Legalizing Physician-Assisted Suicides

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Legaliza tionof Physician-Assisted Suicide:Poin t/Coun erpoinVeronica Sumodi, RN,MSN, CCRN

The issuesof euthanasia and physician-assistedsuicide have been debated in classrooms,courtrooms, medical and ethical journals,ontelevision talkshows,and at the bedsidesofpatients. This article discusses in broadperspective the topicof physician-assisted suicide.The important ethical, legal,and moral issuesarepresented in a debate format. The presentation ofthe arguments is byno means exhaustive butrather reflectiveof current nursing, medical, andethical journal articles published onthe topicofphysician-assisted suicide.An attempt has beenmade to balance each argument without bias,thus allowing thereader to make an individualjudgment.Keywords: Euthanasia, physician-assistedsuicide

V'onica Sumodi, RN, MSN, CCRN, Assistant Nurse Ma-nager, Coronary CareUnt,Meridia Hillcrest Hospital,OH.nEuthanasia and physician-assisted suicideare subjectsof intense interest today. The topics have appeared in awide varietyof literaryj o d , magazines, and newspa-pers. These issues are not new; historically, the legal,moral, and ethical debates surrounding them have beencontroversial. Sterilization and euthanasia of the mentallyi l l was suggested in1931.Extermination of the sociallyand physically unfit was accepted in1936.An organiza-tion was set up to effect a highly successful programofeuthanasi a in Germany in1939.These dates andcircum-stances were part of the introduction to a journal articlewritten by Alexander,MD, in1949describing euthanasiapractices in Germanyduringthe WorldWar II. A historyof subtle propaganda that started with the easingof painand sufferinginthe terminallyill led to a blind acceptanceof the conceptof euthanasia at the whimof one man.Definitions

Euthanasia. The term euthanasia comes from theGreek, meaning "a good or gentle death." Brody (1992)defines "agooddeath" as onethat isfreeof pain or otheruncomfortable symptoms, in asettingof the individual'sown choice, and with the support of his family andfriends. He further states that medicine can provide carethat supports agooddeath;suchsupport, he adds can beinterpreted as a medical success story rather thanamedi-cal failure.Campbell (1992)notes that the term euthana-sia has developed more negative connotations over theyearsbecause of rel i gi ous,professional, andsocial inhibi-tionsagainst the idea of an easy deathoranassistedone.Euthanasiahasbeen definedusingthe words "deliberateaction" to cause the death of another individual (Grant,1986).Active euthanasia. Pellegrino(1992)divides activeeuthanasia into t h ecategories-voluntary, nonvolun-taryand involunw. Voluntaryisthe intentionaltakingofa patient's life by a physician with the patient's consent.

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Legalizationof Physician-Assisted Suicide: PointK ounterpoint

Nonvoluntary is when consent is not possible or withoutconsent. Involuntary is when consentispossible but notobtained. Active euthanasiaistaking deliberate action tohasten the death of another humanbei ng.Passive euthanasia.Passive euthanasia has beendescribedas a decision made not to prolong life. It isthepoint where palliative care replaces curative care(Loui s,1992). It isthe omission of an action that would prolongthe dying process.Physician-assisted suicide.Physician-assisted suicideisgenerally used to describe the situation in which aphysician provides a patient with the means to end theirlifeinthe place and atthetimeof the patients choosi ng.Whether or not physician-assisted suicideisa form of ac-tive euthanasia spart of the csurrent legal/ethical debate.

Oneof the strongest argumentsforlegalizationof physician-assisted suicide isbased on the principleof autonomy

Ethical ConsiderationsWith increasing involvementof patientsintheir medi-cal care, consumersare better educatedand have height-ened concerns regarding their right to make choices.Autonomy, beneficence, nonmaleficence, and justicear erecognized as valid ethical issues nhealthcare delivery.Autonomy. Autonomy isan individuals right tomake decisions that directly affecthi mor her. It istheprinciple of self-determination.

Point.One of the strongest arguments for legal-ization of physician-assisted suicideisbased onthe principle of autonomy. Competent individu-als have the right to make decisions concerningtheir medical care including the withdrawal or

withholding of life-sustaining treatment. Thewithholding of such measures may cause morediscomfort or suffering. If the individual deter-mines the quality of life issopoor that death ispreferable, then the individual has the right to askhis physician to assist him to die with dignity(Young, Volker, Reiger,& Thorpe, 1993).Coyle(1992)states that affirmation of the principle ofautonomyisan affirmationof human dignity andthesanctityof life (p.43).Counterpoint. Pellegrino challenges the abovestatementsonthegroundsof logic. If the requestforeuthanasiaorphysician-assisted suicideistheresultof perceiving no other options and the indi-vidual is insuch severe discomfort that death ispreferred, isthe choice of death really afreeone?Canyou use thefreedomof choice to give up lifeand consciousness, whichare the very conditionsneeded for autonomy to exist? Pellegrino statesthat patients with terminal illnesses often feelthey are a burden to their families, friends, andsociety as a whole. Theyfeela pressure to removethose burdens by dying quickly and quietly. Thequestion then arises that i f the patient was wellcared for and made comfortable without thoseburdens, would they choose an assisted death?Beneficence.The principle of beneficence means todo or promote good and to preventor remove harm. Itimplies positive actions.

Point. A powerful argument for physician-assisted suicide is based on this principle.Beneficence mpli esmercy and compassion, muchpreferable to aligning with pain and suffering.Physician-assisted suicide or voluntary euthanasiaful f i l l s a patient request and benefits that patient,his familyand society as a whole. The individualcandie painfreeand with the dignity he deservesas a conscious, intelligent human being (Pelle-grino, 1992). The families are spared the pain ofwatching their loved one suffer; society benefits

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from an economic and available resources per-spective.A retired surgeon, dying of respiratoryfailure from amyotrophic lateral sclerosis on aventilator, cannot do even the simplest tasks forhimself.After being told repeatedly by hisphysi-ciansthat hewillalways require mechanical ven-tilator support, has asked for a humane termina-tionof hi s life. How isthe health care communitygoing to respond tohisrequest?Counterpaint.Nohealth worker would advocatethathi s or her patientsbeallowed to suffer orbeinpain. The very obligation of the profession impliescompassionate care. Are there no alternativesexcept death for the alert patient on life supportsystems? Can we not as healthcareproviders findsmall ways to help with quality of life for theseindividuals? Beneficencesat the veryCOR of painmanagement and hospice care. To participate inassisted death violates both the physicians' and thenurses' codes of ethics. The Hippocratic oathstates:''Iill neither give a deadlydrug to anyoneif asked for it, nord make a suggestion tothseffect'' (Lace, 1989). The ANA states that thegoalsof nursing are the promotion, maintenance, andrestoration of health and the alleviation of suffer-ing,adding, 'It isa breach of the ethical traditionof nursing and its code for nurses to participateintaking human life" (Coyle,1992).

Nonmaleficence. Nonmaleficence is the principle ofdoing noharm inflicting no evil.Point. Advocates of physician-assisted suicideclaim that it is harmful toallow an individual to

continue in a terminal illness. They emphasizethat terminal illness isaccompanied by severepain and suffering.. Despite all medical efforts,sometimes the patient does not achieve an accept-able level of pain relief and comfort. Life may beextended but with loss of useful or digrufied func-tion. Palliative care may fail and pain persistdespite optimum use of narcotics and comfortmeasures (Brody, 1992).There are numerous

examples of terminal cancer patients whoare liv-ing with the daily choices of being awake withpersistent severe pain or takinglarge doses of painmedication that cause heavy sedation anddecreased awareness. In these cases physician-assisted suicide shouldbean alternative option.Counfpoint.Coyle(1992)maintainsthat physi-cian-assisted suicide violates the very goals ofmedicine by moving from healing and caring toeliminating those the profession is designed tohelp. Research and researchfundingneeds to befocused on quality palliative care. The patientshould notbedenied the opportunity to facefeel-ingsand beliefs regarding death. It ispossible togrow morallyandspiritually even with and possi-blybecause of negative experiences. The verycoreof the patient/physician relationship is based onLegalization of physician-assisted deathwiU com-promise and distort that feeling of trust. Deathisirreversible. Decisionsregardingsuicidear e i rre-vocable (Coyle).

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"It isabreachof the ethical traditionofnursing and its code for nurses to participatein taking human life."

The most powerful argument against physi-cian-assisted suicide involves the "slippery slope,"which isdefinedasthesanctioningor legalizationof anact that in itself may notbemorally objection-able but could lead tootheractsthat are. Abusescan occur espeaallyagainst vulnerable populations,such as the poor, the elderly, the ill and infirm,and minorities. Societycanbepressured to acceptassisted death especially in the light of cost con-tainment and economic constraints( Annas, 993).

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Legalizationof Physician-Assisted Suicide: PointKounterpoint

Justice. Justice is the concept of fairness. It reflectsdecision-making policy and the distribution of goodsand services within a society (Coyle,1992).Point. Individuals' rights do not change be-cause they are dying. They continue to have theright to make decisions that will best benefitthem. Suicideisnot illegal. It is not illegal to has-ten death by terminating artificial life support.Therefore, physician-assisted suicide should notbe illegal if the patient is competent to make therequest. The principle of veracity or "truthtelling" isan important ssue. Itisthe basis for theconcept of informed consent. The patient mustunderstand all the information about the diseasestate, planned care, and other supportive treat-ment options (Toevs, 1993).Counterpoint.Justiceisa societal principle andas such must protect society as a whole. For theindividual, the principle of autonomy may bel im

ited by the principle of justice. If it can be estab-lishedthat physician-assisted suicideisharmul tosociety then it should remain illegal despite theindividual's wishes (Latimer, 1991).~

Active euthanasia has been partof thephysician'srole inthe past.

Socialhioral IssuesPrecedentsand current models. Issues with a social ormoral component are sometimes difficult to define andisolate because often theyar e culturally determined.

Point. Active euthanasia has been part of thephysician's role in the past. It was common prac-tice for Grecian and Roman physicians to assist

their patients with the actof suicide (Lace, 1989).Lace writes in his journal of the AmericanMedical Association editorial that physicians canand shouldbeable to play a positive role in activeeuthanasia f the patient is terminally ill and men-tally competent and makes the decision withoutfear of legal recriminations. "Deadly drugs" werehistorically accepted and given in the earlier cui -tures in Greece and Rome (Campbell,1992).Currently, attention is focused on the Nether-lands as a model for practice of Euthanasia. Inreviewing Netherland, Battin (1990)describes thereview of available data, including guidelines forpractice. She notes exaggerations are frequent,definitions of terms like active versus passive ver-susvoluntary are not the same definitionsused inthe used in the United States, and that the eco-nomics, social circumstances, and healthcaredelivery vary widely from the practices in thiscountry. Comparisons are difficult to make.Physician-assisted suicide by United Statesdefinitionisillegal in Holland; yet, several lowercourts have allowed the practice with supportfrom the SupremeCourt as long as certain guide-lines are followed. Examples of the guidelinesinclude proof of voluntary informed consent,unbearable suffering, irreversible disease, lack ofreasonable alternative treatments, consultationwith a second physician, and arrangement of theprocedure to be performed only by the physician(Battin,1990).Counterpoint.In Fenigsen's (1991) Report of theDutch Governmental Committee on Euthanasia,

the following statistics were cited: 14,691 cases ofinvoluntary euthanasia annually in the Nether-lands. (11.3% of the total number of deaths in thecountry).Thistotal includes:1,OOO cases of activeinvoluntary euthanasia; 8,100cases of lethal i nj ec-tion of morphine, of which 4,941(61%)were with-out patient consent; and8,750cases where life-sustaining treatment was withheld or withdrawnwithout patient consent. The key wordsare "with-14 NursingForum Volume30, No. 1,J anuary-March,1995


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out patient consent. Other statistics n the reportwere also alarming, including the statement thatthe so-called rules of careful conduct (the abovestated guidelines)are often disregarded.The argument of the slippery slope isa sig-nificant moral concern. It was demonstrated inthe extreme in Germany during the World War I I.Euthanasia started with the terminally ill, pro-gressed to the mentally incompetent, and then tothe politically undesirable. Ringerman andKoniak-Griffin (1992) and others have voicedconcerns thatif physician-assisted suicideislegal-ized, even with strict guidelines, abuses willoccur and vulnerable groups of patients (e.g., thepoor, AI DS victims, mentally disabled)willbe atrisk for acts of involuntary or discriminatingeuthanasia (Annas, 1993; Campbell, 1992; Pelle-grino,1992). f voluntary euthanasia or physician-assisted suicide were to be legalized in the UnitedStates, our constitutional rights to due processcould become perverted. The danger isthat theserights mightbeextended to include the incompe-tent as having the right to assisted suicide as wellas the competent; the issue then would arise con-cerning who will make the choicesfor thosedeemed incompetent.

Religioushioral. Many people who follow a formalizedreligion believe that life is ag& from a Divine Entity, andmany issues regarding the ending of that life havebecome controversial-including euthanasia and physi-cian-assisted suicide.Point. Religious teachings regarding the prac-tice of euthanasia are changing. Many organizedreligions have changed their views on withhold-ing extraordinary means of life support for termi-nal illness. In July 1991, the United Church ofChrist became the first major denomination to en-dorse active euthanasia. The General Assembly ofthe Unitarian Universalist Association in 1988supported terminally patients right to die in

accordance with their individual choice. TheEpiscopal Church is currently exploring thesequestions as well (Chandler, 1991; Ringennan&Counterpoint. Islamic belief that only the giverof life has the authority to take i t prohibitseuthanasia of any kind. Judaism in all formsopposes active euthanasia, as does the SouthernBaptist Convention and the Roman CatholicChurch (Chandler, 1991; Ringerman&Koniak-Griffin, 1992). Hunter (1989) ends his editorialwith the following statements. Active euthanasiaviolatesour fundamental precepts of healing anddisrupts important social, emotional, and spiri-

t ual processes. To procure death with honor forour patients, letus not be angels of death, butministers of healing, comfort, and hope (p.3074).

Koniak-Griffin, 1992).

Many organized religions have changed theirviewson withholding extraordinary means oflifesupportfor terminal illness.

When addressing the moral issue, proponentsof physician-assisted suicide see no differencebetween killing the patient and withdrawing orwithholdinglifesupportknowingitwill cause thedeathof the patient. The weakness in the argu-ment is that in physician-assisted suicide theimmediate causeo deathisthe physician, not thediseaseprocess. The argumentisalsomade that nodifference exists between active euthanasia andgivinga patient morphine to relieve painknowingthat the medication maycawthe patient to die. Inthis case intent is the difference. In giving thepatient the morphine the intent iscomfort andpain relief, not death (Pellegrino, 1992).

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~-L egalization of Physician-Assisted Suicide: PoinK ounterpoint

Technol ogyAZesources. There is little doubt that todayshealthcare technology has grown enormously. The allo-cation of that technology asaresourcehasbecome asig-nificant issue.Point. It seems insensitive and unfeeling toplace an economic price on terminal or hospicecare. However, economicsisvery much apartofany healthcare discussion today. Technology thatcan maintain life support for extended periods oftime is very expensive. Wrable (19891, after hav-ing been asked by several patients for assistanceto die, expressed the opinion that active euthana-sia is a realistic alternative to todays extraordi-nary measures in maintaining life. It would saveapproximately$16,500/patient and millionsofdollars overall. The costs of prolonging life in theterminally ill patient might be better spent oneducation, housing, or research into better healthcare and prevention.Counterpoint. f economicssallowed to becomepart of the decision-making process to legalizephysician-assisted suicide, then the reason for theeuthanasia has little to do with human dignity orthe reief of suffering, but rather with money. Thepatients interests are clearly superseded by soci-etys interests. Pellegrino (1992) stated it best:Those who do not take the easy exit that legal-ized euthanasia offers become selfish overcon-sumers of their neighbors resources(p.100).

Legal ConcernsThroughout history many sigruficant controversial ssueshave been addressedfromalegal standpoint as a protec-tion for all participants. Physician-assisted suicide hasbecomesuchan issue.Point. In an attempt to establish some guide-linesto use in legal control of physician-assistedsuicide, Brody (1992) suggeststwopractices thatmight be defensible. The first wouldbeto supplythe patient with a lethal drug that could be taken

when the patient was ready to do so.The secondwouldbefor the physician to inject the lethal drugonly i f the patient was unable to administer it tohimself. Inany case, Brody proposes that eachcir-cumstance be dealt with individually and a legalframework be put in place, supplemented byintraprofessional review and/or arbitrationboards to determine f the caseisdefensible.

An article in theNewEngland J ournal of Medi-cine (Quill,Cassel, Meier, 1992) proposed a list ofclinical criteria for physician-assisted suicide. Thefollowing conditions must be clearly satisfied: (a)the patient must have an incurable disease and bein severe, unrelenting pain; (b) the patient mustunderstand his or her condition along with ailpossible alternative treatment and comfort mea-sures available; (c) all reasonable comfort mea-suresmust have beentried and proved unsuccess-ful; (d) the patient must clearly and repeatedlyrequest to die; (e) any sign of uncertainty orambivalencewillnegate the process;(0he patientmustbecapabIeof understanding the decision;(g)the act mustbecarried out only inthe presence ofa meaningful patient/physician relationship; (h) aconsult with another physician to assess all as-pects must be done; (i) clear documentation mustbe present including signed consent forms, whichinclude signatures from the patient, the primaryphysician, and the consulting physician.Counterpoint.Michigan prior to1991was one ofthe states that did not have a law prohibitingphysician-assisted suicide. The suicide machinesofDr. Jack Kevorkian forced the state to confront thelegal dilemma. The state attempted to prosecuteDr. Kevorkian afterhis first three assisted deaths,but all cases were dismissed because assistedsui-cidewas not illegal.InFebruary1991,apermanentcourt injunction was issued that b md the use ofthe machine. That move did not stop its use. InNovember 1991, Dr. Kevorkians medical licensewas suspendedinMichigan and in April 1993, itwas suspended in California. In Februav of 1993

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Michigans new antiassisted suicide bill becameeffective, after15assisted deaths by Kevorkianwere reported(Annas,1993).Physicians opposed to physician-assistedsui-cideare concerned that societal or legalsanctioningwill encourage assisted suicide by nonphysicians(Hendin&Herman, 1993). Organizations like theHemlockSociety inthiscountry and the VoluntaryEuthanasia Society inBritainare very supportive ofassistedsuicide. The bookFinal Exit (1991),writtenbythe president of the HemockSociety,gives@danceto the lay person on methods of codttingsuicide.Pellegrino (1992) notes that just because some-thing is practiceddoesnot mean it mustberegu-lated by law, and just because a lawispassed doesnot automatically make it moral. Toomanyinstances are found in history of the passage ofimmoral laws: segregation, slavery, suppression ofwomens rights,andsoon.

ConclusionManyargumentsfor and against physician-assisted sui-cide havebeenaddressed and many morecanbeseeninthe literatme.Thisissue will bemucharguedand debated

for years to come. The solutionswillnotbeeasy and a gen-eral consensus may neverbereached, but itisour Ilespon-sibility as healthcare workers to examine ourownfeelingsand beliefs and to add our voices to the debate.Both sides agreeonsome key considerations,suchas:the dignity of the patient, the importance of pain controland comfort measures, the patients need for personalcontrol and participationincare, and the importance ofavailable resources to support these needs. Solutions tothe problem may require building on common ground inan open forum soasnot to erect unscalable walls arounda closed arena.ReferencesAlexander, L. (1949). Medical science under dictatorship.New EnghndJ ournalofMedicine,242,39-47.

Annas, G. (1993). Physician-assisted suicide-Michigans temporarysolution.Legal Issuesin Medicine,328,1573-576.Battin, M. (1990).Seven caveats concerning the discussionof euthanasiainHolland.PerspectivesinBwlogyandd4edicine,34(1), 73-77.Brody, R (1992). Assisted death-a compassionate response to a medi-cal failure. New EnghndJournal OfMedicine,327,1384-1388.Campbell, C. (1992). Aid-in-dying and the taking of human life. ournal$Medical Ethics, 28,128-134.Chandler, R. (1991, November 2). Religion confronts euthanasia. LosAngelesTi mes, 2,25.Coyle, N. (1992). The euthanasia and physician-assisted suicidedebate:Issues for nursing. Oncology Nursing Forum (Supplement),29(7),Fenigsen,R (1991). Thereport of the Dutch governmental committeeoneuthanasia. ssues inLaw&Medicine, 7,340-343.Grant, G. (1986).Technologyand justice. Indiana: Universityof NotreDame Press.Hendin, H.,&Herman,G. (1993). Physician-assisted suicide: The dan-gersof legalization.Amcan ournal of Psychiatry,250,143-145.Humphrey, D. (1991).Fi nal exit: Thepracticalities of self-deliverance andassistedsuicidefor thedying. New York CarolPublishingHunter, S. (1989). Active euthanasia violates fundamental principles.

JAMA,262,3074.Lace,T. (1989). The physician can play a positive role in euthanasia.JAMA, 262,3075.Latimer,E. (1991). Ethical decisionmaking in the care of the dying andits application to clinical practice. J ournal Pain SymptomManagement,6,329-343.

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Loui s,R (1992). Passivetabs.Nursing Times,88(45),37-39Pellegrino,E. (1991).Eth cs. AMA, 265(23) 3118-3119.Pellegrino,E. (1992). Doctors must notkill. TheJ ournalof Clinical Ethics,Quill, T., Cassel, C., &Meier, P. (1992). Care of the hopelessly ill:Proposed clinical criteria for physician-assisted suicide (SoundingBoard).New England J ournalof Medicine, 327,1380-1384.Ringerman, E.,& Koniak-Griffin, D. (1992).A reexamination of

euthanasia: Issues raisedby Final Exit.Nursing Forum, 27(4), 5-8,34.Toevs, A. (1993). Creating an environment of eth cs. AJ N (Supplement),21.60-64.

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Wrable, J. (1989). Euthanasia wouldbea humane way to end suffering.American Medical News,1,3748.Young,A., Volker, D., Reger, I?,&Thorpe,D. (1993). Oncology nursesattitudes regarding voluntary, physician-assisted dying for compe-tent, terminally llpatients,Oncology NursingForum,20,445-451.

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Legalizing Physician-Assisted Suicides