April 24, 2014
Focused Inquiry 112
Die Here, Not There
When considering end of life options for a terminally ill or severely disabled person, there are not many choices available to the patient. Euthanasia is medical aid by a physician to end a patient’s life after an explicit request from the patient. During the AIDs epidemic of the 1980’s and early 90’s, my mother had a friend, Henry Colina, who fought the disease until 1991. Modern medicine had not yet managed the symptoms of the disease, and Henry decided that he would want to die before he became a shell in a hospital bed. This way, he was able to say his goodbyes and end his life before his suffering became unbearable and he could no longer express himself. He died comfortably at home among family, as a doctor risked her license by giving Henry the injection that took his life. From a legal standpoint this is murder, but from an ethical standpoint this is death with dignity.
Although it is illegal in the United States, there is another option that could satisfy the patient’s wish to die. Physician aid in dying (PAD) is similar to euthanasia, except the patient is self-administering the lethal dose of medication. However, when a patient is suffering and wishes to die in America, they must hope that they are in a state that has legalized physician aid in dying. Of all fifty states only four have legalized this practice. The states that have legalized physician aid in dying are Washington, Oregon, Vermont, and Montana. Since assisted suicide is illegal in most states, patients may be inclined to pursue death with dignity illegally. If patients have the right to die in some states and not others, are laws restricting end of life procedures in America ethical? Nationwide legalization of physician aid in dying would make it a safer and more ethical practice because it would beckon more research while respecting patient autonomy.
On February 7th, 2013, a Pennsylvania nurse is charged for assisted suicide of her 93-year-old father, who was suffering from kidney disease, heart failure, and diabetes. The nurse was accused of handing him a nearly full bottle of morphine, which he ingested most of to end his suffering. Her father was revived against his will even though it was “repeatedly noted on hospice records were that he had a living will, a "Do Not Resuscitate" order, wanted to die at home, and that Mancini had his power of attorney to make decisions if he could not make them,” (NBC Philadelphia). Ironically enough, Mancini’s father passed four days after being admitted to the hospital after receiving morphine. Instead of passing peacefully, Mancini’s father witnessed his daughter be prosecuted for respecting his wishes. She was not able to be by his side when he passed, as she should have been. Although the case was dismissed because of lack of evidence, Mancini could have honored her fathers wish to die if she lived in another state. Instead, Mancini lost her job and faced 100,000 dollars in fines or 10 years in prison (NBC Philadelphia).
One argument against PAD is the effect that the patient’s decision will have on their family members. In Mancini’s case, she and her family members were affected negatively by the fact that Mancini’s father could not chose to take his life. The Journal of Pain and Symptom Management published results from a survey, “Views on Physician-Assisted Suicide Among Family Members of Oregon Cancer Patients,” by Linda Ganzini, Tomasz M. Beer, and Matthew C. Brouns. Primary author, Linda Ganzini, is a medical doctor that teaches psychiatry and medicine at the center in ethics for health care at Oregon Health and Science University. She is also a director in the Interprofessional Fellowship Program in Palliative Care at Portland Veteran Affairs Medical Center and as she strives to improve palliative care for the terminally ill. The cross sectional survey reached out to Oregon residents with advanced cancer and their families. In conclusion “ family members of Oregonians who received a lethal prescription were more likely to believe that their loved one’s choices were honored and less likely to have regrets about how the loved one died,” (Ganzini et. al p1). It is normal for family members to grieve the loss of a loved one, and it is possible for them to develop a depression. However, a patient requesting PAD is already expected to die soon, so is merely relieving them of more pain.
Another argument against physician aid in dying comes from a religious perspective. Most major religions condemn suicide and assisting suicide is considered murder. One issue that may arise, even in places where PAD is legal, is the practice of PAD in hospitals and hospices with religious affiliations. The American Journal of Hospice and Palliative Medicine’s article “Legal But Not Always Allowed: Physician Aid in Dying,” by Steven Baumrucker, Matt Stolick, Gregory T. Carter, Paige Mingle, Karrie A. Oertli and Gerald M. Morris touches upon further limitations regarding this controversial practice. The article focuses on the ethics concerning a fictional case of a terminally ill patient, GH, who requests PAD in a Catholic hospital. Palliative care specialist and medical doctor, Baumrucker, states he has “respect patient autonomy but that does not mean that the physician is simply a mechanism through which to get the lethal prescriptions. Physicians, as well as organizations, must have the right to be able to refuse to provide certain types of treatments,” (Baumrucker et al p4). If the organization refuses, they should still assist the patient in exploring their end of life options even if it means transferring to a different facility. Someone who holds the virtue approach in ethics is likely to oppose physician aid in dying because suicide violates moral conduct and is generally looked down upon. Therefore, a person in agreement with the virtue approach to ethics would not want to be seen as the kind of person who would take another person’s life, even if it were by request.
Medicine intended to manage pain has improved significantly, and even if the medicine fails, the patient has a choice similar to death that is legal in all states. This method is called deep terminal sedation, or DTS, and puts the patient in a medically induced coma where they cannot respond to stimuli. In a sense, they are emotionally dead. DTS could be a better alternative to cutting off medical treatment, but it still imposes a financial burden because the patient is still being taken care of. Anesthesiologist Gail A. Van Norman expresses her concerns with the practice of PAD and DTS in the current opinion article “Physician Aid In Dying: cautionary words.” Norman is devoted to the ethical treatment of patients in end of life care and believes that “Both practices pose risks to vulnerable populations, such as depressed and disabled patients, and it is not entirely clear that safeguards are always followed,”(Van Norman p3). Someone who is considering assisted suicide should receive counseling, but it is not unusual for one who is facing death to feel depressed. Social interaction and mental alertness are signs of a good dying process, which is why some might want to end their life before they regress further (Van Norman p4). Van Norman finds “A particularly disturbing aspect of DTS in clinical practice is that opioids are often used inappropriately for sedation, and that DTS is frequently managed by unskilled physicians in the absence of consultation with clinical specialists in palliative care,”(Van Norman p5). This expert finds that both practices cannot be justified until medical advances and strict regulations are implemented when undergoing DTS and or PAD.
Ultimately, the patient has the right to end their suffering on their own terms. Physician aid in dying should be legalized and regulated in all states because “to deny a patient the access to another provider who is willing and qualified to comply with the patient’s request would represent a complete lack of respect for the patient’s autonomy,” (Baumrucker et al. p4). Preserving patient autonomy should be principal, especially as they approach the end of their life and lose the ability to enjoy life, take care of themselves, and experience significant pain and discomfort. Also, if the patient is physically unable to administer the lethal dosage, they should be allowed to have it administered by a nurse or a family member because “The distinction between legal and illegal suicide should not be dexterity in the index finger,” (Baumrucker et al. p3). It is unethical that some patients can end their life because they can physically give themselves the medication while those who are disabled lose the option. This solution agrees most with the rights approach, because patients have the right to maintain autonomy. If a patient is terminally ill and they are mentally capable in making the decision to end their life, they have the right to do so. The physician has the right to determine if the patient is in the right state of mind to go through with the treatment. The utilitarianism approach would also support PAD because it presents the most good with the least harm .The patients who wish to die would be treated equally and the end of their suffering will outweigh the negative stigma associated with suicide.
Palliative care facilities should keep the patient’s needs and wishes their top priority, and if they deny a treatment they should assist the patient in transferring facilities. Instead of ending all treatment or traveling to a state that provides the preferred end of life procedure, the suffering patient should be able to control where and when they will pass. Some states may not allow an out of state patient to receive PAD, so the options for those who do not live in a state that permits it are slim. Withdrawing medical treatment is painful and discomforting. They also have the option to be euthanized illegally. This option puts themselves, their loved ones, and their doctor at risk. It is also possible that the procedure is not performed properly since it is unregulated. Deep terminal sedation is not always ideal because the patient is using additional resources and depending on a hospital staff to keep them in a state that mimics death. All in all, further research in end of life procedures such as PAD and DTS should be implemented so that people can experience minimal pain and suffering when facing death. Once improved, it should be legal for those who qualify in all states.