Up@dawn 2.0

Monday, February 25, 2013

The Ethics of Physician-Assisted Suicide

[Komron MacLean]
Hey everyone, this is my mid-term report. I chose to discuss physician-assisted suicide (PAS) because I feel that it is an area of human medicine that, in our society, is misunderstood and undervalued, for several reasons. By reading ahead, you will see that I address both sides of the argument, for and against. You may learn a little about the technical aspects of PAS and also the laws that govern it in the United States. Although not comprehensive, I hope this essay contributes to your understanding of PAS and its significance to human medicine in our world today. 

The Ethics of Physician-Assisted Suicide
                The Hippocratic Oath, written between 400 and 300 B.C. is still taken and honored by medical doctors today, albeit in many different, highly modified forms. The mere fact that it has lasted so long, withstanding the trials and modifications of even this past century’s technological, cultural and medical advancements, proves its value and command over both ancient and modern practical medical ethics. It is a fact that the original Oath states, “To please no one will I prescribe a deadly drug nor give advice which may cause his death.”[1] The ancient guiding principle of health care, Primum non nocere- do no harm, is one principle that remains even today. Others pertain to patient confidentiality and honoring one’s teachers. Thus, it is clear that the original ethical code established for the governance of medical ethics holds a bold and unwavering stance on the subject of euthanasia. The Oath is not one bound by law but one simply of tradition and honor.
                Modern medical professionals display contrasting emotions regarding the Oath. Many feel that in order to practice modern medicine, which may require such actions as administering toxic chemotherapy, treatment with radiation and inducing potentially harmful events to yield a diagnosis, the do no harm aspect of the Oath must be violated daily.[2] As many other laws have since been adapted to modern society and many once unacceptable practices deemed necessary and suitable to our needs as a dynamic species, perhaps this oath will soon be amended to afford some form of physician-assisted suicide for the terminally ill. Currently, state laws govern such practices.
                There are three separate modes of euthanasia: passive euthanasia, non-active euthanasia and active euthanasia. Passive euthanasia involves withholding life support measures such as administration of fluids, antibiotics or other medications or treatments necessary to sustaining a patient’s life, while knowing that in doing so, and as a direct result of that action, the patient is certain to perish. Non-active euthanasia involves the termination of life support of a patient who can no longer consciously make that decision himself. Finally, active euthanasia, the most controversial means of euthanasia, is the direct administration of a lethal dose of a toxic substance to a patient in an attempt to abruptly end their life. Active euthanasia is the topic most often in question due to its common interpretation as homicide. 
               Active euthanasia and physician-assisted suicide (PAS) are viewed as two entirely separate events. Active euthanasia requires a physician to personally end the life of a patient in their care. Physician-assisted suicide on the other hand, refers to the physician providing the means and understanding by which a patient may, by his or her choice, ultimately end their life themselves.[3] After centuries of debate, consensus has not been reached among scholarly parties concerning this matter in particular. Is it murder or is it mercy? And, where are the lines drawn?
                This is indeed a multi-party debate not limited only to physicians, patients and state legislature. Monotheistic religion, as broad of a category as it is, has actually for the most part, come to a general agreement concerning the act of suicide itself. “Life is a gift from God, and  ‘each individual [is] its steward.’ Thus, only God can start a life, and only God should be allowed to end one.”[4] Some go so far as to say suicide is a sin. Followers of faith in a divine Creator believe that God would not give humanity anything it cannot handle, thus we must live as he created us and leave the physical world when called and not a minute sooner. In some religions such as Islam, the concept of “life not worth living” simply does not exist and any measure taken to counteract the continuance of life is considered cowardice or sinful.
                Meanwhile, other religious viewpoints described as being “liberal” and not believing in a single Creator or any at all, dictate an opposing view; “Each person has autonomy over their own life. Persons whose quality of life is nonexistent should have the right to decide to commit suicide, and to seek assistance if necessary.”[5] Both sides present strong arguments, but those acting on faith bear the burden of proof to justify their cause.
                Arguments supporting PAS include respect for autonomy, justice and compassion. The elements of respect for autonomy and compassion for the suffering are self explanatory. For a moment, place yourself in the shoes of a person suffering from Huntington’s disease.
You are 35 years old and your life is just falling into place. You are newly married and you are finally advancing in your career. One day you drop a coffee pot in the kitchen, and five years later, you are taking your meals through a tube to your stomach while your husband or wife works two jobs to support you while answering phone calls from the bank and collection agencies. All you can do is cry and blink. The doctor says you have two more years. Perhaps faith in God will soothe you while your wife changes your fecal bag.
                Justice applies to treating all cases individually but fairly. Not all cases are alike. One terminally ill patient who no longer has the desire to continue suffering may hasten their imminent demise by simply refusing treatment, or completing a DNR (do not resuscitate order). Another terminal patient in similar anguish, but with a differing medical issue, may not be able to quicken death simply by refusing treatment. Thus suicide becomes their only option for achieving swift freedom from torment. Both deserve equal consideration of their differing circumstances, and both should be given options suiting their needs. A woman indefinitely connected to a respirator; another with a degenerative neurological condition; a twelve-year old with cerebral palsy in constant, intractable pain; and a transient man with no identification who hit by a car, is now comatose and mortally injured in a public hospital’s ICU supported by tax dollars- four cases, all different. All are deserving of independent review and treatment. All will fall under separate ethical guidelines, but they certainly cannot be lumped under the same.
                Perhaps the clear, virtual basis for legalized PAS- the more rational component of justification- plays the leading role in support of physician-assisted suicide. The abortion of a healthy fetus upon request is legal in four US states regardless of justification. If aborting a healthy, viable life for any reason whatsoever is sanctioned, why then is a humane, physician guided endpoint for the terminally ill suffering from unmanageable pain or progressive, irreversible loss of somatic control deemed unlawful in the same states?[6]
                Thirty-five states actively euthanize convicted inmates as a form of capital punishment for crimes against their fellow citizens.[7] The definition of the noun form of the word “murder” is the killing of a human being under the conditions specifically covered by law.[8] Therefore if lethal injection, which is certainly the killing of a human being, is legal under U.S. law in thirty-five states as a means of terminating the life of a criminal, then it is arguable that a perfectly innocent, terminally ill patient, suffering in their own existence by no fault of their own, who has been deemed mentally stable, should be able to seek the help of knowledgeable personnel in reaching a swift, humane endpoint. This is not a question of yet legislated legal practice, but instead, of the ethical and moral principles that have guided our government’s decisions for the past 237 years of its existence. 
                The financial burden to caretakers of the terminally ill can also present an argument for PAS. It is no mystery that medical costs in the United States are high. Imagine a family with a single source of income, no health insurance and the significant financial burden of managing a terminal illness. In a best case scenario, the patient’s suffering is attenuated for a few months or years until they die; and in the meantime, the family is driven to financial ruin. PAS would be a significantly easier way of avoiding the total financial destruction of the household of a terminally ill patient while also providing the patient with a dignified endpoint, if they so chose it.
                Finally, openness of discussion brings up a very important and more legally limited point. There will, with certainty, be instances where patients “accidentally die of morphine overdose due to medical negligence”. It may be assumed that in some of those cases, there was a mutual understanding between physician and patient that the overdose of a barbiturate, opiate or other sedative would lead to a quick, painless death.[9] PAS’s illegalization prevents open discussion regarding the procedure and therefore precludes disclosure of its occurrence to everyone involved in the patient’s care, possibly leading to complications. These complications can further jeopardize the patient’s health.
Definitive arguments against PAS, excluding those concerning religion, include: potential abuse of the method, the marring of professional integrity, and fallibility of the profession. The argument surrounding abuse stems from the potential of a person without access to proper medical care, to be influenced in their decision to seek an easier, more “convenient” option rather than carrying on and possibly becoming a burden on those close to them. This is a very valid point, especially in light of recent events such as one case involving Dr. Jack Kevorkian, who claimed to have assisted in the deaths of at least 130 persons. Dr. Kevorkian claimed that he operated under strict guidelines. Examples of these guidelines seemed reasonable, such as only assisting diagnosed, terminally ill patients who had received matching diagnoses from at least two physicians and had expressed repeatedly their desire to die. Mental stability confirmed by a clinical psychologist was also a prerequisite. Yet a Detroit Free Press investigation in 1997 showed that “In fact, at least 60 percent of Kevorkian's suicide patients were not terminal. At least 17 could have lived indefinitely and, in 13 cases, the people had no complaints of pain”[10]. In the event that PAS were to be legalized, the definition of physician assisted suicide would need to be clear in both its limits as well as the circumstances surrounding its justification. Any right must not be abused.
Preservation of professional integrity dates back to the third century B.C. and is not a statute easily corrupted by any force, no matter how bold. With legalization of regulated physician-assisted suicide in the United States, there would be significant opposition even from within the medical community.
The Hippocratic Oath, whose guidance has given the medical trade honor and virtue for centuries, will be contested.  Also, the modern institutions that guide and represent doctors and other practitioners of medicine such as the American Medical Association, who feel that such permissive legislation will tarnish the “do no harm” reputation of its entrusted practitioners, also object.
The final and most logical of the arguments against PAS, is concern for fallibility of the profession. Doctors will inevitably make mistakes that could unnecessarily harm a patient promised a quick and painless release from their already agonizing life. While no doctor will claim to be infallible, the objection is sustained. This is a potential complication that must have its edges ironed out by bioethicists and physicians alike.
Ultimately, the best way to curb the debate and reach a logical and reasonable conclusion is that each case be treated individually, and for each decision to be reached independently and scientifically, rather than by merit of ancient tradition alone. The Oath, treated as a time honored guide for medicine, will remain debated from a contemporary perspective. In the end the decision will lie in the hands of the practitioner, whose ancient art is based on the Oath which in part reads, “I will give no deadly medicine to any one if asked, nor suggest any such counsel”[11] Perhaps medicine will retain its traditional values and keep separate the arts of healing the body and freeing the soul. Or, perhaps it will recognize that the same progression of thought and the bold pushing of boundaries that have raised the quality of life of the average individual from what it was centuries ago may elevate patient care even beyond what we now perceive as “ethical”.

Works Cited
Bioethics Education Project. Braddock, Clarence H.  University of Washington.  April 11th, 2008. Sept. 17th 2009 http://depts.washington.edu/bioethx/topics/pas.html#ques4
Cheyfitz, Kirk. "Suicide Machine, Part 1: Kevorkian rushes to fulfill his clients' desire to die". March 3, 1997. Detroit Free Press. Archived May 26, 2007.
Clark, Richard. Capital Punishment UK 1995. Sept. 17th 2009. http://www.capitalpunishmentuk.org/injection.html
Collier, P.F.  et. al. "Harvard Classics Volume 38" 1910. Sept. 17th 2009 http://www.euthanasia.com/oathtext.html  
"Murder." Dictionary.com Unabridged (v 1.1). Random House, Inc. 17 Sep. 2009. Dictionary.com http://dictionary.reference.com/browse/murder>.
NOVA http://www.pbs.org/wgbh/nova/doctors/oath_doctors.html  Retrieved 2-23-2013
Patients Rights Council  http://www.patientsrightscouncil.org/site/assisted-suicide-state-laws/ 2013Retrieved 2-22-13
Robinson, B.A. “Euthanasia and Physician-Assisted Suicide (PAS)” Religious Tolerance.org  2009-SEP-03. Sept. 17th 2009 http://www.religioustolerance.org/euthanas.htm
Weber, David O.  “Malpractice insurance rates reach boiling point: Physicians burned by lawyers,                     lawsuits and jury awards - Doctors, Lawyers and Lawsuits” BNet . March 2002. Sept. 17th 2009                      http://findarticles.com/p/articles/mi_m0843/is_2_28/ai_84236557/

[2] http://www.pbs.org/wgbh/nova/doctors/oath_doctors.html. Retrieved 2013-02-23
[6] http://www.patientsrightscouncil.org/site/assisted-suicide-state-laws Retrieved 2013-02-22
[10] http://www.freep.com/article/20070527/NEWS05/70525061/SUICIDE-MACHINE-PART-1-Kevorkian-rushes-fulfill-his-clients-desire-die Retrieved 2013-02-22


  1. Engaging discussion, Komron. "Harm" isn't so black & white as we used to think it was. A "good death" may sometimes require professional assistance, it's good you're reflecting on it now. Life's a gift that sadly becomes a curse for some with terminal. conditions.

  2. I sort of skimmed over this, so I'm sorry if I missed a reference, but there are a couple of great documentaries on Netflix about this subject. One is called "The Suicide Tourist," it is about a man who is dying of Lou Gehrig's Disease (ALS), and while is still able to speak, decides to travel abroad to Switzerland to a non-profit organization that legally assists suicide. The organization of course does it only for special cases in which people are terminal or quickly losing control of their body. While I absolutely agree with the organization, it was definitely a tear-jerker. Definitely one I would recommend anyone watching. Good topic!

    1. Is this the one where the patients take a pill; he has a big party to celebrate the end?

    2. No, its more like a concoction made up of mostly sleeping meds.

  3. This comment has been removed by a blog administrator.

  4. Thanks for this!! This is one of the interview review cases I still have trouble defining a direct answer. It was nice to see a perspective being negated and promoted within itself.

  5. Great paper, Komron. I too agree that each case must be handled independently of the others. Had Hippocrates known what we now know about disease and medicine, I truly believe he would have had more thoughts on the "I will give no deadly medicine" clause. Our (future) jobs, I believe, are not to "do no harm" but instead to do as much good as we possibly can. With the latter you automatically imply that no harm will be done, but you also allow the physician to put the patient in a better place, whatever course of action that dictates.

  6. excellent and well thought out paper. one area that would be interesting to look at would be the Insurance arena. insurance companies lobby legislative groups form local to national to better favor their capitalist responsibility to their investors. when a person comits suicide their life insurance policy is revoked. adjusters often try to find ways to make it seem less then natural if at all possible. so for me to see how the big insurance companies would try their hardest to ensure that no suicide be a payable event is no stretch. this would be just another smaller point to place into your paper.

    1. Nick, that is a very good point. Certainly this issue is a contributing factor to the lack of progress with respect to PAS. Drawing the lines will be the hardest task for the ethicists and physicians and legislators who are involved in this debate. I wish it was easier to take capital gain out of the picture, but in our society, it IS our society. Insurance companies are, for the most part, for profit. In order to make a profit, they cannot have people "buying" their insurance just to turn around the next week and drink some death syrup and have their families benefit at the expense of investors and those that pay the premiums for 50 years. If that was possible, then the whole " no discrimination based on preexisting health conditions" clause of the ACA would fall flat on its face. I certainly don't claim to have a definitive solution to that problem. It wouldn't be fair to refuse longstanding clients' claims because they chose to leave this world sooner than "nature would provide" but again, insurance companies would be forced to discriminate based on preexisting health conditions to safeguard against scammers. Forcing a patient to live out the remainder of their natural life in agony simply to ensure that their families are not bankrupt when they do pass on, is wrong. I suppose if patients met a particular "pain and hardship" criterion, they could be exempt from the "rules" regarding suicide? but again, still a lot of grey area and and infinite number of variables.