Exploring the Issues behind Patient-Assisted Suicide Essay Death is as much a part of human existence, of human growth and development, like birth. All humans need to undergo all these processes as they journey through life. However, death sets a limit on our time in this world, and life culminates in death. However, when we intervene with some of these natural processes, problems arise because it intrudes in lifeâ€™s natural processes. This is why, suicide is not just perceived as a medical problem because it also involves legal, ethical, social, personal, and financial considerations. It is not just morally reprehensible for a physician, or any medical practitioner, to assist the patient to conduct this procedure because it negates their responsibility to preserve life, suicide also devalues the life of the patient as its fate is put entirely in the hands of a human being to intrude with the natural process of things. For this reason, the debate over euthanasia (or patient-assisted suicide) involves many professionals, as well as the patients and their families. The arguments now have to do with the dignity of the patients, the quality of their lives, their mental state, and sometimes their usefulness to society. For example, the patient who is in a vegetative state is considered dead by some but not by others, and this case presents substantial ethical and logistical problems. The Oxford Dictionary of English (2005) defines euthanasia as â€œthe painless killing of a patient suffering from an incurable and painful disease or in an irreversible comaâ€. However, euthanasia means much more than a â€œpainless deathâ€, or the means of procuring it, or the action of inducing it. The definition specifies only the manner of death, and if this were all that was implied a murderer, careful to drug his victim, could claim that his act was an act of euthanasia. We find this ridiculous because we take it for granted that in euthanasia it is death itself, not just the manner of death. How can someone administer a medical â€œprocedureâ€ to the one who dies in the end? If a person requests the termination of his or her life, the action is called voluntary euthanasia (and often also assisted suicide). If the person is not mentally competent to make an informed request, the action is called non-voluntary euthanasia. Both forms should be distinguished from involuntary euthanasia, which involves a person capable of making an informed request, but who has not done so. Involuntary euthanasia is universally condemned and plays no role in current moral controversies. A final set of distinctions appeals to the activeâ€“passive distinction: passive euthanasia involves letting someone die from a disease or injury, whereas active euthanasia involves taking active steps to end a personâ€™s life. All of these distinctions suffer from borderline cases and various forms of ambiguity. The focus of recent public and philosophical controversy has been over voluntary active euthanasia (VAE), especially physician-assisted suicide. Supporters of VAE argue that there are cases in which relief from suffering supersedes all other consequences and that respect for autonomy obligates society to respect the decisions of those who elect euthanasia. If competent patients have a legal and moral right to refuse treatment that brings about their deaths, there is a similar right to enlist the assistance of physicians or others to help patients cause their deaths by an active means. Usually, supporters of VAE primarily look to circumstances in which (1) a condition has become overwhelmingly burdensome for a patient, (2) pain management for the patient is inadequate, and (3) only a physician seems capable of bringing relief (Dworkin, Frey Bok, 1998). One well-known incident that VAE came into the headlines was when it was provided by the bizarre activities of Dr.Â Jack Kevorkian in early 1990s (or â€œDr Deathâ€ as the media have dubbed him) in the USA. Dr. Kevorkian, a retired pathologist, assisted over forty people to commit suicide in recent years in circumstances which were somewhat removed from regular medical practice. These people travelled to Kevorkian from all over the USA to seek his assistance in suicide. He assisted them, sometimes by attaching them, in the back of his rusting Volkswagen van, to his suicide machine, which injected them with lethal drugs when they activated it. Despite being prosecuted for assisted suicide on several occasions, Kevorkian escaped conviction and continued his personal campaign for relaxation of the law in his peculiar way. It was only when he moved from assistance in suicide to euthanasia that he was finally convicted. He filmed himself administering a lethal injection, and the film helped secure his conviction for murder (Keown 2002, p. 31). Of course, his actions provoked discussion of the thin line separating passive euthanasia, which is legal in this country, and active euthanasia. Opponents of Kevorkianâ€™s actions state that he is practicing assisted suicide, which is illegal. Proponents of Kevorkianâ€™s actions argue that the patientâ€™s right to control his or her medical treatment is sufficient justification for assisted suicide. Euthanasia is Not Ethical According to Somerville (2006), there are two major reasons why people should not allow euthanasia to be legalized. One is based on principle: it is wrong for one human to intentionally kill another (except in justified self-defense, or in the defense of others). The other reason is utilitarian: the harms and risks of legalizing euthanasia, to individuals in general and to society, far outweigh any benefits. While Mak, Elwyn Finlay (2006) reasoned that â€œmost studies of euthanasia have been quantitative, focusing primarily on attitudes of healthcare professionals, relatives, and the publicâ€. Pain is usually identified as a major reason for requesting euthanasia; other influences included functional impairment, dependency, burden, social isolation, depression, hopelessness, and issues of control and autonomy. This is why, Mak, Elwyn Finlay (2006) thought that legalizing euthanasia is a â€œprematureâ€ move when research evidence from the perspectives of those who desire euthanasia is not yet proven to be necessary. They said â€œmore qualitative patient based studies are needed to broaden our understanding of patientsâ€. What needs to be done, they deemed, should be the â€œinclusion of medical humanities, experiential learning, and reflective practice into medical education should help ensure doctors have better communication skills and attitudesâ€. By examining ways to improve care at all levels, healthcare professionals can eliminate the side effects of poor end of life care, then euthanasia would not be needed anymore. In 1988, the Journal of the American Medical Association published a statement on its take about patient-assisted suicide when a gynecology resident agreed to conduct assisted suicide to a young woman, dying of cancer, whom he has never seen before. Horrified by her severe distress, and proceeding alone without consultation with anyone, the doctor gives her a lethal injection of morphine. The publishing of this gynecology residentâ€™s letter caused media hype and was featured in the previous issue in JAMA, where it was titled as â€œItâ€™s Over Debbieâ€ (1988). This is how the JAMA took its position regarding the matter: 1. ) On his own admission, the resident appears to have committed a felony: premeditated murder. Direct intentional homicide is a felony in all American jurisdictions, for which the plea of merciful motive is no excuse. That the homicide was clearly intentional is confirmed by the residents act of unrepentant publication. Law aside, the physician behaved altogether in a scandalously unprofessional and unethical manner. He did not know the patient: he had never seen her before, he did not study her chart, he did not converse with her or her family. He never spoke to her physician. He took as an unambiguous command her only words to him, Lets get this over with: he did not bother finding out what precisely she meant or whether she meant it wholeheartedly. He did not consider alternative ways of bringing her relief or comfort; instead of comfort, he gave her death. This is no humane and thoughtful physician succumbing with fear and trembling to the pressures and well-considered wishes of a patient well known to him, for whom there was truly no other recourse. This is, by his own account, an impulsive yet cold technician, arrogantly masquerading as a knight of compassion and humanity. (Indeed, so cavalier is the report and so cold-blooded the behavior, it strains our credulity to think that the story is true. ) Law and professional manner both aside, the resident violated one of the first and most hallowed canons of the medical ethic: doctors must not kill. Generations of physicians and commentators on medical ethics have underscored and held fast to the distinction between ceasing useless treatments (or allowing to die) and active, willful taking of life; at least since the Oath of Hippocrates, Western medicine has regarded the killing of patients, even on request, as a profound violation of the deepest meaning of the medical vocation. The Judicial Council of the American Medical Association in 1986, in an opinion regarding treatment of dying patients, affirmed the principle that a physician â€œshould not intentionally cause death. â€ Neither legal tolerance nor the best bedside manner can ever make medical killing medically ethical (Baird Rosenbaum 1989, p. 26). Indeed, the laws of most nations and the codes of medical and research ethics from the Hippocratic Oath to todayâ€™s major professional codes strictly prohibit VAE (and all forms of merciful hastened death), even if a patient has a good reason for wanting to die. Although courts have often defended the rights of patients in cases of passive euthanasia, courts have rarely allowed any form of what they judged to be VAE. Those who defend laws and medical traditions opposed to VAE often appeal to either (1) professional-role obligations that prohibit killing or (2) the social consequences that would result from changing these traditions. The first argument is straightforward: killing patients is inconsistent with the roles of nursing, care-giving, and healing. The second argument is more complex and has been at the center of many discussions. This argument is referred to as the wedge argument or the slippery slope argument, and proceeds roughly as follows: although particular acts of active termination of life are sometimes morally justified, the social consequences of sanctioning such practices of killing would run serious risks of abuse and misuse and, on balance, would cause more harm than benefit. The argument is not that these negative consequences will occur immediately, but that they will grow incrementally over time, with an ever-increasing risk of unjustified termination (Dworkin, Frey Bok, 1998). Refusal of Treatment When a patient refuses treatment, the physician is faced with a great dilemma. Doctors maintain that if the patient does not want treatment, physicians do not have a duty to start it. Once treatment is started, however, physicians have a duty to continue it if discontinuing it would lead to the patients death. They are not required to force a patient to go on a respirator if the patient refuses, but once the patient has gone on the respirator, doctors have a duty to keep him on it, even contrary to the patients wishes, if taking him off would result in his death. Suffice it here to point out one important limit: a doctor is not ethically bound to assist a refusal of treatment which is suicidal, that is, made not because the treatment is futile or excessively burdensome but in order to hasten death (Keown, 2002, p. 253). Actual suicide has been a felony in England in the past but today, suicide has been decriminalized in most part of the world. Attempting to take ones own life, however, remains criminal in some jurisdictions. In these as well as in those states where it is not a crime, the state has intervened in some cases to order life-sustaining treatment in the face of objection by a competent adult. The most widely cited case in which this was done is John F. Kennedy Memorial Hospital v. Heston (1971), where a twenty-two-year-old unmarried woman refused a blood transfusion because she was a Jehovahâ€™s Witness. She was forced to have one anyway on the theory that there is no difference between passively submitting to death and actively seeking it. The state regards both as attempts at self-destruction and may prevent them. Since this case, however, the trend of cases has been away from this reasoning and toward subordinating the states interest in the prevention of suicide to the rights of patients to forgo or have withdrawn life-sustaining treatment (Berger 1995, p. 20). However, when the patient is terminal and death is imminent, no treatment is medically indicated, and the competent patientâ€™s rightful refusal of treatment does not conflict with the health providerâ€™s form of beneficence. There may be an emotional problem in admitting defeat, but there should be no ethical problem. It should be noted that, although the patient may not be competent at the end, refusal of treatment may be accomplished through a living will or a surrogate, especially through a surrogate who has durable power of attorney for health matters. In the case when the patient is terminal but death is not imminent, for example when the disease or injury progresses slowly, and granted the consent of the patient or surrogate, it appears ethical to omit treatment on the ground that nothing can be accomplished in thwarting the progress of the disease. But it is not ethical to omit care, since human dignity is to be respected. To solve this dilemma, the AMA Council on Ethical and Judicial Affairs (1996) takes a clear stand on the issue: E-2. 20 Even if the patient is not terminally ill or permanently unconscious, it is not unethical to discontinue all means of life-sustaining medical treatment in accordance with a proper substituted judgment or best interests analysis. The treatments include artificially supplied respiration, nutrition, or hydration. In its recent opposition to physician-assisted suicide, the AMA has strongly endorsed a program to educate physicians to the appropriateness of switching from therapeutic treatment to palliative care. The group has gone from a tentative, negative position (â€œnot unethicalâ€) to a much stronger positive stand (AMA, 1996). On the other hand, we should also consider the reasoning behind the ethical correctness of not beginning or of stopping treatment in the case of the consenting patient who is terminally ill. First, the health care provider has no obligation to prolong dying merely for the sake of prolonging it. That is, it makes no sense to prolong life when the true result is the prolongation of the dying process. Furthermore, when treatment is only prolonging the agony of the patient, its continuation is unethical as an insult to human dignity (Cahill, 1977). In such cases, the health care provider would be ethically justified in discontinuing treatment, except when the patient insists on treatment. Even in this case, however, there can be exceptions. When there is a severe shortage of medical resources, the physician might be justified in stopping nonindicated treatment even over the protests of the patient. We say â€œmight be justified,â€ since justification would depend, among other things, on a new social consensus about the duties of health care professionals and on a reasonable certainty that a shortage exists. There are also problems in discontinuing treatment when the patientâ€™s surrogate(s) objects. It should be noted that cessation of life-sustaining treatment does not always bring about a swift and painless death, even though it may speed up the process of dying. For example, if kidney dialysis is discontinued, the person remains conscious and suffers vomiting, internal hemorrhage, and convulsions. The removal of a respirator does not lead to death immediately, and the patient suffers the pain and panic of suffocation. The obligation to care for the patient demands that every ethical effort be made to alleviate these sufferings with drugs and other methods that will not prolong life. Much recent research suggests that physicians are particularly deficient in their willingness and ability to provide adequate pain palliation for dying patients (SUPPORT, 1995). This could be one of the main concerns that drive the interest in physician-assisted suicide. Beyond this, when such pain relief is not possible for the patient, or when the harm is not the pain, but the insult to dignity, there arises the difficult problem of actively cooperating in the suicide of the patient. Religious Issues Several religions have a negative take on any form of suicide. Those who oppose active euthanasia on religious grounds, the basic concern seems to be the view that our lives are not ours but gifts from God. In this view, humans hold their lives as a trust. If this is true, then we are bound to hold not only the lives of others inviolate but also our own, since to take our life is to destroy what belongs to God. For Christians, in Exodus 34:7 and Daniel 13:53, scriptures taken from the Old Testament, the doctrine of the sanctity of life principle is upheld, except in rare instances of self defense. Judeo-Christian precepts generally condemn active euthanasia in any form, but allow some forms of passive euthanasia. The difference is that of omission and commission: While the Judeo-Christian philosophy might tolerate the allowance of death, acts that permit death, it draws the line in regard to acts that cause death. For Buddhists, they perceive it as an involvement of the intentional taking of life. This is why euthanasia is contrary to basic Buddhist ethical teachings because it violates the first of the Five Precepts. It is also contrary to the more general moral principle of ahimsa. This conclusion applies to both the active and passive forms of the practice, even when accompanied by a compassionate motivation with the end of avoiding suffering. The term â€˜euthanasiaâ€™ has no direct equivalent in canonical Buddhist languages. Euthanasia as an ethical issue is not explicitly discussed in canonical or commentarial sources, and no clear cases of euthanasia are reported. However, there are canonical cases of suicide and attempted suicide which have a bearing on the issue. One concerns the monastic precept against taking life, the third of the four parajika-dharmas, which was introduced by the Buddha when a group of monks became disenchanted with life and began to kill themselves, some dying by their own hand and others with the aid of an intermediary. The Buddha intervened to prevent this, thus apparently introducing a prohibition on voluntary euthanasia. In other situations where monks in great pain contemplated suicide they are encouraged to turn their thoughts away from this and to use their experience as a means to developing insight into the nature of suffering and impermanence (anitya) (Dictionary of Buddhism, 2003). Nonreligious arguments against active euthanasia usually follow a slippery slope or wedge line of reasoning. In some ways the arguments recall the parable of the camel who pleaded with his owner to be allowed to put his nose into the tent to keep it warm against the cold desert night. Once the nose was allowed, other adjustments were requested, and the owner found himself sleeping with his camel. Is there something so persuasive about putting others to death that, if allowed, would become gross and commonplace? The Nazi â€œfinal solution,â€ which brought about the death of millions of Jews, gypsies, and other eastern Europeans, could be traced to compulsory euthanasia legislation that, at the time of its enactment, included only mental cases, monstrosities, and incurables who were a burden of the state. Using the Nazi experience as a guide, critics of active euthanasia do see some seductiveness to killing that humans do not seem able to handle. Perhaps Sigmund Freud (1925) was right as he wrote: What no human soul desires there is no need to prohibit; it is automatically excluded. The very emphasis of the commandment â€œThou shalt not killâ€ makes it certain that we spring from an endless ancestry of murderers, with whom the lust for killing was in the blood, as possibly it is to this day with ourselves. The religious take on euthanasia often focus on the sanctity/inviolability of life. In Western thought, the development of the principle has owed much to the Judaeo-Christian tradition. That traditionâ€™s doctrine of the sanctity of life holds that human life is created in the image of God and is, therefore, possessed of an intrinsic dignity which entitles it to protection from unjust attack. With or without this theological underpinning, the doctrine that human life possesses an intrinsic dignity grounds the principle that one must never intentionally kill an innocent human being. The right to life is essentially a right not to be intentionally killed (Keown, 2002, p. 40).
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