Written by: Vanessa Niu
Edited by: Isabel Angres
Edited by: Isabel Angres
Medicine has shifted throughout the course of history to have respect for competent decisions made by patients. Furthermore, recent advances have resulted in a great change in how patients are treated and experience the end of life. This relationship between medicine, choice, and death has ever-changing perspectives on the ethics of medically assisted dying.
In the healthcare field, the observance of death is inevitable. However, when is the assistance of death by a physician or emerging technologies morally permissible? There is no clear answer that lies within the various ethical arguments surrounding this issue. Proponents argue medical-assisted dying is the ethical decision for terminally ill patients or those with chronic suffering to face the end of life with comfort and dignity instead of prolonging suffering through palliative care, which “intends to neither hasten nor postpone death” (Fontalis). Opponents raise concerns of the right to life and adequate decision-making among patients who might be experiencing distress or consider themselves a burden to family members. While both arguments have their own validity, this article aims to delineate the concentration of assisted dying and shed light on current standings of this controversial measure.
Understanding the four pillars of medical ethics might aid in approaching an answer to this question of what is right or wrong. The four pillars include beneficence (doing good), non-maleficence (performing no harm), autonomy (providing the patient freedom of choice when they are able), and justice (ensuring fairness).
The general idea of physician-assisted dying involves the patient’s decision and perspective, the physician’s type of care, and the patient’s family. The fundamental physician-patient relationship is based upon trust, respect, and non-maleficence; moral arguments regarding medical-assisted dying revolve around these core principles. Autonomy is a critical aspect of providing care to dying patients. A terminally ill or suffering patient may experience stressful emotions, feeling as if they are a burden, suffer from treatment, or believe that they have a lack of control over their quality of life. These factors can lead certain patients to consider physician-assisted dying. However, from the doctor’s standpoint, the principles of beneficence and non-maleficence come into play when finalizing a request to either continue or cease treatments. The physician is not completely bound to respect the patient’s autonomy since their physical health, mental state, and well-being must also be taken into account. The conflict between beneficence, non-maleficence, and autonomy when considering to alleviate a patient’s suffering is at the forefront of the controversy. If a physician agrees to respect a patient’s autonomy and assist in their death, this is viewed as causing harm through the traditional ethical principles of medicine. In contrast, this same action can be viewed by the terminally ill patient as the ultimate act of beneficence on behalf of the physician and an acknowledgement of the patient’s ability to make coherent decisions. It may be received from certain people of society or the family of the patient that justice involves the patient’s constitutional right to life. Yet, justice and fairness for the patient also describes what the individual is entitled to, which is possibly the request for death.
Whether physician-assisted dying as a whole is morally ethical is determined in the same way that other medical decisions are made: by examining the patient’s condition and concerns. In addition, situations vary between each patient and contribute to the overall determination of action. Each physician has their own principles that they might adhere to on top of medical guidelines, and each patient has their own unique concerns, emotions, or viewpoint from which they make their request for death. When examined through the lens of the legal system, the legal status of assisted dying is ambiguous as states might “criminalize assisted suicide” but “state prosecution of assisted suicide is not common” (Benedict). There are “ethical objections regarding the integrity of the patient-physician relationship and last resorts in ending life, professional concerns about medicalization and a diminished identity of medicine as a healing profession, and social responsibilities to provide equal access to basic health care and to hospice care” (Campbell). These objections bring to light important factors in determining what allows for the “correct” criteria to be satisfied in terms of granting patient autonomy for assisted suicide. Ethical arguments and patient advocacy prompted the National Academy of Medicine to maintain that “the right to die should encompass (1) physician-administered medications for terminally ill persons, some of whom may no longer have and (2) decision-making capacity” (Campbell). In addition, since advocates argue “that certain medical conditions afflicting chronically ill persons can impose an experience of unbearable pain and suffering for which even the best of palliative care measures are inadequate for the patient, access to either self-administered or (3) physician-administered medications to end life should also be available to (4) non-terminally ill persons with no terminal diagnosis but who are experiencing (5) a grievous and irremediable medical condition” (Campbell). The moral and ethical argument has evolved to base medical-assisted dying on the patient’s decision to receive death through medication or the refusal/withdrawal of treatment if the patient is terminally ill or there is “non-relievable pain or suffering; this... ethical terrain, which historically has been designated by the concept ‘euthanasia,’ has been re-conceptualized as a patient’s right to medically-assisted dying” (Campbell). This differentiation between medical-assisted dying and the past associations of killing with euthanasia is key to understanding the moral and ethical grounds of decisions in the medical field.
Furthermore, the grounds by which physicians determine a patient’s capability to make decisions centers around the burdens a patient faces regarding the “statutory provisions that require a patient to self-administer the life-ending medication and to retain decision-making capability throughout their dying process” (Campbell). The question of capability among patients either suffering from non-relievable pain or terminal illnesses is another essential determinant of medical-assisted dying that has its own set of moral and ethical issues. Furthermore, there appears to be blurred lines between the patient’s own autonomy in decision-making and having “surrogate decisions for the patient based on the patient’s values in the event of loss of decision-making capacity” (Campbell). In a situation where a patient does not have the capability of decision-making, physicians must decide whether or not to take into consideration the choices of family members based upon the patient’s values. Ultimately, it is the physician’s own decision to choose whether they refuse to grant the family member’s request for medical-assisted death; there is a clear difference between a patient’s refusal of treatment and right to physician-assisted death and a family member’s similar request.
The current system in place for those who seek a physician-assisted death depends upon the location and legal system of the area. As mentioned before, states may criminalize certain situations of assisted suicide but not prosecute cases. Past juries have “found those accused of murder or manslaughter in these instances ‘not guilty’” (Benedict). However, there is a clear line between manslaughter or murder and assisted suicide that is made through the terminally ill patients’ request to relieve the suffering they experience compared to an involuntarily death.
Medical-assisted dying remains controversial among the public and professional institutions. The legalization of physician-assisted dying varies by region, and with increasing medical and technological progress, methods of assisted dying are also rapidly changing. Opponents who deplore physician-assisted dying argue that it “devalues human life, which should be treasured and protected”, and proponents claim that physician-assisted dying “is a more respectful and dignified way for terminally ill patients to die” (McKinnon). Amidst differing perspectives, it is clear that both proponents and opponents of medical-assisted dying believe in respect, care, and dignity for the patient but are divided by contrasting values and moral principles.
References
Annadurai K, Danasekaran R, Mani G. 'euthanasia: Right to die with dignity'. Journal of family medicine and primary care. 2014 [accessed 2023 Mar 2]. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4311376/
Benedict S, Pierce AG, Sweeney S. Historical, ethical, and Legal Aspects of Assisted Suicide. Journal of the Association of Nurses in AIDS Care. 1998;9(2):34–44. doi:10.1016/s1055-3290(98)80059-9
Campbell C, Mortal responsibilities: Bioethics and medical-assisted dying. The Yale journal of biology and medicine. [accessed 2023 Mar 2]. https://pubmed.ncbi.nlm.nih.gov/31866788/
Fontalis A, Prousali E, Kulkarni K. Euthanasia and assisted dying: What is the current position and what are the key arguments informing the debate? Journal of the Royal Society of Medicine. 2018;111(11):407–413. doi:10.1177/0141076818803452
McKinnon B, Orellana-Barrios M. Ethics in physician-assisted dying and euthanasia. The Southwest Respiratory and Critical Care Chronicles. 2019;7(30):36–42. doi:10.12746/swrccc.v7i30.561
In the healthcare field, the observance of death is inevitable. However, when is the assistance of death by a physician or emerging technologies morally permissible? There is no clear answer that lies within the various ethical arguments surrounding this issue. Proponents argue medical-assisted dying is the ethical decision for terminally ill patients or those with chronic suffering to face the end of life with comfort and dignity instead of prolonging suffering through palliative care, which “intends to neither hasten nor postpone death” (Fontalis). Opponents raise concerns of the right to life and adequate decision-making among patients who might be experiencing distress or consider themselves a burden to family members. While both arguments have their own validity, this article aims to delineate the concentration of assisted dying and shed light on current standings of this controversial measure.
Understanding the four pillars of medical ethics might aid in approaching an answer to this question of what is right or wrong. The four pillars include beneficence (doing good), non-maleficence (performing no harm), autonomy (providing the patient freedom of choice when they are able), and justice (ensuring fairness).
The general idea of physician-assisted dying involves the patient’s decision and perspective, the physician’s type of care, and the patient’s family. The fundamental physician-patient relationship is based upon trust, respect, and non-maleficence; moral arguments regarding medical-assisted dying revolve around these core principles. Autonomy is a critical aspect of providing care to dying patients. A terminally ill or suffering patient may experience stressful emotions, feeling as if they are a burden, suffer from treatment, or believe that they have a lack of control over their quality of life. These factors can lead certain patients to consider physician-assisted dying. However, from the doctor’s standpoint, the principles of beneficence and non-maleficence come into play when finalizing a request to either continue or cease treatments. The physician is not completely bound to respect the patient’s autonomy since their physical health, mental state, and well-being must also be taken into account. The conflict between beneficence, non-maleficence, and autonomy when considering to alleviate a patient’s suffering is at the forefront of the controversy. If a physician agrees to respect a patient’s autonomy and assist in their death, this is viewed as causing harm through the traditional ethical principles of medicine. In contrast, this same action can be viewed by the terminally ill patient as the ultimate act of beneficence on behalf of the physician and an acknowledgement of the patient’s ability to make coherent decisions. It may be received from certain people of society or the family of the patient that justice involves the patient’s constitutional right to life. Yet, justice and fairness for the patient also describes what the individual is entitled to, which is possibly the request for death.
Whether physician-assisted dying as a whole is morally ethical is determined in the same way that other medical decisions are made: by examining the patient’s condition and concerns. In addition, situations vary between each patient and contribute to the overall determination of action. Each physician has their own principles that they might adhere to on top of medical guidelines, and each patient has their own unique concerns, emotions, or viewpoint from which they make their request for death. When examined through the lens of the legal system, the legal status of assisted dying is ambiguous as states might “criminalize assisted suicide” but “state prosecution of assisted suicide is not common” (Benedict). There are “ethical objections regarding the integrity of the patient-physician relationship and last resorts in ending life, professional concerns about medicalization and a diminished identity of medicine as a healing profession, and social responsibilities to provide equal access to basic health care and to hospice care” (Campbell). These objections bring to light important factors in determining what allows for the “correct” criteria to be satisfied in terms of granting patient autonomy for assisted suicide. Ethical arguments and patient advocacy prompted the National Academy of Medicine to maintain that “the right to die should encompass (1) physician-administered medications for terminally ill persons, some of whom may no longer have and (2) decision-making capacity” (Campbell). In addition, since advocates argue “that certain medical conditions afflicting chronically ill persons can impose an experience of unbearable pain and suffering for which even the best of palliative care measures are inadequate for the patient, access to either self-administered or (3) physician-administered medications to end life should also be available to (4) non-terminally ill persons with no terminal diagnosis but who are experiencing (5) a grievous and irremediable medical condition” (Campbell). The moral and ethical argument has evolved to base medical-assisted dying on the patient’s decision to receive death through medication or the refusal/withdrawal of treatment if the patient is terminally ill or there is “non-relievable pain or suffering; this... ethical terrain, which historically has been designated by the concept ‘euthanasia,’ has been re-conceptualized as a patient’s right to medically-assisted dying” (Campbell). This differentiation between medical-assisted dying and the past associations of killing with euthanasia is key to understanding the moral and ethical grounds of decisions in the medical field.
Furthermore, the grounds by which physicians determine a patient’s capability to make decisions centers around the burdens a patient faces regarding the “statutory provisions that require a patient to self-administer the life-ending medication and to retain decision-making capability throughout their dying process” (Campbell). The question of capability among patients either suffering from non-relievable pain or terminal illnesses is another essential determinant of medical-assisted dying that has its own set of moral and ethical issues. Furthermore, there appears to be blurred lines between the patient’s own autonomy in decision-making and having “surrogate decisions for the patient based on the patient’s values in the event of loss of decision-making capacity” (Campbell). In a situation where a patient does not have the capability of decision-making, physicians must decide whether or not to take into consideration the choices of family members based upon the patient’s values. Ultimately, it is the physician’s own decision to choose whether they refuse to grant the family member’s request for medical-assisted death; there is a clear difference between a patient’s refusal of treatment and right to physician-assisted death and a family member’s similar request.
The current system in place for those who seek a physician-assisted death depends upon the location and legal system of the area. As mentioned before, states may criminalize certain situations of assisted suicide but not prosecute cases. Past juries have “found those accused of murder or manslaughter in these instances ‘not guilty’” (Benedict). However, there is a clear line between manslaughter or murder and assisted suicide that is made through the terminally ill patients’ request to relieve the suffering they experience compared to an involuntarily death.
Medical-assisted dying remains controversial among the public and professional institutions. The legalization of physician-assisted dying varies by region, and with increasing medical and technological progress, methods of assisted dying are also rapidly changing. Opponents who deplore physician-assisted dying argue that it “devalues human life, which should be treasured and protected”, and proponents claim that physician-assisted dying “is a more respectful and dignified way for terminally ill patients to die” (McKinnon). Amidst differing perspectives, it is clear that both proponents and opponents of medical-assisted dying believe in respect, care, and dignity for the patient but are divided by contrasting values and moral principles.
References
Annadurai K, Danasekaran R, Mani G. 'euthanasia: Right to die with dignity'. Journal of family medicine and primary care. 2014 [accessed 2023 Mar 2]. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4311376/
Benedict S, Pierce AG, Sweeney S. Historical, ethical, and Legal Aspects of Assisted Suicide. Journal of the Association of Nurses in AIDS Care. 1998;9(2):34–44. doi:10.1016/s1055-3290(98)80059-9
Campbell C, Mortal responsibilities: Bioethics and medical-assisted dying. The Yale journal of biology and medicine. [accessed 2023 Mar 2]. https://pubmed.ncbi.nlm.nih.gov/31866788/
Fontalis A, Prousali E, Kulkarni K. Euthanasia and assisted dying: What is the current position and what are the key arguments informing the debate? Journal of the Royal Society of Medicine. 2018;111(11):407–413. doi:10.1177/0141076818803452
McKinnon B, Orellana-Barrios M. Ethics in physician-assisted dying and euthanasia. The Southwest Respiratory and Critical Care Chronicles. 2019;7(30):36–42. doi:10.12746/swrccc.v7i30.561
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