Skyllar Kuppinger
As disease shifts from acute to chronic, the last months or even years of a person’s life tend to be spent in illness. The laws vary between countries, but in general, a terminally ill patient must choose between further medical interventions, palliative (end-of-life) care, or physician-assisted suicide. Physician assisted suicide is a topic of great debate amongst the medical community due to its implications about healthcare.
Firstly, physician assisted suicide (PAS) is defined as the process by which a patient voluntarily ingests a lethal substance that was prescribed by a physician. PAS is not to be confused with euthanasia, which is when the physician, not the patient, administers the lethal dose (Bakker et al. 2017). Euthanasia is illegal in all states, whereas PAS is legal only in California, Colorado, Oregon, Vermont, Washington, Hawaii, Montana, New Jersey, Maine, and D.C. (FindLaw 2016). Oregon was the first state to legalize PAS by passing the Death with Dignity Act, which went into effect in 1997. Thus, PAS laws in other states, such as the End of Life Options Act in California, closely mirror the Death with Dignity Act (Findlaw 2016).
PAS has been most thoroughly studied in Oregon, as it has been legal in this state for the longest amount of time. The number of people who used physician-prescribed drugs to end their lives in Oregon increased from 16 in 1998 to 188 in 2019 (OPHD 2019). In California, 337 people died in this way in 2018 (CDPH 2018). It is of note that about 90% of all people who have undergone PAS were white (Kane 2014). Cancer was the most common ailment among these patients, and the average age was between 69 and 89 years (Kane 2014). Additionally, the most recent survey of physicians’ opinions on PAS showed that 54% of U.S. doctors believed that PAS should be allowed (Kane 2014).
Perhaps the most relevant question regarding the ethicality of PAS is whether choosing death over life is ever acceptable or beneficial. Many argue that PAS is ethical as it provides a way for terminally ill patients to end their suffering. These individuals assert that choosing to “die with dignity” is an essential right and that nobody should be forced to spend the last months of his/her life in agony (Bakker et al. 2017). On the other hand, some people insist (for spiritual or non-spiritual reasons) that life is always superior to death and that a physician’s job is to promote life, not death (Bakker et al. 2017).
Clearly, PAS complicates the role of a physician. The decision to allow a patient to proceed with ending his/her life is one that will undoubtedly weigh on the physician’s conscience. In addition, the Hippocratic Oath states that a physician shall not administer lethal poison to a patient. Many doctors interpret this to mean that PAS is a violation of the Hippocratic Oath (Phillips 2015). For these reasons, physicians in states where PAS is legal may opt out of performing PAS. In this case, the patient must find another doctor if they wish to proceed with PAS (OHA [date unknown]).
Another ethical concern surrounding PAS is its exploitability: How can we ensure that PAS is not abused by the mentally ill or by individuals whose conditions are not terminal? In the United States, there are many safeguards in place to limit eligibility for PAS. The patient must be 18 or older, have the mental capacity to make the decision, be diagnosed with a terminal illness that is expected to lead to death within six months, and undergo multiple approvals and waiting periods (OHA [date unknown]). However, there have still been cases in which arguably ineligible patients were approved for PAS. For example, research indicates that in Oregon, people with undiagnosed clinical depression were given lethal drugs for the purpose of ending their lives (Dobscha et al. 2008). In addition, a 47 year old woman in the Netherlands was granted her wish for lethal drugs due to tinnitus, also known as ringing of the ears (Byock 2015). Critics of PAS use these cases as evidence that the abuse of PAS is inevitable. Supporters of PAS argue that such cases are only exceptions and should not be used to deny others the right to die with dignity. Furthermore, although the answer may seem obvious, it is important to consider why non-terminal conditions such as tinnitus are not valid reasons to pursue PAS. Who, if anyone, is to decide how ill a patient must be in order to be eligible for PAS?
In summary, the topic of end-of-life care is a controversial one. The legalization of PAS is a relatively recent development in medicine, which shows that the medical field is constantly evolving along with societal perceptions about healthcare. Thus, it is important for both sides of the debate to ponder the implications of PAS on the role of healthcare and the role of the physician.
References:
Firstly, physician assisted suicide (PAS) is defined as the process by which a patient voluntarily ingests a lethal substance that was prescribed by a physician. PAS is not to be confused with euthanasia, which is when the physician, not the patient, administers the lethal dose (Bakker et al. 2017). Euthanasia is illegal in all states, whereas PAS is legal only in California, Colorado, Oregon, Vermont, Washington, Hawaii, Montana, New Jersey, Maine, and D.C. (FindLaw 2016). Oregon was the first state to legalize PAS by passing the Death with Dignity Act, which went into effect in 1997. Thus, PAS laws in other states, such as the End of Life Options Act in California, closely mirror the Death with Dignity Act (Findlaw 2016).
PAS has been most thoroughly studied in Oregon, as it has been legal in this state for the longest amount of time. The number of people who used physician-prescribed drugs to end their lives in Oregon increased from 16 in 1998 to 188 in 2019 (OPHD 2019). In California, 337 people died in this way in 2018 (CDPH 2018). It is of note that about 90% of all people who have undergone PAS were white (Kane 2014). Cancer was the most common ailment among these patients, and the average age was between 69 and 89 years (Kane 2014). Additionally, the most recent survey of physicians’ opinions on PAS showed that 54% of U.S. doctors believed that PAS should be allowed (Kane 2014).
Perhaps the most relevant question regarding the ethicality of PAS is whether choosing death over life is ever acceptable or beneficial. Many argue that PAS is ethical as it provides a way for terminally ill patients to end their suffering. These individuals assert that choosing to “die with dignity” is an essential right and that nobody should be forced to spend the last months of his/her life in agony (Bakker et al. 2017). On the other hand, some people insist (for spiritual or non-spiritual reasons) that life is always superior to death and that a physician’s job is to promote life, not death (Bakker et al. 2017).
Clearly, PAS complicates the role of a physician. The decision to allow a patient to proceed with ending his/her life is one that will undoubtedly weigh on the physician’s conscience. In addition, the Hippocratic Oath states that a physician shall not administer lethal poison to a patient. Many doctors interpret this to mean that PAS is a violation of the Hippocratic Oath (Phillips 2015). For these reasons, physicians in states where PAS is legal may opt out of performing PAS. In this case, the patient must find another doctor if they wish to proceed with PAS (OHA [date unknown]).
Another ethical concern surrounding PAS is its exploitability: How can we ensure that PAS is not abused by the mentally ill or by individuals whose conditions are not terminal? In the United States, there are many safeguards in place to limit eligibility for PAS. The patient must be 18 or older, have the mental capacity to make the decision, be diagnosed with a terminal illness that is expected to lead to death within six months, and undergo multiple approvals and waiting periods (OHA [date unknown]). However, there have still been cases in which arguably ineligible patients were approved for PAS. For example, research indicates that in Oregon, people with undiagnosed clinical depression were given lethal drugs for the purpose of ending their lives (Dobscha et al. 2008). In addition, a 47 year old woman in the Netherlands was granted her wish for lethal drugs due to tinnitus, also known as ringing of the ears (Byock 2015). Critics of PAS use these cases as evidence that the abuse of PAS is inevitable. Supporters of PAS argue that such cases are only exceptions and should not be used to deny others the right to die with dignity. Furthermore, although the answer may seem obvious, it is important to consider why non-terminal conditions such as tinnitus are not valid reasons to pursue PAS. Who, if anyone, is to decide how ill a patient must be in order to be eligible for PAS?
In summary, the topic of end-of-life care is a controversial one. The legalization of PAS is a relatively recent development in medicine, which shows that the medical field is constantly evolving along with societal perceptions about healthcare. Thus, it is important for both sides of the debate to ponder the implications of PAS on the role of healthcare and the role of the physician.
References:
- Bakker J, Churchill G, Downar J, Ely EW, Goligher EC, Hosie A, Patel BM, Payne K, Raphael J, Sulmasy DP, Volandes AE, White DB. 2017. Physician-assisted suicide and euthanasia in the intensive care unit: A dialogue on core ethical issues. Crit Care Med. 45(2):149-155.
- Byock I. 2015. Expanding the Right to Die. The New York Times. [accessed 2020 Nov 29]. https://www.nytimes.com/roomfordebate/2014/10/06/expanding-the-right-to-die/doctor-assisted-suicide-is-unethical-and-dangerous
- California Department of Public Health. California end of life option act 2018 data report [internet]. Available from https://www.cdph.ca.gov/Programs/CHSI/CDPH%20Document%20Library/CDPH%20End%20of%20Life%20Option%20Act%20Report%202018-FINAL.pdf
- California Euthanasia Laws. 2016 Jun 21. Findlaw. [accessed 2020 Nov 29]. https://statelaws.findlaw.com/california-law/california-euthanasia-laws.html
- Dobscha SK, Ganzini L, Goy ER. 2008. Prevalence of depression and anxiety in patients requesting physicians aid in dying: cross sectional survey. BMJ. 337(a1682).
- Gonchar M. 2014 Oct 24. Should Physician-Assisted Suicide Be Legal in Every State? The New York Times. [accessed 2020 Nov 29]. https://learning.blogs.nytimes.com/2014/10/24/should-physician-assisted-suicide-be-legal-in-every-state/
- Kane L. 2014. Medscape Ethics Report 2014, Part 1: Life, Death, and Pain. Medscape. [accessed 2020 Nov 29]. https://www.medscape.com/features/slideshow/public/ethics2014-part1
- Oregon Public Health Division. Oregon death with dignity act: 2019 data summary [internet]. Available from: https://www.oregon.gov/oha/ph/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year18.pdf
- Philips S. 2015. Physicians, the morality of euthanasia, and the Hippocratic Oath. Bioethics at TIU. [accessed 2020 Nov 16]. http://blogs.tiu.edu/bioethics/2015/07/15/physicians-the-morality-of-euthanasia-and-the-hippocratic-oath/
- Public Health's Role: Oregon's Death with Dignity Act. Oregon Health Authority . [accessed 2020 Nov 29]. https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Pages/ohdrole.aspx
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