Physician-Assisted Suicide: Ethical Problems with Death with Dignity Laws

Introduction: The Ethics of Physician-Assisted Suicide

Euthanasia and physician-assisted suicide (PAS) is a topic that constantly sparks ethical debate. Euthanasia has become a subject of growing interest, especially in the industrialized countries of the world, because of the high standards for medical care and the idea that physician-assisted suicide can improve end-of-life care by alleviating suffering and preventing patients from attempting to end their lives through more painful means. For some, the "right-to-die" movement is compassionate, as it can liberate one from the pain and suffering associated with terminal illnesses; oftentimes these patients are anxiously awaiting death so that they may be released from the agony of their condition.

In the article "Physician-Assisted Suicide: Compassionate Liberation or Murder," Lachman (2010, 121) states that in Ancient Rome, voluntary suicide was sanctioned, and it continued to be sanctioned throughout the Middle Ages. It was the influence of the Christian church, it is suggested, that "ascribed a sinful nature to suicide, which kept it from being explicitly accepted" (2010). There are a number of factors that seem to inspire varied responses to the idea that, to quote Francis Bacon, "the dying may pass more easily and quietly out of life" (Birnbacher & Dahl 2008, v). Some of those reasons are religious, as noted above; others may have to do with the historical experience of the abuse of euthanasia at the hands of reckless physicians (2008, v); and still others reflect the Hippocratic tradition of forbidding any physician from using medicine to actively bring about the death of a patient (2008, v).

Whether one says "physician-assisted suicide," "euthanasia," "right-to-die," "death with dignity," "good death," "rational suicide," "aid in dying," or "merciful release," these are all euphemisms for the possibility of killing someone or helping individuals to kill themselves (2010, 121). PAS gives a human being — who is imperfect and thus capable of error — the role of God, and with this role will inevitably come varying opinions on what constitutes a sufficient reason for being granted the right to die. This paper illustrates the major problems with PAS, with a specific focus on the State of Oregon's Death with Dignity Act, which gives physicians the power to determine who is permitted to die.

Lachman (2010, 121) asserts that physician-assisted suicide, or euthanasia in general, is an issue that lies in a person's moral conscience as well as in any legal or ethical considerations surrounding the patient. Literature and legislation on euthanasia — specifically in the United States, Australia, Japan, Canada, and New Zealand — concerns nurses as well as doctors (Quaghebeur, Dierckx de Casterle & Gastmans 2009, 466) because of each profession's specific role in the care of dying patients. Nurses and doctors alike are intimately involved in the whole process of patient care and are often asked by patients to help assist them in dying. Quaghebeur et al. note that a range of feelings accompanies this topic for nurses and doctors — personal conflict, moral uncertainty, fear, guilt, secrecy, and frustration (2009, 467). These feelings are an inevitable part of any engagement with the concept of assisted suicide, as it means taking an active part in another person's death and claiming the authority to make a decision that no human should be permitted to make for another. While a dying patient will have his or her own reasons for wanting to die, as well as personal beliefs about the ethical or religious challenges involved, there is a fundamental difference between a person taking their own life and a person helping to take another's. There is no ethical or moral framework within which physician-assisted suicide can be soundly rationalized.

Oregon's Death with Dignity Act and Its Safeguards

In October 1997, five months after the U.S. Supreme Court ruled that there was no constitutional right to assisted suicide — but implied that states have the right to decide for themselves whether to prohibit PAS — the Oregon Death with Dignity Act was enacted. After facing its own legal challenges, the Act allowed the primary care physician managing a patient's terminal illness to prescribe a lethal medication, which the patient then self-administers (Carlson, Simopolous, Goy, Jackson & Ganzini 2005, 1160). It was believed that the Oregon Death with Dignity Act (ODDA) would serve as a kind of laboratory for the rest of the United States, demonstrating how PAS would function in practice (Hendin & Foley 2008, 1614). However, this has not occurred because the Oregon Public Health Division (OPHD), which is charged with monitoring the law, has interpreted its mandate in an extremely restrictive manner (2008, 1614). OPHD limits its annual reports to general "epidemiological data" (2008, 1614) and collects limited information from doctors who have prescribed lethal medication. According to Hendin and Foley, doctors who refused to prescribe lethal medication, as well as nurses, social workers, pharmacists, and family members involved in these cases, are not interviewed. Furthermore, all information collected is withheld from the public and destroyed after one year.

Since the passing of the ODDA, however, several sources — including patients, families, healthcare workers, doctors, nurses, social workers, chaplains, and advocacy groups — have provided more specific information suggesting that the implementation of the ODDA has had "unintended, harmful consequences for patients" (Hendin & Foley 2008, 1614).

The law does put in place what appear to be logical safeguards for end-of-life patients, including: offering options for palliative care; ensuring that patients are mentally competent to make this decision for themselves; limiting the procedure to terminally ill patients; ensuring the voluntariness of the PAS request; obtaining a second physician opinion; requiring the request for PAS to be persistent; encouraging family involvement; and requiring doctors to inform OPHD of all cases in which a prescription for PAS has been written (Hendin & Foley 2008, 1614). However, Hendin and Foley note that evidence strongly suggests these safeguards are "circumvented in ways that are harmful to patients" (2008, 1614).

In one case discussed in Hendin and Foley's article, an Oregon woman named Helen was denied PAS by her long-time physician for unspecified reasons. A second physician also refused her request for PAS on the grounds that Helen was depressed. Helen's husband then contacted an organization called Compassion for Dying and was referred to a physician who agreed to help her.

Case Study: Helen and the Failure of Safeguards

The medical director of Compassion for Dying spoke with Helen and her son and daughter by telephone, describing Helen as "rational, determined, and steadfast," and questioned the judgment of the physician — with whom the medical director also spoke by phone — who believed her depression was affecting her wish for PAS (Hendin & Foley 2008, 1616). The medical director said that Helen was frustrated because she felt powerless. She was no longer able to exercise or garden, her favorite activities, and even though she was not bedridden or in much pain, the "quality of her life was just disappearing," and the medical director believed it was best to act quickly before Helen could no longer make decisions for herself (2008, 1617). He said she was "going downhill rapidly... She could have had a stroke tomorrow and lost her opportunity to die in the way that she wanted" (2008, 1617).

The physician who agreed to prescribe the medication met Helen two and a half weeks before her death. He reported that she had more physical pain than Compassion for Dying had indicated — after twenty years, her cancer had spread to her lungs, causing pain and shortness of breath. He followed a protocol, giving her an anti-nausea medication before arriving to be with her family when she died. She then took a mixture of barbiturates (nine grams) and syrup, followed by a glass of brandy, and died within thirty minutes (Hendin & Foley 2008, 1617).

The problems with this case are significant. Helen received two contradictory sets of professional opinions regarding the appropriateness of her decision. As the decision-making process progressed, no one questioned the fact that two other doctors had denied Helen's request for PAS — one without explanation and one on grounds of depression that he believed was clouding her judgment rather than reflecting a coherent and autonomous choice.

What becomes clear in reading the case is that the doctor who ultimately facilitated Helen's death was strongly influenced by her determination to die (Hendin & Foley 2008, 1618). Although the doctor noted that he was disturbed by her haste, he ultimately could not resist. Hendin and Foley observe that such haste or "stubborn urgency is often a sign of irrational motives" (2008, 1618). In an article published in the British journal Lancet, the doctor issued the following statement:

"The thought of Helen dying so soon was almost too much to bear... On the other hand, I found even worse the thought of disappointing this family. If I backed out, they'd feel about me the way they had about their previous doctor, that I had strung them along, and in a way, insulted them" (Hendin & Foley 2008, 1619).

This statement is deeply troubling. Neither a reluctance to see Helen die nor a desire to avoid disappointing her family should have been a factor in helping this woman end her life. This is a prime example of why individuals — physicians included — should not be permitted to assist another person in suicide. As human beings, we are too subject to emotion ("the thought of Helen dying so soon was almost too much to bear") and to social pressures ("even worse the thought of disappointing this family") to make sound and genuinely ethical decisions in such circumstances.

Conclusion: The Doctor as Healer, Not Killer

The role of the doctor is as healer, not killer; this is the way it has been throughout history and this is the way that it must continue to be. To be a healer is to work in the best interest of the individual, which means finding ways to help patients manage their pain and improving palliative care. Giving physician-assisted suicide a gentle name is both wrong and manipulative, as it frames what is, in ethical terms, a deeply problematic act as though it were a compassionate medical service. "Death with Dignity," or whatever name it is given, functions to obscure what many would recognize as ethically wrong if it were described plainly. As the saying goes: if it looks like a duck, it is a duck. Giving patients medication with which to kill themselves is killing, however it is framed. While states like Oregon and Washington have found ways to create legal frameworks around PAS, the evidence from Oregon's own experience already demonstrates that physicians should not be entrusted with the power to determine the fate of another human being.