Euthanasia and Physician Assisted Suicide - Morally and Professionally Repugnant Activities - Assignment Example

Euthanasia and Physician Assisted Suicide: morally and professionally repugnant activities Introduction Suicide is a nettlesome ethical problem. Moral objections almost invariably have their origins in religious belief.1 While as a practical matter in the United States criminal proceedings are no longer brought against persons who attempt suicide,2 individuals who assist them, irrespective and familial or professional relationship, may face severe criminal penalties.3 Physician assisted suicide Physician-assisted suicide (PAS), like euthanasia, has been forbidden since antiquity.4 However, as a practical matter, physicians have likewise had a measure of latitude in the specific application. Thus, for example, a prospectively fatal dose of an opiate might be administered to counteract intractable pain in a terminal patient, with a not unexpected resulting death.5 Unlike euthanasia, PAS involves the physician as a facilitator of patient termination, one in which the patient still participates, in however limited a fashion, as an active participant. In much of northern Europe PAS has been legislated, albeit with varying limitations on both patient and provider.6 In the United States, only Oregon currently permits PAS. A few jurisdictions do not distinguish between PAS and any other form of assisted suicide. Estonia, for example, has no legislation criminalizing suicide and, as a corollary, does not criminalize any assistance in the act. German practice replicates that of Estonia, although certain ancillary acts (e.g., unlawfully importing controlled substances to accomplish an assisted suicide) may be justiciable. Euthanasia Euthanasia, while similar in many respects to PAS, usually removes the patient as a direct participant in the death process. Putting a patient, terminal or otherwise, to death in order to end intractable pain and suffering defines active euthanasia. However, there are a number of medical treatment regimes that are regularly classified as euthanasia, although they are more accurately accounted species of palliative care. These include passive euthanasia, the decision of medical providers to discontinue or not undertake ‘fruitless’ intervention to preserve life in terminal cases, and the closely related voluntary ‘do not resuscitate’ orders, whether established by the patient or a competent surrogate. Palliative care regimes Palliative care regimes do not fall under the rubric of either euthanasia or PAS. For many years, ethical medical practice in the United States has found acceptable, either explicitly or tacitly, certain activities and non-interventions which are expected to result in the death of a patient. For example, residents of nursing homes—especially those in extreme old age—often maintain legally acceptable ‘do not resuscitate’ instructions for staff response to medical emergencies (e.g., cardio-vascular accident). Parents of profoundly disabled neo-natal infants may elect to forego massive medical intervention, preferring simple palliative care as nature takes its course. Likewise, persons with increasingly untreatable illnesses certain to lead to death (e.g., a metastasized cancer) may elect simple palliative care, with associated pain management (perhaps in a hospice environment), in preference to further aggressive medical intervention. Thesis Statement Considered in the balance, the moral value of human life is such that its active termination as an alternative to continued medical treatment should be forbidden. Background At present there are only four jurisdictions that openly and legally authorize direct physician assistance in the death of a patient. They are Oregon (PAS only, since 1997), Switzerland (PAS and layman assisted suicide, since 1941), Belgium (PAS and voluntary euthanasia, since 2002) and the Netherlands (PAS and voluntary euthanasia, since 2002, but effectively made legal in 1984 by action of the appellate court.7) Oregon and Switzerland both forbid PAS by lethal injection. Laws in the other countries are silent on the matter. According to Humphrey (March 2005), “Two doctors must be involved in Oregon, Belgium, and the Netherlands, plus a psychologist if there are doubts about the patients competency. But that is not stipulated in Switzerland, although at least one doctor usually is because the right-to-die societies insist on medical certification of a hopeless or terminal condition before handing out the lethal drugs.” PAS in Europe PAS appears in two distinct patterns, one in which it is either not an offense or, at most a minor one and the other in which it remains a species of manslaughter, albeit one with much reduced penalties. The VES briefing paper (April 2003) notes, “In Belgium, Switzerland, Germany, France, Sweden, Finland and, where assistance is provided by a medical practitioner, the Netherlands, assisted suicide is not an offense. In other countries, such as Denmark and Norway, the penalties for such offenses have been downgraded to as little as 60 days imprisonment.” It should be understood that for at least some of these countries there is no effective distinction between PAS and suicide assistance provided by a layman. For example, in Germany, which has no penalty for either attempted suicide or suicide assistance, in 2000 an appellate court “cleared a Swiss clergyman of assisted suicide because there was no such offence, but convicted him of bringing the drugs into the country. There was no imprisonment [Humphrey].” At the other end of the spectrum is the United Kingdom that retains severe penalties for assisting another in suicide—up to 14 years imprisonment in England and Wales. Even so, as a practical matter, such draconian penalties are never meted out. Humphrey (March 2005) notes, “Oddly, suicide itself is not a crime, having been decriminalized in l961. Thus it is a crime to assist in a non-crime. In Britain, no case may be brought without the permission of the Director of Public Prosecutions in London, which rules out hasty, local police prosecutions. It has been a long, uphill fight for the British--there have been eight Bills or Amendments introduced into Parliament between l936-2003, all trying to modify the law to allow careful, hastened death. None have succeeded.” (Suicide has never been illegal in Scotland. Humphrey continues, “There is no Scots authority of whether it is criminal to help another to commit suicide, and this has never been tested in court, [although such a person] might be criminally liable on a number of other grounds such as: recklessly endangering human life, culpable homicide (recklessly giving advice or providing the means, followed by the death of the victim), or wicked recklessness.”) PAS in the United States As noted above, Oregon is the only state with a legislatively established PAS program. Oregon voters approved the Death With Dignity Act in 1997 and the law took effect in January 1998. Based on data derived from the Oregon Department of Health Services (March 2007), as of December 31, 2006 (latest date for data compiled by the Oregon Department of Health Services is available), a total of 496 PAS prescriptions had been written. They, in turn, resulted in 292 deaths (the remaining patients either dying before ingesting the lethal medications or deciding against PAS). In descriptive terms, the patients opting for PAS averaged 69 years of age, were rather will educated (over 50 percent university graduates) and had cancer (84 percent). “Physicians indicated that patient requests for lethal medications stemmed from multiple concerns related to autonomy and control at the end of life. The three most commonly mentioned end-of-life concerns during 2006 were: loss of autonomy, a decreasing ability to participate in activities that made life enjoyable, and losing control of bodily functions.” The moral dimensions of PAS Traditional philosophical arguments The moral component of PAS lies within the confines of the consideration of suicide itself. Classical philosophers (and a few modern ones, e.g. David Hume) treated suicide in terms of its impact on the community or as an expression of personal autonomy. The New York Task force on life and the law (December 2001) reviewed the classical ethical perceptions relating to suicide. “Plato considered the individual’s desire to live or die largely irrelevant to determining whether suicide might be an appropriate act. An objective evaluation of the individual’s moral worthiness, not the individual’s decision about the value of continued life, was critical. In contrast to Plato, the Stoics of the later Hellenistic and Roman eras focused more strongly on the welfare of the individual than on the community. They believed that, while life in general should be lived fully, suicide could be appropriate in certain rare circumstances when deprivation or illness no longer allowed for a ‘natural’ life. The Stoics did not, however, maintain that suicide would be justified whenever an individual loses the desire to live.” Western religious tradition However, for most present-day Americans, opposition to suicide finds its origins in religious teachings. The New York Task Force (December 2001) provided an overview of Western religious perspectives. “Since ancient times, Jewish and Christian thinkers have opposed suicide as inconsistent with the human good and with responsibilities to God. In the thirteenth century, Thomas Aquinas espoused Catholic teaching about suicide in arguments that would shape Christian thought about suicide for centuries. Aquinas condemned suicide as wrong because it contravenes one’s duty to oneself and the natural inclination of self-perpetuation; because it injures other people and the community of which the individual is a part; and because it violates God’s authority over life, which is God’s gift. This position exemplified attitudes about suicide that prevailed from the Middle Ages through the Renaissance and Reformation.” It is safe to say that this reasoning underlies the thinking of the great majority of Americans today. Moral and ethical considerations of PAS Arguments advanced in favor of legalization Arguments in favor of legalized PAS extend from considerations of personal autonomy to those relating to precepts underlying a liberal democratic society. Respect for autonomy: Voluntary decisions about the time and circumstances death are very personal. In a certain sense, the end of life—death—is a person’s most private act. Other factors in life—e.g., birth, sexuality—occur in conjunction with other persons. Death occurs alone. This, of course, raises the rhetorical question, “just whose life is it, anyway?” Understood in these terms, a competent individual should have the right to elect death as an option. Individual liberty v. state interest: Though society has strong interest in preserving life, that interest must be balanced against a comparable requirement to respect individual autonomy. It appears obvious that state interest recedes and is overtaken by the demands of personal autonomy when a person is terminally ill and evinces a strong desire to end what has become an intolerable existence. A complete prohibition on assisted death excessively limits personal liberty. Therefore PAS should be allowed in certain cases. Justice: Justice requires that we ‘treat like cases alike.’ Competent, terminally ill patients are allowed to hasten death through treatment refusal. For some patients, however, treatment refusal will not suffice to hasten death. In such cases the only option is active intervention that achieves the same goal. Justice requires that we should allow assisted death for this latter group. Compassion: Suffering often extends beyond considerations of pain and its amelioration. There are other physical and psychological burdens (e.g. quadriplegia) that often involve unbearable suffering. Under such circumstances, the individual should have the right to call upon assistance to terminate it once and for all. Arguments advanced in opposition to legalization As in the case of arguments in favor of PAS, arguments in opposition extend from philosophical considerations to the specifics of medical practice and patient treatment. Sanctity of life: American democracy and limited government rest to a considerable extent on religious traditions that, inter alia, find suicide morally objectionable. To act in a manner that fundamentally opposes such a broadly based moral precept may serve to undermine others upon which the nation’s principles of limited government are built. Distinction between passive and active participation: Passive treatment (e.g., palliative care) does not bring about the death of the patient. Rather, it allows nature to take its course—in this case, the outcome being death. Treatment denial (e.g., in ‘futile care’ cases) or withholding (e.g., in ‘do not resuscitate’ cases) lacks the specific objective of bringing about the death of the patient. Conversely, PAS has the immediate objective of ending the individual’s life. The fact that in certain instances the specifics of individual cases may be virtually identical—with one falling under the palliative care regime and the other under prospective PAS—is beside the point. It is the intention of the caregiver that is the determinant. Potential for abuse: Under a PAS regime, it may become financially attractive to caregivers (and, perhaps, health insurance underwriters) to foster PAS as a tacit cost containment strategy. Indeed, it is even possible that burdened families might encourage afflicted relatives to accept PAS in lieu of expensive, long-term treatment with little likelihood of favorable outcome. To protect against these prospective abuses, PAS should remain illegal. PAS in the context of medical treatment While considerations of PAS and euthanasia are often expressed in abstract or ‘universal’ terms, actual medical decisions implicating PAS application occur in specific cases. By the same token, advances in medical science may well obviate at least some of the arguments currently advanced in favor of PAS and euthanasia. Medical reasons advanced to legalize PAS In general terms, efforts to legalize PAS stem from a number of interrelated, yet distinct, perceived shortfalls in the provision of health care. PAS proponents desire to (1) formalize what is already pretty much an established practice (thus immunizing practitioners from legal retribution), (2) define precise limits of acceptable professional behavior where none exists, and (3) preclude the physical agony and emotional stress that can accompany certain terminal diseases or conditions. Formalizing current practice: This was the case in the Netherlands in 1984. It is the primary argument in the United Kingdom today. According to a 1998 British Medical Association (BMA) report, 15 percent of UK physicians admit to having helped a patient die at his own request. A BMA survey of hospital doctors in 1996 (Care, August 1999) found that 3 percent admitted to having “ended the lives of terminally ill patients at their request.”8 In the absence of a legal framework, identical cases of professional behavior can have radically different juridical outcomes. While, as noted above, public prosecutors in the UK do not appear overly disposed to prosecute healthcare providers for PAS offenses, such a possibility always exists. Defining limits of professional behavior: Government researchers in Belgium and Australia determined that the level of ‘non-voluntary euthanasia’ (doctors ending the lives of patients absent the latter’s stated preference) was five times higher in those countries than in the Netherlands (which had already established a PAS program). According to the VES report (April 2003), “The Belgian research showed that where there was no system of regulation less attention was given to careful end-of-life decision-making, putting the vulnerable at risk. Therefore, for public policy reasons the Belgian Parliament voted in favor of legalizing assisted dying to make sure medical practice is properly regulated so that everyone is protected.” Precluding the rigors of a painful death: As noted above, the Oregon experience with PAS shows that the preponderance of patients opting for PAS have terminal cancer, with an average life expectancy of no more than several weeks. (Candidates for PAS must be certified to be terminal and within six months of mortality.) Proponents of PAS argue that if it is accounted legitimate to assist suicide in cases where curative treatment is to no avail when death is imminent it is just as reasonable to permit it in cases where death is just as certain but likely more distant in time. Certain ailments (e.g., ALS, the progressive motor-neuron impairment commonly called ‘Lou Gehrig’ Disease) cannot be effectively treated, given the current level of medical knowledge. Proponents argue that such persons should be permitted to avail themselves of the same opportunity as cancer patients. Much more difficult are those cases in which mental faculties become gravely impaired as the disease progresses (e.g., Creuzfeld Syndrome or ‘mad cow’ disease; AIDS in its terminal stages) to the extent that the patient no longer has the capacity to commit suicide, however much he may be assisted.9 Prospects for improved palliative care While it may sound rather callous, it is almost always considerably cheaper to provide a terminal patient with the means of ending his or her own life rather than have that same individual continue draining healthcare provider limited assets (both human and material). To date, this has not been a consideration in the American debate over PAS. American medicine emphasizes care and cure in even the most extreme cases, something that few, if any, other countries do.10 However, opponents of PAS, pointing obliquely to the history of PAS in Europe, are not sanguine that current American attitudes will be sustained. The practice of physician-assisted suicide creates a duty to die. Escalating health-care costs, coupled with a growing elderly population, set the stage for an American culture eager to embrace alternatives to expensive, long-term medical care. The so-called ‘right to die’ may soon become the ‘duty to die’ as our senior, disabled and depressed family members are pressured or coerced into ending their lives. Death may become a reasonable substitute to treatment and care as medical costs continue to rise. [Citizen Link, March 2001] There is a growing body of evidence that increasing the availability of palliative care reduces the demand for PAS. According to Wineberg (April 2001), “Recent improvements in palliative care in Oregon may have allowed some people to die in relative comfort without having to hasten their death. Oregon has one of the highest rates of hospice admission and morphine usage per capita in the United States.11 It is estimated that about 45% of the patients for whom a substantive intervention is made will change their minds about wanting a prescription for a lethal medication.” Final thoughts No person of good conscience can fail to be moved at the thought of the terminal cancer patient suffering from intractable pain or of the quadriplegic imprisoned in a body that has been reduced to a shell. But, like it or not, in such cases when the ending of suffering assumes a moral primacy, some diminution of the moral value of life itself will likely follow. Considered in a larger context, there is the prospect of a ‘slippery slope,’ one in which an ostensibly limited practice, over time, finds its constraints increasingly relaxed. There is direct evidence for this, in the case of the Netherlands. Allowing physicians to cross the line into killing does not stop with willing patients who request it. A case in point is in the Netherlands where doctors have practiced physician-assisted suicide and euthanasia for more than a decade. Two Dutch government reports, conducted in 1990 and 1995, found that, on average, 26 percent of euthanasia deaths in Holland were ‘without the explicit consent of the patient.’ In 1995, 21 percent of the patients who were killed without consent were competent. [Citizen Link, March 2001] In recent years Dutch doctors have resorted to euthanasia to for infants born with spina bifida and even for patients suffering from clinical depression (but with no significant physical infirmities or illnesses). Whatever protestations to the contrary that may be forwarded by the healthcare providers involved, the fact remains that they have accepted a considerably reduced valuation on the integrity of the human person. To do so implicitly rejects a substantial portion of the moral underpinnings of western civilization. Furthermore, it likewise implicitly denies one of the hallmarks of that same civilization—scientific progress—in favor making morally dubious medical responses to difficult medical conditions rather than expending the effort to find ways to cure them. It is for these reasons that PAS and euthanasia should be forbidden. Works consulted in the preparation of this report [Anon.] (March 2001), Physician-assisted suicide and euthanasia, Citizen Link BMA [British Medical Association] (August 1999), Debate on physician-assisted suicide [position paper], Care, Emanuel, E. J. (June 9, 2001), Euthanasia: where the Netherlands leads will the world follow?, BMJ [British Medical Journal] Humphrey, D. (March 1, 2005 [updated]), Assisted suicide laws around the world, Assisted Suicide New York State, Task force on life and the law (December 2001), When death is sought: assisted suicide and euthanasia in the medical context, Executive summary, December 2001 (December 2001), The ethical debate, Oregon Department of Human Services (March 2007), Physician assisted suicide, Ninth annual report on Oregon’s Death with Dignity Act [Annual report for 2006] VES [Voluntary Euthanasia Society of the United Kingdom] (April 2003), Choice or dignity: the law is not working, Briefing paper Wineberg, H. (April 2001), Physician-assisted suicide in Oregon: why so few occurrences?, MJA [Medical Journal of Australia] Read More