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  • Writer's pictureSociety of Bioethics and Medicine

The Ethics of Physician-Assisted Death

Written by Sultona Davlatova

Edited by Raheem Sheikh

Physician-Assisted Death. It’s a jarring phrase. Perhaps contradictory, or even paradoxical to what we know a physician should be: someone who saves lives, not someone who ends them. However, there is so much more to uncover here than what one may see on the surface. Indeed, the Hippocratic Oath, taken by aspiring physicians, promises that doctors should “first, do no harm.” However, we must wonder, is the practice of Physician-Assisted Death consistent with that pledge?

Per the American Academy of Hospice and Palliative Medicine, Physician-Assisted Dying (PAD) is defined as a physician providing, at the patient’s request, a prescription for a lethal dose of medication that the patient can self-administer by ingestion, with the explicit intention of ending life. It is legal in ten U.S. states and the District of Columbia. Euthanization is another commonly used term within this topic of interest. The main difference is that euthanization involves the physician administering the substance that would end the person’s life, rather than the lethal dose being self-administered. Given the complexity and gravity of this issue, it is not surprising that there is a significant amount of debate regarding the ethics of this practice.

Individuals that are pro-PAD place a heavy emphasis on a patient’s right to autonomy—the capacity to decide for oneself. As it is their life that could end if the circumstances call for PAD, supporters claim that it should be their well-informed decision on how their life ends. In this regard, by permitting PAD, physicians are respecting this right to patient autonomy. The second main argument that proponents of PAD support is that allowing a patient to die on their own terms saves them from avoidable pain and suffering at the end of their life. At its core, medicine’s goal is to end or lessen the patient’s pain caused by illness and disease. In a way, it is seen as a humane way to let someone go. Patients would get to end their life peacefully and with as little pain as possible, instead of foregoing the dying process as their bodies slowly shut down, which may only lead to prolonged suffering. At this time, healthcare workers may be able to help mitigate the pain the patient is feeling with hospice care (a type of medical care that is provided to patients with a prognosis of 6 months or less with the aim of prioritizing their comfort as they reach the final stages of their life, excluding curative treatment), or palliative care (a type of medical care that also focuses on caring for the comfort of a patient, but takes place at any stage of their disease and often occurs at the same time as curative treatment). However, if the patient feels that they are finally ready to go, and want only this, one must ask if it is fair to dictate what they do with the end of their life. Additionally, it is essential to note that many might not be able to afford end-of-life care, and thus may need this ability to choose PAD as an end-of-life option. Furthermore, PAD is said to be a safe medical practice where there are many precautions in place to ensure the patient is making a sound decision. These include requiring that a patient electing PAD be informed of all end-of-life options; that two witnesses confirm that the patient is requesting autonomously; and that patients are free of coercion and able to ingest the lethal medication themselves.

Those opposing PAD mainly state fears around this practice based on the possibility of PAD not fulfilling its intended, specific purpose. For example, Suicide Contagion is a process by which exposure to the suicide or suicidal behavior of one or more persons influences others to commit or attempt suicide. Many fear that this phenomenon increases the amount of Physician-Assisted Deaths taking place as data, published in the Yale Journal of Biology and Medicine, supports this trend. From 1998 to 2013, the number of lethal prescriptions written each year increased at an average of 12.1%. During 2014 and 2015, however, this increase doubled, suggesting that high-profile PAD leads to more PAD. Additionally, those opposing PAD state that patients are increasingly choosing Physician-Assisted Death for reasons beyond its main aim. Cumulative Oregon data suggest that the vast majority of patients elect AID (Aid in Dying) because they are concerned about “losing autonomy” (90.6%) or are “less able to engage in activities making life enjoyable” (89.1%). Some fear a “loss of dignity” (74.4%); being a “burden on family, friends/caregivers” (44.8%); or “losing control of bodily functions” (44.3%). Concern about inadequate pain control was the reason for pursuing lethal ingestion in only 25.7% of cases. Additionally, depression is prevalent in up to half of patients with cancer, thus, many worry that the reason for a patient electing PAD would be due to the depression they are experiencing, rather than it being a decision made of sound mind. The impacts of such detrimental diseases, like cancer, take a toll on not only a patient's physical state but also their mental state. Patients may feel hopeless and turn to PAD simply because they are too tired to continue and feel that there is no end to their suffering in sight. Depression and suicidality often go hand-in-hand. Thus, many worry that the reason for a patient choosing PAD would be solely due to their suicidality, and be an early death that could have been avoided. Additionally, as briefly mentioned before, other options like hospice care or palliative care are available for patients to choose from instead of or before deciding to elect PAD. A person with a serious/terminal illness does have other choices that could significantly reduce their pain and/or allow them to live a longer life. Many against PAD encourage routes like these rather than or far before choosing to end one's life.

It is important to mention how religion also tends to play a part in this debate, due to many religions’ vehement beliefs in the immorality of willfully taking one’s own life. As this is an integral part of many people’s lives and belief systems, it plays a heavy role in how PAD is seen from an ethical viewpoint. Thus, it is hard to say whether there is a concrete “correct” answer in this discussion because it can be so subjective at times. However, from a secular point of view, is it really humane to let someone suffer when they are bound to die? Is it ethical to take away a person's bodily autonomy because of their loved ones’ inability to let go? Does a person deserve to perpetually teeter between existence and death, risking the loss of their sense of self? Then, we must also consider the very real possibility of Physician-Assisted Death being abused. In one case, Micheal Freeland, who had a 43-year medical history of depression and suicide attempts, requested arranging an assisted suicide with a doctor. Knowing Freeland’s medical history, the physician said that there was “no need” for a psychiatric evaluation. In this way, the necessary safeguards aren’t put in place in order to make sure that this extremely important decision is a decision made competently, without the possibility of mental health issues playing a crucial role in the decision-making process. In a second case, Kathryn Judson had taken her seriously ill husband to the doctor and expected him to be taken care of by the physician, with the aim of improving his physical state. Instead, she overheard the doctor endorsing assisted suicide to her husband, saying how he wouldn’t be such a burden on his wife if he chose the option of assisted suicide. This case is important to note because a rather large percentage of people elect PAD so that they could lessen the burden they feel they are putting on their loved ones. Moreover, this scenario shows how PAD can be presented in a biased manner, thus not allowing a patient to make a well-informed decision for themselves. These are but a few of the many varied cases showcasing complications with PAD that have been recorded. However, in the case of Lynda Bluestein, who is a 75-year-old woman who has terminal fallopian tube cancer and is at the end of her life, the option of PAD comes as a relief to her. She says, “The importance of the peace of mind knowing that I will now face fewer obstacles in accessing the autonomy, control, and choice in this private, sacred and very personal decision about the end of my life is enormous.” In this way, PAD is fulfilling its main purpose: to allow the individual autonomy and lessen the pain that they are already experiencing. Within the complexities of this argument, there is so much to contemplate and turn over in our minds, reflecting upon our own values and beliefs.

Taking all this into account, is it really practical to say that there can be one right answer in this discussion of right and wrong? Or is it perhaps the freedom to choose how one dictates the end of their life that truly defines the morality of this argument?

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