Support of Physician-Assisted Suicide: A Gift of Mercy and Compassion
HTH 423: Ethics and Critical Thinking in Healthcare
December 6, 2016
Allison Cubbage, Taylor Abrams, Sara Treen
Position Statement
Physician-assisted suicide is currently a major bioethical topic regarding healthcare boundaries and the role of a physician. Physician-assisted death not only provides a painless escape for those suffering from terminal disease, but supports the idea that a physician’s obligation is to relieve pain and suffering while maintaining the patient’s human dignity as much as possible. Physicians must respect a competent, terminal patient’s wishes to forgo treatment, and this includes physician-assisted death. The government should legalize a nationwide Death with Dignity Act to provide mercy and compassion to those who need it most to not only free those in pain, but to save family members the financial burden of end-of-life care.
Background
There are people all over the world at this moment fighting a terminal illness. Most of these people are in pain and left to live the rest of their days in palliative care to ease their suffering. In some parts of the world, physician-assisted death is an acceptable means of hastening the inevitable. Physician-assisted suicide (PAS) is the practice of supplying the means of death to a competent, terminally ill individual, upon a patient’s request (Varelius, 2016). There are several steps that need to be taken before the medicine is prescribed, which include, but not limited to: must be 18 or older, live in a state that has legalized PAS, be terminally ill (usually with six or less months to live), and be competent (Orentilcher, Pope, & Rich, 2016). However, laws vary state to state and country to country (Emanuel, Onwuteaka-Philipsen, & Urwin, 2016). For example, in the United States, it is generally customary for patients to be evaluated by two doctors and a psychologist before receiving the medicine (Varelius, 2016). In other countries, for example Columbia, doctors just give medicine discreetly (Emanuel et al., 2016).
Physician-assisted suicide is not a new idea. Ancient Greeks and Romans, before the coming of Christianity, often performed many controversial procedures (“History of Euthanasia”, 2013). Abortions, infanticide, suicide and active euthanasia was all considered to be tolerant acts until Christianity and Judaism arose (“History of Euthanasia”, 2013). It wasn’t until the 1900s that people began to speak up and support physician-assisted death (Dees, Vernooij-Dassen, Dekkers, Vissers, & Weel, 2011). In 1915, Dr. Harry J. Haiselden sent shockwaves across the U.S when he refused to perform a surgery on a deformed baby that could have very well save his life. He told the press that instead of intervening, he would rather “merely stand by passively” and “let nature complete its bungled job” (“History of Euthanasia”, 2013).
This was the starting point of a revolution. Some time later, in 1977, eight states — California, New Mexico, Arkansas, Nevada, Idaho, Oregon, North Carolina and Texas — all passed a “right to die” law (Silbergeld-Jecker, Jonsen, & Pearlman, 2007; “Death with Dignity Around the U.S.”, 2016). It wasn’t until November of 1994 when the first Death with Dignity law was passed in Oregon (Onwuteaka-Philipsen, Rurup, Pasman, & Heide, 2010). It remained in tact and paved the way for five other states — California, Colorado, Montana, Vermont and Washington — to pass similar Death with Dignity laws (“Death with Dignity Around the U.S.”, 2016). Currently, 19 other states are considering Death by Dignity this congressional session, while 24 (including Virginia) are not considering it this year (“Death with Dignity Around the U.S.”, 2016).
A research study in the Netherlands concluded that only ⅓ of 7% of deaths were due to euthanasia (Onwuteaka-Philipsen et al., 2010). The most frequently cited reasons for choosing PAS include loss of functioning (96.2%), loss of autonomy (92.4%), and loss of dignity (75.4%) (Onwuteaka-Philipsen et al., 2010). The demographics of those who requested PAS were caucasian and well-educated (93.1%) and diagnosed with terminal cancer (72%) (Onwuteaka-Philipsen et al., 2010). According to research, physicians who accept a request for PAS usually do so for the following reasons: no prospect of improvement (84%), autonomy of the patient (83%), symptoms (other than pain) (60%>), and “loss of dignity” (60%) (Onwuteaka-Philipsen et al., 2010).
Literature Review
Respect for a Patient’s Autonomy and Suffering
According to literature that expresses modern opinions, physician-assisted suicide is in line with medical ethos which involves respecting a patient’s autonomy and the ability to make decisions with good intentions (Martin, Mauron, & Hurst, 2011). Each individual has their own definition of quality-of-life and tolerance for pain; therefore, they are the most qualified to make their own end-of-life decisions. In order to aid with the definition of quality of life the Health-related quality of life (HRQoL) assessment was created to assess daily life functions through domains related to physical, mental, emotional, and social functioning (“Health-related quality of life and well-being,” n.d.). A related concept of HRQoL is well-being, which assesses the positive aspects of a person’s life, such as positive emotions and life satisfaction (“Health-related quality of life and well-being,” n.d.). The research conducted by the organization Coping With Cancer, an institution specialized in improving the quality of life for advanced cancer patients, demonstrated that the patient worry was one of the most influential predictors of worsened quality of life (Zhang, 2012). The results highlighted the reduction of patient anxiety as a top priority for care aimed at enhancing quality of life (QOL) at the end of life. (Zhang, 2012).
Along with anxiety, those who feel a therapeutic alliance with their physicians have the highest quality of life (Zhang, 2012). The health-related quality of life is determined from three main measurements; one being from the patient reported outcomes measurement information system (PROMIS), which calculates QoL through fatigue, emotional pain, distress, social activities; the Well-Being Measures, which assesses the positive evaluation of people’s life and the realization of their potential: and Participation Measures, how the individual views the health impacts on their social participation such as employment and duty to society (Health-Related Quality of Life and Well-Being, n.d.). In order for people to maintain life in terminal illnesses, they very often have to be on high quantities of drugs that make them sick, queasy, and that make them extraordinarily sad, which sinks them into a depression regardless. The drugs that are keeping them alive needs to be counteracted with drugs to try and lift their spirits like with antidepressant (Karsho et al., 2016). It is a balancing act of depressants and life prolonging medicine, which negatively impacts their quality of life at the end of life.
Many proponents of physician-assisted suicide have made claims that palliative care is often the source of prolonged suffering for the patient and the patient’s family (Karsoho, Fishman, Wright, & Macdonald, 2016). The advancements in new life- prolonging technologies has created new forms of dying (Karsoho et al., 2016). Nowadays, “dying naturally is very difficult; there’s almost always a medical intervention at the end of life, because of the patronizing attitudes of the medical profession, they just want to keep on treating. The medical profession has been slow to understand the limits of medicine” ( Karsoho et al.,2016). One doctor expressed his opinion on the illogical idea that he is allowed to place a patient in a coma and keep them alive in a degrading way while prolonging the family’s suffering, but is not allowed to provide a patient with the means to end their life in the same scenario (Karsoho et al., 2016).
A Physician’s Role
Physicians have a responsibility to provide the best care to their patients without causing harm. The argument that physician-assisted death has a place in healthcare stems from the idea that life prolonging measures and the inability to choose to die with self-dignity is causing the patient harm (Malpas & Owens, 2016). Although physician-assisted death is legal in a few states, evidence has shown that there are physicians who assist their patients with dying in places where it is not, suggesting that some doctors do see this as part of their role in patient end-of-life care (Malpas & Owens, 2016). The idea that a patient is someone who is suffering and the application of medical skills can relieve that suffering is seen to be consistent with a physician’s role as a healer (Malpas & Owens, 2016).
Another important aspect of a physician’s role is to maintain an open, positive physician-patient relationship. Previous studies on patients’ and society’s views have contradicted the contemporary belief that legalizing physician-assisted death will lead to the distrust of medical professionals (Lindblad, Lofmark, & Lynoe, 2009; Hall, Trachtenberg, & Dugan, 2005). In fact, evidence from one study concluded that if legal physician-assisted death were available at the end of life it would increase trust in medical services (Lindblad et al., 2009). One study, from Iowa, reported that the vast majority of primary care patients (85–90%) thought that a physician who assisted with suicide or performed euthanasia would still be trustworthy and capable of being a caring provider (Hall, 2005). Furthermore, placing physician-assisted death within the constructs of the medical field will cause physicians to expend emotional labor that could have the ability to restructure physician-patient relationships (Karsoho et al., 2016). Often times, patients take comfort in just knowing that they have the possibility available to them and it does not necessarily increase the likelihood of going through with the process. It is often the significance of the medicolegal process of physician-assisted death that is stressed as being important, regardless of whether the patients ever use or obtain the lethal medication (Karsoho et al., 2016).
Financial Costs and Barriers
The lethal medication utilized in physician-assisted suicides costs approximately 35 to 50 dollars compared to long term palliative care the costs are significantly more affordable (Mack & Leirer, 2016). The costs of palliative care a terminally ill person would need to prolong the end of life, varies on the medical needs of the individual. Hospitals approximately charge inpatient care $6,200 per day, and costs to maintain palliative care in an ICU can reach up to $10,000 per day (Zuckerman, Stearns, & Sheingold, 2016). Around 85% of end of life care are covered by Medicaid, Medicare, and private insurance companies, but for those that are uninsured the costs can be unbearable (Mack & Leirer, 2016). For the uninsured routine home care can exceed $146.63 per day for day services a patient would require, while continuous home care costs $855.79 per day for crisis events or at least eight hours to manage acute symptoms (Zuckerman, Stearns, & Sheingold, 2016). The national saving of physician assisted suicides averages around 10,000 dollars per person and totals around 627 million dollars, which is one percent the total United States health care expenditure (Mack & Leirer, 2016). The percent is a low figure due to the fact only a small percentage of Americans receiving palliative care would qualify for physician-assisted suicide (Mack & Leirer, 2016). Studies regarding HMO’s proposals have proven that the $1,000 cap in coverage for home care for terminally ill patients has created financial pressure in a patient’s decision (Mack & Leirer, 2016). The Oregon Health Plan would cover lethal medications utilized in physician assisted suicide, but maximum coverage plans for hospice care would be limited to $1,000 (Mack & Leirer, 2016).
Conclusion
The principle of patient bodily integrity requires physicians — whether in an active or passive role — to respect patients’ competent decisions to forgo life-sustaining treatment. Progress is being made throughout the country through existing physician-dying laws, mirroring those put in place by Oregon’s Death with Dignity Act. These acts ensure the protection of the patients and eliminates misuse, which guarantees that the end-of-life decision is decided by terminally ill people, not by the government and its interference, politicians and their ideology, or religious leaders and their dogma. We should be empathetic towards the terminally ill and should be take into consideration how much pain and suffering they can endure without physician-assisted death. Multiple studies have demonstrated that the prescription of multitudes of drugs through palliative care significantly increases the amount of anxiety and depression the patient suffers from, ultimately worsening the patient’s quality of life. Palliative care, with the best intentions in mind, has unfortunately created new forms of dying and has prolonged the inevitable end of life process, while adding a monumental financial burden onto the family at the same time.