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Essay: Ethical issues in Professional Practice Report (euthanasia, nursing case study)

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This report is going to discuss ethical issues around euthanasia from the point of view a nurse working at palliative ward and one of her patients. A 65 years old patient with stage 1 chronic obstructive pulmonary disease, with life expectancy around 3 months, is asking a nurse for help to end his life. What should she do with it? (Healthline, 2019)

What are euthanasia and assisted suicide?

The term euthanasia comes from Greek and means good death. Euthanasia includes different forms:

  • Active euthanasia, when a person introduces something to cause a patient’s death;
  • Passive euthanasia, when patient dies due to withholding treatment or supportive measures;
  • Voluntary euthanasia, which occurs when a patient gave consent to withdraw treatment;
  • Involuntary euthanasia, when consent must be given by a guardian or a person responsible for the patient;
  • Physician-assisted euthanasia, where a physician prescribes the medicine and patient, or the third party administers the medication to cause death.
  • Indirect euthanasia, when the provided treatment that has no intention to kill the patient, usually pain relieving, has a side effect of speeding the patient’s death.

Assisted suicide is a way of providing help to a person, that request assistance with killing themselves, for example by getting drugs for the person and putting those drugs within their reach.

The law and nurse practice code.

According to English law both euthanasia and assisted suicide are illegal. The consequences of disobeying law may result in the person to be treated as a murderer and facing 14 years in prison under the 1961 Suicide Act. That also includes assisting, aiding or counselling somebody in relation to taking their own life. The suicide itself under the 1961 Suicide Act is legal.

The authorities may decide not to prosecute in cases of euthanasia after considering the circumstances of the death.

In September 2009 the Director of Public Prosecutions introduced the criteria that indicate whether a person is prosecuted. The important factor, in order to avoid prosecution, is if the suspect knew the person who died and if the death was a one-off incidence.

According to the Human Rights Act 1998, the denial of a right to release oneself from unbearable pain amounts to inhuman and degrading treatment (Article 3 of the European Convention on Human Rights), is a violation of privacy and family life (Article 8), amounts to discrimination given the legality of suicide itself, and that an individual’s inherent dignity and ‘right to die’ is violated by the current legislation. (Fergusson, 2005) (European Convention on Human Rights, 1950)

According to the Nursing and Midwifery Council (NMC), nurses are required to follow the NMC’s Code: standards of conduct, performance and ethics for nurses and midwives (2015), which directs nurses to: (Nmc.org.uk, 2018)

  • keep to the laws of the country in which you are practising
  • make sure that people’s physical, social and psychological needs are assessed and responded to, by prioritising people
  • to practise effectively and act without delay if it is believed there is a risk to patient safety
  • share information if there is a danger that someone may be at risk of harm
  • acknowledge and act on all concerns that are raised, investigating, escalating or dealing with those concerns where it is appropriate to do so
  • not obstruct, intimidate, victimise or in any way hinder a colleague, member of staff, person you care for or member of the public who wants to raise a concern
  • promote professionalism and trust
  • be a model of integrity and leadership for others to aspire to.

According to the Mental Capacity Act of 2005 clinical practice can sometimes involve assessing a patient’s mental capacity by a doctor. When a patient request for assisted suicide, the doctor will assess patients for mental capacity, to investigate the need for protecting them from harm or self-harm. However, the Act was not designed or intended to regulate capacity assessment in the context of euthanasia or assisted suicide. (Gmc-uk.org, 2019)

Is the euthanasia legal in other countries? (Cheatle, 2019)

Currently, voluntary euthanasia and/or doctor-assisted suicide is legally available in Belgium, Canada, Colombia, Luxembourg, The Netherlands, Switzerland, and in six US States (California, Colorado, Montana, Oregon, Vermont and Washington State).

In Switzerland, assisting suicide has not been a crime since suicide was decriminalised during the age of enlightenment. But if this kind of assistance would be done without patient will, according to the law from 1918 this kind of behaviour should be punished. In other words, there would not be any legal consequences if a person that helped to commit suicide was acting selflessly.

The person being assisted must be an adult, mentally capable and committing suicide by themselves. Voluntary euthanasia is prohibited in Switzerland.

Currently, there are two large organizations, both called Exit, based in Geneva and Zurich, which are for Swiss nationals only, and another two which are mainly for foreigners: Dignitas, near Zurich, and Lifecircle, in Basel. Switzerland is the only country which helps die to foreign nationals.

Adults eligible to use those organizations must be terminally ill, suffer from a severe disability, or be elderly with medical conditions related to old age that would make their lives too difficult.

Regardless of assisted suicide being legal in Switzerland, still, only about 1.5% of Swiss deaths are due to assisted suicide.

In the Netherlands, both voluntary euthanasia and doctor-assisted suicide are legal from 2002. It is eligible for people who are experiencing unbearable suffering without the prospect of improvement; therefore, the patient does not have to be terminally ill and there is no mandatory waiting period. In practice, very few Dutch nationals choose doctor-assisted suicide, preferring euthanasia.

In Belgium, voluntary euthanasia and doctor-assisted suicide are legal since 2002. The palliative care services and the option of medically-assisted dying is well integrated. Same as in the Netherlands, doctor-assisted suicide is rarely requested by a patient, as the euthanasia is preferred. It is eligible to all competent adults who are suffering irreversibly or are terminally ill, with a one-month waiting period, for those who are not terminally ill, before euthanasia can be performed.

In Luxembourg, voluntary euthanasia is legal since 2009 but considering the size of this country less than fifty of its citizens had died this way until 2015.

In Colombia, where it’s Constitutional Court had approved the possibility of voluntary euthanasia in 1997, the first such death only occurred in 2015. This is the only jurisdiction that requires the prior approval of euthanasia requests by an independent committee.

The province of Quebec adopted legislation for doctor-assisted suicide in 2014, and the Federal Government took similar steps in 2016. Canada, excluding Quebec, allows either medically assisted suicide or euthanasia. In Quebec, only euthanasia is allowed.

In 1997 Oregon became the first state to legalize doctor-assisted suicide for terminally-ill adults. Later, in 2008, Washington State adopted the same law: to be followed by Vermont in 2013, and California and Colorado in 2016. In Montana, it’s Supreme Court, in 2009, agreed that doctor-assisted suicide could be allowed.

In these States, the doctor must write a prescription for the necessary medication, but he is not obligated to be present when the terminally-ill patient decides to die. All these States require a fifteen-day period between two oral requests and a two-day waiting period between a final written request and the dispensing of the prescription.

Patient’s view.

As the patient may not be aware of the current UK law, he may ask for help with ending his life.

For the patient with chronic obstructive pulmonary disease, this type of request may be a result of depression or basically unbearable pain that the patient is experiencing. As his treatment is mainly focused on managing his symptoms and maintaining his quality of life, the feeling of hopelessness, limited time and losing control over his life may be the factors to express willingness to die as the life is no longer worth living. Also due to illness patient may feel like he has lost the autonomy to control his life, therefore he would like to end his life under his own conditions, but as it was said before under UK law patient autonomy gives him only the right to refuse treatments, but then again it is not giving him a right to demand help with assisted suicide. This brings another dilemma around facing the consequences of treatment or non-treatment. Another thing that could be considered towards expressing to die is that the patient is isolated in hospital, with some visits from friends and family, which can make him feel like he became a burden to them.

What is the nurse’s responsibility?

When the patients make direct on indirect statements about the desire of ending their life, the nurse must follow the UK law and the Nursing and Midwifery Council (NMC) Code of Conduct. As it is required that the nurse will keep professional boundaries with the patient or his relatives, it would be inappropriate to discuss the personal views on the matter of assisted suicide, assisted dying, or euthanasia with anyone in your care or their relatives or guardians. Therefore, a nurse as a representative of her profession must support governments and NMCs view in this matter to maintain trust for this occupation. It is also unprofessional and more likely illegal to provide contact details or website addresses for organisations that promote or provide support for people wishing to commit suicide, as under current legislation giving this kind of assistance may be seen as doing an act capable of encouraging or assisting the suicide or attempted suicide of another person, which is criminal offence with risk of spending up to 14 years in prison.

When the nurse is approach with this kind of request it is a good practice to offer the patient the counselling sessions to find out the underlying causes of a patient is suicidal. Also providing the comfort of living and treatment focused on easing pain may be very important in kind of cases.

Conclusion

As described above in this ethical scenario, according to UK law, the nurse is not allowed to help with the suicide or direct the patient or anyone from patient family, guardians or friends to organizations or websites that will guide the patient with information how to take his life.
Nurse as a representative of her profession must act accordingly to NMC code as well. By sharing information about patient willing to die with her supervisor, she is avoiding a danger that the patient may be at risk of harm or self-harm. Therefore, the counselling sessions or capacity assessment may be advised.

As the law is changing all the time, there were several propositions to change the law that would legalise euthanasia in the UK. In 2007 The Times published the British Social Attitudes survey, in which 80% of the public would like the law to be changed for terminally ill patients, giving them the right to die with a doctor’s help.

Also, according to the same survey, 45% of the public supported the idea of giving the option of euthanasia to patients with non-terminal illnesses. Most of the participants were against involving relatives in a patient’s death.

References

Cheatle, P. (2019). Assisted Dying in Other Countries – My Death, My Decision. [online] My Death, My Decision. Available at: https://www.mydeath-mydecision.org.uk/info/assisted-dying-in-other-countries/ [Accessed 7 May 2019].

European Convention on Human Rights (1950). [online] Echr.coe.int. Available at: https://www.echr.coe.int/Documents/Convention_ENG.pdf%23page=9 [Accessed 7 May 2019].

Fergusson, A. (2005). Euthanasia – arguments from autonomy. [online] Christian Medical Fellowship – cmf.org.uk. Available at: https://www.cmf.org.uk/resources/publications/content/?context=article&id=1607 [Accessed 7 May 2019].

Gmc-uk.org (2019). About this guidance. [online] Gmc-uk.org. Available at: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/consent/about-this-guidance [Accessed 7 May 2019].

Healthline (2019). COPD Life Expectancy and Outlook: What You Need to Know. [online] Healthline. Available at: https://www.healthline.com/health/copd/life-expectancy#mortality-rates [Accessed 7 May 2019].

Nmc.org.uk (2018). Read The Code online. [online] Nmc.org.uk. Available at: https://www.nmc.org.uk/standards/code/read-the-code-online/ [Accessed 7 May 2019].

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