Physician-Assisted Suicide In End-of-Life Care

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Physician-assisted suicide (PAS) is a highly controversial, ethical dispute in end-of-life care. Its aim is to help those with terminal illness end their lives at a time of their choosing, with dignity and without pain. PAS is defined by Gaston, Randall, and Kiesel (2018) as “the process that allows terminally ill adults to request from their physician, receive from the pharmacist, and take a lethal dose of medication to end their life” (p. 73). It is not a matter exclusive to the medical world as it also involves politics, religion, and sociology.

According to Sulmasy, Finlay, Fitzgerald, Foley, Payne, and Siegler (2018), “the United States Supreme Court has ruled PAS is not a constitutional right, but states may choose to legalize it” (p. 1394). PAS is currently legal in Oregon, Washington, Vermont, Montana, California, Colorado, and Washington D.C. (Sulmasy et al., 2018). Cherry (2018) adds that Canada, Western Europe, Belgium, Luxemborg, and the Netherlands have also accepted the practice of medically-assisted death.

PAS revolves around death, which can be a highly spiritual matter, and its existence causes concern with religious groups. From a Christian viewpoint, “suicide, including PAS and voluntary euthanasia, involves a purposeful turning away from God” (Cherry, 2018, p. 6). The position taken by a professional organization on PAS skews society’s perception of the medical profession. PAS may also alter the trust between the patient-physician relationship. Even a neutral stance on PAS sends a message to the population that “medicine is avoiding taking responsibility for defining its fundamental ethical principles” (Sulmasy et al., 2018, p. 1397).

PAS and matters of end-of-life care are so controversial because people’s morals, values, and perspectives differ. This paper will discuss the arguments and counter-arguments for both sides of this issue, specifically addressing patient autonomy, reasons for choosing PAS, and effective palliative and end-of-life care.

Arguments

In health care, autonomy is an essential piece in delivering patient-centered care. According to Potter, Perry, and Stockert (2016), “respect for autonomy is a relatively new concept and reflects a movement away from paternalistic patient care in which the physician made all decisions” (p. 292). Modern medicine allows patients to make their own decisions when it comes to their care. A patient with a terminal illness who may be suffering physically, emotionally, or spiritually, should be able to create a plan of care with their provider(s) that resolves this suffering. For example, options may be extreme treatments or the discontinuation of treatments, pain medication, sedation, or PAS. Some say that PAS and forgoing life-sustaining treatment are not so different (Sulmasy et al., 2018). “The primary duty of medicine is to relieve suffering” (Sulmasy et al., 2018, p. 1395).

Sprung et al. (2018) states a reason a patient may choose PAS is to avoid being a burden on their family or support system, which includes financial burden. As the baby boomer generation ages, the anticipation of potential medical care and costs has become overwhelming. The implementation of PAS in Canada could decrease its annual health care spending by $138.8 million (Sprung et al., 2018).

Other PAS motivation is driven by hopelessness, fear, isolation, not being able to enjoy life, and loss of control, function, autonomy, dignity, and meaning (Sprung et al., 2018). It is not necessarily due to lack of appropriate palliative or end-of-life care. 68% of Americans approve of PAS (Gaston et al., 2018).

Counter-Arguments

Pro-PAS vies for the right of patient autonomy. However, honoring autonomy does not mean “I want, therefore I must get” (Sulmasy et al., 2018, p. 1397). Providers cannot bend to every patient request, such as prescribing antibiotics for the common cold or allowing cigarette smoking during a hospital stay. Simply stating that PAS is “patient desired or requested does not change the moral character of the act or its spiritual significance” (Cherry, 2018, p. 4). Health care staff must follow other principles of ethics like beneficence, non-maleficence, justice, and respect for the common good (Sulmasy et al., 2018). Providers must also honor their own autonomy, being allowed to choose when asked to perform duties that do not align with personal or religious beliefs, such as PAS (Potter et al., 2016).

Although a patient’s intention for seeking PAS may include hopelessness, fear, and isolation, we do not know if these are sparked by the dying process or actually symptoms of mental health conditions. “Less than 5% of assisted suicide cases in Oregon since 1997 (859) were referred for psychiatric evaluation” (Sprung et al., 2018, p. 199). A proper mental health assessment can help determine if the reasonings for PAS can be addressed and resolved without ending in PAS. Almost half of those seriously considering PAS changed their mind over time (Sprung et al., 2018). Another problem with PAS is that, aside from diagnosis, criteria is highly personal and subjective and not medical (Sulmasy et al., 2018). The few doctors who patients seek out to perform PAS have no established relationship with the patient and therefore an inadequate understanding of their lives outside the clinic (Sulmasy et al., 2018).

Many people believe death is a lonely and painful process full of suffering. Terminal patients may refuse pain medication due to misconceptions that it leads to addiction or abuse (Sprung et al., 2018). However, progression with symptom control, pain management, and palliative and hospice care proves these misconceptions to be wrong (Sulmasy et al., 2018). Even in suffering though, Cherry (2018) states a person can “discover meaning and value in his continued existence, instead of experiencing himself as powerless, alone, and a burden on his caregivers” (p. 5). Some may not think about how PAS also affects those left behind. “20% of relatives of patients who died following PAS demonstrated full or partial posttraumatic stress disorders and 16% had symptoms of depression up to two years after their loss” (Sprung et al., 2018, p. 200).

“The Hippocratic Oath states, ‘I will neither give a deadly drug to anybody who asks for it, nor will I make a suggestion to this effect.’ The oath is no longer used in universities in jurisdictions where PAS is legal” (Sprung et al., 2018, p. 200). Is it okay to legalize a medical practice that alters the Hippocratic Oath, the basis of all medicine?

Personal Position

We all believe that patient autonomy should be respected, reasons for choosing PAS be addressed, and proper end-of-life care be given. “Physicians have a duty to eliminate the pain and suffering, not the person with the pain and suffering. Solutions for suffering lie in improving palliative care and social conditions and addressing the reasons for PAS requests” (Sprung et al., 2018, p. 197). As health care providers, I believe we must first assess these patients holistically to determine the “why” of their PAS request. Symptom treatment and management, whether that is physical, mental, or spiritual, should be at the forefront, rather than focusing on PAS. This includes more training for health care providers in the management of mental health, palliative and hospice care, helping to create policies and being advocates in legislature to ensure all patients have access to that care, and doing our due diligence in educating patients and families on the dying process and the various treatment options available to them. I do believe that PAS should be an option, as a last resort. The opinion of a social worker gathered by Gaston et al. (2018) conveys this best:

I believe that the expansion of readily accessible palliative and hospice care—with skillful and empathetic providers—would sharply limit the number of individuals interested in such an option. Proper care at this stage of life—on medical, psychosocial, and spiritual levels—can help bring great life to the dying process to an extent for many PAS would no longer be considered. Nevertheless, it should be an available option and, I believe, can be seen as consistent with extremely compassionate care (p. 87).

References

Cherry, M. J. (2018). Physician-assisted suicide and voluntary euthanasia: How not to die as a Christian. Christian Bioethics, 24(1), 1-16. doi:10.1093/cb/cbx021
Gaston, N. R., Randall, J. M., & Kiesel, L. R. (2018). Physician-assisted suicide and Midwest social workers: Where do they stand? Journal of Social Work in End-of-Life and Palliative Care, 14(1), 73-92. doi:10.1080/15524256.2018.1433097
Potter, P. A., Perry, A. G., & Stockert, P. (2016). Fundamentals of nursing, (9th ed.). [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9780323327404
Sprung, C. L., Margaret, A. S., Radbruch, L., Collet, N. S., Duttge, G., Piva, J. P., … & Ely, E. W. (2018). Physician-assisted suicide and euthanasia: Emerging issues from a global perspective. Journal of Palliative Care, 33(4), 197-203. doi: 10.1177/0825859718777325
Sulmasy, D. P., Finlay, I., Fitzgerald, F., Foley, K., Payne, R., & Siegler, M. (2018). Physician-assisted suicide: Why neutrality by organized medicine is neither neutral nor appropriate. Journal of General Internal Medicine, 33(8), 1394-1399. doi:10.1007/s11606-018-4424-8

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