
27
Legalizing euthanasia would send the message that the lives of the sick or disabled are less valuable
17
19
7
16
8
Legalizing euthanasia would establish clearer guidelines for doctors to deal with end-of-life decisions
2
1
5
27
32
Legalizing euthanasia would give people who are suffering an opportunity to ease their pain
0
1
7
30
29
When a person has a disease that cannot be cured and is living in severe pain, doctors should be allowed by law to assist the patient to commit suicide if the patient requests it.
3
3
5
29
27
Key:
SD = Strongly Disagree
D = Disagree
NA = No opinion/not sure
A = Agree
SA = Strongly Agree
Table 3
Survey response percentages
Likert-Scaled Statements
%SD
%D
%NA
%A
%SA
Total %
Total
I believe that unbearable suffering is the dominant motive for most people requesting physician-assisted suicide.
4.48
5.97
5.97
34.33
49.25
67
Physicians have a moral obligation to relieve patients' unbearable suffering.
1.49
2.99
7.46
37.31
50.75
67
Physicians shouldn't play God by helping people die.
22.39
25.37
13.43
20.90
17.91
67
The type of diagnosed terminal illness has a major impact on the decision to seek physician-assisted suicide.
5.97
4.48
10.45
40.30
38.81
67
Members of low-income minority groups are more likely to want physician-assisted suicide compared to more affluent white Americans.
20.90
26.87
10.45
22.39
19.40
67
Legalizing euthanasia would leave vulnerable people without sufficient legal protection
7.46
10.45
8.96
32.84
40.30
67
Legalizing euthanasia would send the message that the lives of the sick or disabled are less valuable
25.37
28.36
10.45
23.88
11.94
67
Legalizing euthanasia would establish clearer guidelines for doctors to deal with end-of-life decisions
2.99
1.49
7.46
40.30
47.76
67
Legalizing euthanasia would give people who are suffering an opportunity to ease their pain
0.00
1.49
10.45
44.78
43.28
13.43
67
When a person has a disease that cannot be cured and is living in severe pain, doctors should be allowed by law to assist the patient to commit suicide if the patient requests it.
4.48
4.48
7.46
43.28
40.30
67
Key:
%SD = Percentage that Strongly Disagrees
%D = Percentage that Disagrees
%NA = Percentage with no opinion/not sure
%A = Percentage that Agrees
%SA = Percentage that Strongly Agrees
Part Three: Graphic and Narrative Interpretation
As shown in Figure 4 below, a clear majority of the respondents (56 or 83.6%) either strongly agreed (33 or 49.25%) or agreed (23 or 34.33%) with the statement, "I believe that unbearable suffering is the dominant motive for most people requesting physician-assisted suicide," while four respondents (or 5.97%) used the NA option. Just three respondents (or 4.48%) strongly disagreed and four respondents (or 5.97%) disagreed with this statement.
Figure 4. Responses to the statement, "I believe that unbearable suffering is the dominant motive for most people requesting physician-assisted suicide"
As shown in Figure 5 below, a clear majority of the respondents (59 or 88%) also either strongly agreed (34 or 50.75%) or agreed (25 or 37.3%) with the statement, "Physicians have a moral obligation to relieve patients' unbearable suffering," while five respondents (or 7.5%) opted to use the NA option. By contrast, three respondents (or 4.5%) either disagreed (2 or 3%) or strongly disagreed (1 or 1.5%) with this statement.
Figure 5. Responses to the statement, "Physicians have a moral obligation to relieve patients' unbearable suffering"
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