This article begins an inquiry into the implications and applications of physician assisted suicide and euthanasia within the context of hospice and end of life healthcare; accompanied by psychological and therapeutic considerations. The foundation for this research lies in the acknowledgement of my own (the author’s) biases, beliefs, and curiosities. “The physicians had argued that the claimed right [to die] was analogous to woman’s right to decide to have an abortion.” (Mariner, 1997, p.2059) In acknowledgement of my own beliefs and preferences and in regard to abortion I am a proponent of choice in the hope that “life” will be chosen. The intent of this article is to explore previous literature and investigate if I, or the reader, can settle upon a similar decision for end-of-life decisions as I do to the corresponding stance on beginning-of-life decisions (the aforementioned opinion on abortion).
“The world euthanasia… means a good death.” (Math & Chaturvedi, 2012, p.899) Math and Chaturvedi (2012, p.899) state that there are several dimensions of euthanasia which range from “active” (introducing something to cause death) to “passive” (withholding treatment); and from “voluntary” (explicit consent of the patient) to “involuntary” (consent from the patient’s guardian or representative) and “physician assisted” (physician’s prescribe medications and the patient or third party administers the medication in order to induce death). End of life decisions and the decision to end life are difficult and full of complications. Yet, each person’s life will
someday end and thus these decisions become not only inevitable but imperative considerations.
Mak and Elwyn (2005) state that “the desire for euthanasia cannot be interpreted at face value. Its meaning is not confined to the reality of physical disintegration or suffering from the effects of cancer, but includes fears and existential concerns with desires for connectedness, care and respect, understood within the context of the patient’s whole lived experience (p.348).” This illustrates that there are many more facets that factor into endoflife decisions than physical suffering and termination of biological existence. This article will examine such concepts from the perspectives of legislative decisions, cultural arguments for and against euthanasia, opinions of dying patients, and considerations for hospice care, social workers and psychotherapists, and health care workers. Furthermore, the purpose of this article is to explore the history, desires for and against, and the emotional and practical complications surrounding a person’s right and will to live and die.
“… people cannot determine the time or manner of their own death unless they commit suicide, and no law prevents anyone from attempting or committing suicide in this country.” (Mariner, 1997, p.2061). In 1997 the United States Supreme Court rejected the “constitutional right” of terminally ill patients to physician assisted suicide and allowed states to independently prohibit or permit assistance in suicide.” (Mariner, 1997, p.2058). Mariner (1997) also points out the fact that though suicide is not a legal crime in any state, that does not imply it is a constitutionally enabled right (p.2058). Assistance in suicide, on the other hand, is still punishable in some states by up to a ten thousand dollar fine or five years in prison (Mariner, 1997, p.2058). The previous citations illustrate the legal considerations for active and physician assisted euthanasia. However, matters become more complicated when a passive approach is considered.
In its 1997 decision, the Supreme Court asserted that the right to refuse treatment did deserve constitutional protection (Mariner, 1997, p.2060). The Supreme Court stated that, “Any person can refuse any treatment for any reason. This includes people who are not mentally competent: their preferences can be expressed by a surrogate decision maker or advance directive (Mariner, 1997, p.2060).” Another complication with this directive is the scope of its practice. “If the constitution protects a right to assistance in suicide, there is no constitutional principle that would limit its exercise to a small, ill defined group of ‘terminally ill’ people (Mariner, 1997, p.2059).” Mariner suggests that principle behind the Supreme Court’s decisions may be the intent of the practices imposed. For example, when refusing lifesaving treatment “the disease is still the cause of death” whereas the intent of physician assisted suicide “is to kill”; which may present moral/ethical/legal complications (1997, p.2060).
1997 also marked the year in which Oregon enacted its “Death with Dignity Act”; which legalized physician assisted suicide defined as “intentional termination of life by another at the explicit request of the person who wishes to die” and “causing the death of a person through a direct action in response to a request from that person (Bevacqua & Kurpius, 2013, p.172172).” Currently, four states have legalized physician assisted suicide: Oregon (1994), Washington (2008), Montana (2009), and Vermont (2013); thirty nine states have laws prohibiting assisted suicide; three states (Alabama, Massachusetts, and West Virginia) and the District of Columbia prohibit assisted suicide by common law; and four states (Nevada, North Carolina, Utah, and Wyoming) have “unclear” legislature on the legality of assisted suicide (ProCon.org, 2013). All four states with legal physician assisted suicide require residency in the state and all but Montana require participants to be a minimum of eighteen years old, have a life expectancy of six months or less, require two requests to a physician at least fifteen months apart, and a third written request; Montana has no legal protocol in place (other than state residency) at the time of this writing (ProCon.org, 2013).
There is vast degree of variance within states that have passed legislature and common laws prohibiting physician assisted suicide. Of the forty two states with legislation prohibiting physician assisted suicide, twenty one consider the act to be a felony: AL, CA, FL, ID, IN, IL, IA, KS, KY, MD, MI, MS, NE, NH, NM, OK, RI, SC, SD, TN, and WI (ProCon.org, 2013). Seven of the fortytwo states consider physician assisted suicide as manslaughter (AK, AZ, AR, CO, DE, NY, and ND) and two (CT and HI) consider it second degree manslaughter (ProCon.org, 2013). The remaining twelve states have variable punishments ranging from “professional discipline” to $14,000 dollar fines and/or imprisonment; typically pending whether the suicide is committed or attempted (ProCon.org, 2013).
“There is no reason to believe that it is a crime for a physician to prescribe a medically indicated drug for a patient’s medical condition, especially when the physician does not specifically intend that the patient commit suicide.” (Mariner, 1997, p.2061). This is an argument for negligence on the physician’s part where the physician abides by appropriate medical practice in prescribing medication and is absolved of responsibility when it comes to the manner, method, and quantity of ingestion. However, an argument in favor of physician assisted suicide is closely tied to this. Mariner (1997) writes, “If a physician intends to kill the patient to relieve suffering, he or she should be willing to do so all at once, instead of titrating doses according to the level of pain (p. 2061).” Mariner’s resting conclusion is that “prescribing and administering drugs with the intention of providing pain relief to patients is not assisted suicide: it is good medical practice (1997, p.2061).”
Math and Chaturvedi present an article which hosts several potential arguments in opposition to physician assisted suicide. The authors (2012) state, “Euthanasia opposers argue that if we embrace ‘the right to death with dignity’, people with incurable and debilitating illnesses will be disposed from our civilized society.” (p.899). However, one could easily argue in contrast
that a large number of the old and/or dying have already been quarantined within our country to the stations of hospice facilities and nursing homes.
Math and Chaturvedi also write, “‘Right to life’ is a natural right… but suicide is an unnatural termination or extinction of life and, therefore, incompatible and inconsistent with the concept of ‘right to life’ (2012, p.899).” Indeed, it would seem that there is some disjuncture between one’s “right to life” and “right to die”, but there are undoubtedly many common themes and concerns. Math and Chaturvedi (2012) also raise the issue of care versus cure. This argument suggests that medical professionals “may get frustrated and lack ‘care’ when a ‘cure’ cannot be invoked (p.900).” This argument places little faith in medical professionals and, if true, raises a much more concerning scope than that of the terminally ill. While it may very well be the case in some situations, it is a quite broad and sweeping assumption with little (if any) empirical support.
Lastly, Math and Chaturvedi mention that “attempted suicide is considered a sign of mental illness (2012, p.900).” In this comment alone there are many things to consider. Firstly, in regard to assessing “mental illness” it is important to note that “signs” and symptoms in and of themselves are not explicit confirmation and grounds for a confining diagnosis. Secondly, as alluded to earlier in this article, constitutional rights are not provisional upon one’s mental health or well being. The fact that assorted legislature discriminates punishment based on mental state is irrelevant on this particular topic unless the point of interest is the physician’s mental capacity. Thirdly, person’s wishing to commit suicide may be thought by some to be in an “altered state of mind”, in part, no doubt, due to the inconsideration of how such actions would impact loved ones and interconnected persons. However, the issue becomes much more complicated, for example, when a decision to end life has been decided upon by an individual and discussed in depth with friends, family members, and medical and therapeutic staff.
Mak and Elwyn conducted a study in which they found that that; “The thematic analysis corresponded to the concept of personhood… The sense of existence in relation to the world of relationships, roles, and rights within the person’s unique context are also relevant dimensions of one’s personhood other than the body, mind, and spirit (2005, p.348).” While considering the implications and applications of physician assisted suicide it is important to understand the context in which these decisions are being made. In other words, legal regulations and rulings are founded in social and cultural principles. When considering all the implied connecting relationships involved in these proceedings it may become easy to lose sight of one very important category. That is, the opinions and viewpoints of the patients and people seeking to end their life; specifically within a medical and health care context. “The lack of previous analysis from the patient’s perspective should temper the call to legalize euthanasia… The clinical mandate requires a paradigm of care beyond the biomedical model, but reorienting the patient’s personhood. We should not focus on our patient’s mental competency in their decision making, but rather our professional duty in ensuring competent existential care, by exploring the covert meaning of the desire of euthanasia (Mak & Elwyn, 2005, p.349).”
Mariner (1997) cites a Dutch study which found only one thousand cases of euthanasia where the explicit consent of the patient was given in comparison to nearly five thousand cases where there was no explicit consent of the patient (p.2059). This is quite a disturbing finding. Rather than care providers and loved ones acting in the best interest of the patient, perhaps they
have been overcome by their own fears, reactions, and concerns about how they will react to someone else (whom they care for/about) dying. Mak and Elwyn found that their data analysis revealed eighteen minor themes (for patient motivations to die) which the authors categorized into five major themes: reality, perception, anticipation, desire, and holding environment (2005, p.345).
Mak and Elwyn provide definitions for each of these categories for further explanation and consideration. Reality (of disease progression) was defined by the authors’ statement; “As the disease progressed, the participants were aware that death was inevitable and an incurable disease meant hopelessness. They were no longer the person they used to be, having had to face losses of roles, routines, mobility, and independence, dreams, and aspirations (Mak & Elwyn, 2005, p.345).” Mak and Elwyn also found that “the perception of suffering was multidimensional, ranging from physical, functional, social and psychological to existential issues…” (2005, p.345). The authors continue by stating; “Participants perceived that they were causing suffering for others. They felt a sense of burden by having witnessed the impact of their cancer on the well being of their significant others (Mak & Elwyn, 2005, p.345).”
Mak and Elwyn also found that participants felt that they had received “inadequate knowledge about their prognosis” and “anticipated a future by recounting their observations of other patients” with “unbearable pain, helplessness, and indignity (2005, p.345).” The authors described this category as “Anticipation” (of a future worse than death itself) (Mak & Elwyn, 2005, p.345). The previous categories provide a transition to the following category described by Mak and Ewlyn as “Desire.” “Participants desired an escape in order to relieve the suffering for themselves as well as their significant others. They hoped for holistic care, namely pain and symptom control, maximizing functional potential, psychospiritual support, and relieving the burden of their relatives (Mak & Elwyn, 2005, p.347).”
Furthermore, one can conclude from the Mak and Elwyn analysis that dying people’s desires are highly influenced by not only their own medical, psychological, and emotional anxieties, but the suffering they perceived in other persons within their social spectrum (family members, spouses, and patient peers).
This “social spectrum” is (in part) encompassed in and embodied by Mak and Elwyn’s final category; “Holding Environment.” Mak and Elwyn found that “participants appreciated the care, connectedness, and respect from healthcare professionals and their significant others”; that “family and friends provided (the patients) with a sense of intimacy and relatedness”, and that “for participants one, three, and five, their suffering was more tolerable and continual existence meaningful (2005, p.347).”
Another dense arena for consideration is the many professions that are involved in the dying and health care process. Mariner (1997) writes that “… there is no reason why any right to assistance in suicide should be limited to assistance by physicians… logically, the right would have to encompass all individuals and all reasonably effective methods (p.2059).” Several publications offer insight to opinions of and considerations for “care givers” that expand beyond physicians. Firstly, in a global scope, physicians, nurses, and social workers within the United States are generally less supportive of physician assisted suicide than other countries and view such practices as “immoral” and/or “unethical” (Harvath et al., 2004, p.236). A 2004 study (Harvath et al.) found that nurses and social workers in hospice were more supportive of voluntary refusal of food and fluids (VRFF) than physician assisted suicide (PAS) and were “more likely to consider VRFF themselves than PAS (p.239).”
Bevacqua and Kurpius published a study examining the ethical guidelines and opinions of professional counselors. In regard to published guidelines by the American Counseling Association (2005) and the American Mental Health Counselors Association (2010); “both codes (ACA A.9.a and A.9.b; AMHCA Standard 8) stress the counselor’s responsibility for ensuring quality care for the client. That includes taking into account physical, emotional, social, and spiritual needs; allowing clients to make self-determined and well informed decisions whenever possible… (Bevacqua & Kurpius, 2013, p.174).” When interviewing counseling students Bevacqua and Kurpius found that “while there was not a significant effect for age of client or type of euthanasia, there was a significant interaction between the two that indicated much more support for the seventy seven year old client seeing active euthanasia than for the twenty five year old client doing so (2013, p.182).” This finding brings another ethical issue into the fold; that of ageism. “The fact that for active euthanasia differences were found by age of client suggest ageism, a values bias related to client age that may impact clinical perceptions and treatment and violates our ethical standards (Bevacqua & Kurpius, 2013, p.183).” Furthermore, as prompted by Bevacqua and Kurpius’s findings, persons involved with the care of dying people should be aware of personal values that may subtly or overtly affect their involvement with the dying person. “Just as the Supreme Court’s decision placed the onus squarely on the shoulders of the states to continue the discussion of hastened death, so it is within the mental health professions we must continue our own discussion so that we can be active members of what will continue to be an important and contentious debate (Werth Jr. & Gordon, 2002, p.163).”
These discussions have an explicit impact on hospice organizations who, by their very nature, cater to dying patients. Campbell and Cox (2010) state that data collected from 1998 to 2009 suggest that 88.2% of terminally ill patients who used Oregon’s “Death with Dignity” law to end their life were enrolled in hospice care (p.2627). That percentage increased to 95.1% in 2008 and 2009 (Campbell & Cox, 2010, p.27). Campbell and Cox write that physician assisted suicide presents several challenges to hospice care providers such as: “reconciling the commitment not to hasten death…”, “reconciling the commitment not to abandon patients and their families with the general posture of avoiding involvement with medication or assistance regarding the act of medication ingestion”, and “reconciling the commitment to respect the integrity of the physician-patient relationship (2010, p.28).”
There are several points worth noting in these statements. Firstly, there is the contradiction of a hospice program who alleges to neither hasten or prevent death offering involvement in suicidal practices. Furthermore, hospice agencies and their staff have a professional obligation not to abandon patients and their family members by avoiding and abstaining from involvement in discussions and decisions involving euthanasia. Also, the “integrity of the physician-patient” relationship is largely founded on the hospice offering of “holistic” treatment. As such the relationship and rapport between the parties involved is in question if specific treatment options (such as PAS; or lack there of refusal of food, fluids, or treatment) are intentionally withheld from the patients and/or their spokespersons.
Summary and Conclusions:
This article has illustrated an anthropological lineage of legal decisions, popular arguments against, viewpoints of the patients considering, and complications for professions and professionals involved in euthanasia and physician assisted suicide. I, the author and human service professional, will valiantly protest against one’s taking of their own life. However, I find myself forced to take a more ambiguous stance; such as on that of abortion. Perhaps the one (and only?) thing a person has complete control over is their ability to end their own life. As such, impairing that ability appears to derive the person in question of some of their personal freedom which may very well be the cause of their search for suicide in the first place. The opportunity for choice in an imperative completely independent (though not unrelated to) of the consequences of one selected decision or another.
Many of the argumentative stances against physician assisted suicide have little or no input or concern for the considerations and needs of the actual person who is dying. However, the considerations of patients seeking to end their life is largely confounded by social and familial interactions and relationships. Perhaps a more apt endeavor might be to add “life” to one’s “years” rather than years to one’s life. Neither of which require the induction or hastening of death.
The Supreme Court made a wise decision. Most states within the United States have taken to one side or the other in the argument over physician assisted suicide. Regardless of legal precedence there is a imperative moral reconciliation to be made. Where will the person of a religious faith prohibiting suicide find themselves when they are the patient or, perhaps, the physician? What decisions will need to be made to continue support for socialcultural needs of the dying (or people in general) who seek to end their life (regardless of the reason why)? How will organizations such as hospice agencies and therapeutic associations respond to, react to, and adapt to the needs of a patient who is “ready to die?”
See link to original publication on Google Drive.