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This research paper opens with a concise history of the right to die movement. Then it provides a conceptual framework, explaining key terms that are often utilized by those who advocate physician aid-in-dying: liberty, autonomy, dignity, respect, concern, quality of life, and suffering. Contra quality-of-life considerations, arguments relating to the sanctity of life are presented. Reﬂecting on whether the physician’s role includes also termination of life, guidelines are suggested that balance between patient’s wishes and our shared concern to prevent abuse, explaining that while physicians cannot be obligated to end life, those who accept that patients do have the right to die may come to their assistance.
Consider the following scenario: A patient suffers from an incurable disease and great pain. The agonized patient loses hope and expresses a desire to die. Consequently, she asks for the physician’s help. Those who believe life is intrinsically valuable object to taking life and to providing aid-in-dying. They believe that end-of-life issues are decided by nature; these are not decisions that people should take. However, this objection ignores the autonomy of the patients concerned and their explicit wishes. In these contexts, a patient clearly says: “I would like to die. I would rather die in these circumstances because I lost the zeal for life. Just hanging on there is not enough. I want to live, not just to survive.” A number of questions arise: Can life be intrinsically valuable independently of the interests of the individual? Does the state have the right to impose continuation of living on patients who wish to die? Should the medical profession provide aid-in-dying? These are the questions we face.
When speaking of the right to die, usually people refer to gravely ill patients who have a certain perception of themselves within a subjective time framework. These are people who appreciate their past, are unhappy with their present condition, and wish to have a short future as the prospect of continued living under the challenging circumstances is not appealing. While people cannot decide the moment when they come to the world, some people wish to decide the moment they depart the world. To make a strong argument for the right to die, people resort to the concepts of liberty, autonomy, dignity, respect, concern, quality of life, and suffering. Those who endorse physician aid-in-dying accentuate respect for the patient’s autonomy and freedom of conscience as well as opposition to coercion of any form. They speak of physicians’ requirement to respect all legitimate concerns and needs of their patients. Those who reject physician aid-in-dying raise concerns regarding potential abuse, the possibility that patients who do not wish to die might be killed, and the risk to vulnerable populations, especially children, elderly patients, poor patients, and demented and other incompetent patients. They also speak of the limitations on physician’s duties. These duties include healing, relieving suffering, and providing care and comfort for the patients. These duties, so the opposition claims, do not include the duty to end life.
This research paper opens with a concise history of the right to die movement. Then it discusses the above concepts and offers guidelines that strike a balance between the patient’s wishes and our shared concern to prevent abuse, explaining that while physicians cannot be obligated to end life, those who accept that patients do have the right to die may come to their patients’ assistance.
History And Development: Background Of The Right To Die Movement
The Netherlands is one of the most liberal societies in the world. Its underlying values are peace, freedom, openness, tolerance, and compromise. During the 1960s, the Netherlands was transformed from a conservative, tradition-bound country into a society of social and cultural experimentation. The Netherlands took a prominent place in the sexual revolution, the legalization of prostitution and abortion, the acceptance of nonaddictive drugs, the democratization of educational institutions, and the questioning of religious authority. The process of secularization that started in the 1960s gradually undermined the status of traditional institutions. The student revolution of 1969 had a profound effect on the country as the social movement rebelled against traditional values, autocracy, and established hierarchies. Societal relationships also changed to the effect that the social distance between ordinary people and people in power positions declined. As such, ordinary people developed expectations about their role and inﬂuence in society and their ability to affect matters concerning their lives (Grifﬁths et al. 1998).
The essential moral foundations that were established included the shifting of the focus to autonomy and individuality, emphasis on individual choice, and liberation from collective morality. The religious view of the sacredness of life was abolished and replaced by secular moral views. The discussion on morality has revolved since then around the rights of the individual, including issues such as contraceptives, abortion, suffering, and ending life. The increased democratization of society and the emphasis on individual control thus made the practice of euthanasia more open and available (Cohen-Almagor 2004).
In 1969, Jan Hendrik van den Berg (1978), a renowned psychiatrist, published his book Medical Power and Medical Ethics. The book discussed the tragic conditions of various patients, who were described as victims of medical power. Had they lived 100 or even 50 years ago, they would have been allowed to die in peace. These days, however, they are being kept alive simply because the capacity to do this is available, regardless of the patients’ best interests. Van den Berg suggested granting patients a digniﬁed death. His book started in earnest the debate on the right to die that culminated in 2002, when the Netherlands became the ﬁrst country in the world to legally allow euthanasia. The Dutch experience has inﬂuenced the debate on euthanasia and death with dignity around the globe, especially with regard to whether physician-assisted suicide (PAS) and euthanasia should be legitimized or legalized (Youngner and Kimsma 2012).
In 1980, the World Federation of Right to Die Societies was founded. It has 53 organizations from 26 countries, all working to protect the right of individuals to self-determination at the end of life (see http://www.worldrtd.net/). The same year, 1980, in the United States, Derek Humphry founded the Hemlock Society in order to help patients who suffer from incurable diseases to die peacefully. In 1991, Humphry published Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying which provides guidance on assisted suicide. The book made it to the top of the New York Times best-seller list.
The right to die movement emphasizes the patient’s liberty, her autonomy to make fatal choices at the end of life, the patient’s desire to maintain her dignity, and the medical team’s effort to see that the patient’s dignity is preserved. The right to die movement speaks of our shared commitment to show respect and concern for vulnerable patients at the time of need, the importance of quality-of-life considerations, and the avoidance of suffering. Patients who are in a state of irremediable and unbearable suffering are no longer able to appreciate and enjoy life. Some of them, especially those who are autonomous and strong willed, may wish to decide the moment of their own death. Responsible and conscience supporters of the right to die share with those who oppose that right deep and unequivocal concern about the crucial need to prevent abuse. After all, matters of life and death are most significant and thus necessitate erecting ample monitoring and control mechanisms to see that the right to die is not transformed into a duty to die. The medical profession is not immune to paternalism, when some people around the patient’s bed believe they know better what the patient’s best interests are, better than the patient herself. This is a dangerous tendency against which vulnerable patients need protection.
Liberty is required in order to enable people to discover, from the open confrontation of the ideas that are cherished in their society, their own views, their beliefs, and their future life plans. Liberty enables autonomy, self-rule, and self-direction. Accordingly, the view is that individuals should be left to govern their affairs without being overwhelmingly subject to external forces. We are said to be free when our acts are not dominated by external impediments, thus enabling us to form judgment, to decide between alternatives, and to act in accordance with the action-commitments implied by our beliefs. Patients, it is argued, should be at liberty to end their lives if they so choose.
The notion of autonomy assumes some degree of rationality. It involves the person’s ability to reﬂect upon beliefs and actions, and the ability to form ideas about them, so as to decide how to lead one’s life. The term “autonomy” is derived from the Greek autos (“self”) and nomos (“rule,” “governance,” or “law”). By choosing among conﬂicting options, individuals consolidate their opinions more fully and review the ranking of values for themselves. Obviously, in order to be able to exercise autonomy, agents need to have a range of options to choose from, some may be of signiﬁcance to the agents, others may not. Having options enables individuals to sustain activities that they regard as worth pursuing and to decide what is worthwhile and what is not. Those who support the autonomy-based approach do not perceive life itself as an absolute virtue. Life allows us to attain certain goals. When patients reach the conclusion that life no longer has meaning to them, they should have the right to opt for death.
Two clariﬁcations are in order. First, autonomy enables us to develop certain capabilities and to cancel others. People may choose a path that negates further self-realization, regarded as valuable to the extent that it outweighs other capabilities with which they are blessed. Second, an autonomous choice does not have to be the best one available. It presupposes that the agent exercises some extent of rationality, but not perfect rationality. The emphasis is not on deciding the “best” objective options, or on holding the “true” objective opinions, but on the way in which we come to make the decisions and to hold our subjective opinions (Cohen-Almagor 1994).
The term “dignity” is derived from the Latin noun dignitas, which means (a) worthiness, merit; (b) greatness, authority; and (c) value, excellence. The noun is cognate with the adjective dignus (worthy), from the Sanskrit root dic and the Greek root deik, which have the sense of “bringing to light,” “showing,” or “pointing out” (Bayertz 1996). Human dignity is the inherent value of personhood by virtue of being human.
When people endorse death with dignity, the focus is on the dominion of the patient over her body. Should life be preserved at any cost? Two principled opinions are expressed. One emphasizes the sanctity of life and sees its maintenance as a substantive intrinsic value. Christian theologians and Jewish law (Halachic) thinkers are among those who associate themselves with this opinion. The other emphasizes the autonomy of the patient and her right to formulate a judgment whether or not to continue living. This view is espoused by prevalent liberal thinking. When using the term “death with dignity,” liberals refer to both (1) the timing of death (people should be allowed, whenever possible, to choose the time of their departure) and (2) the way people die (with the help of medical professionals, people should be able to control the process of dying, maintaining autonomy at the end-of-life, not being humiliated, and perceiving themselves with honor). The concept of dignity refers to a worth or value that ﬂows from an inner source. It is not given from the outside but rather is intrinsic to the bearer of dignity (Cohen-Almagor 2001). The World Medical Association Declaration of Helsinki (1964) holds that “It is the duty of the physician in medical research to protect the life, health, privacy, and dignity of the human subject.” The Universal Declaration of Human Rights (1948), the International Covenant on Civil and Political Rights (1966), and the International Covenant on Economic, Social, and Cultural Rights (1966) also emphasize the inherent dignity of the person.
All people have a right to dignity. Dignity is something that must be accorded to every person from birth, some say from the moment of conception. We are endowed with dignity and have the right to be treated with dignity. Furthermore, dignity involves not only objective but also subjective notions. It is the source from which human rights are derived, and it also refers to one’s own feelings about oneself. To have dignity means to look at oneself with self-respect, with some sort of satisfaction. It means to feel human, not degraded. A subjective concept of the self refers to how a person conceives of her life, her achievements, and her place in the world. This subjective evaluation is affected by the individual’s self-respect, relative to the abilities she believes she possesses and relative to her peers and surroundings.
More speciﬁcally and with reference to the role of physicians, preserving dignity means helping patients to feel valuable. The physical move from the familiarity of the home to an unfamiliar hospital entails the transformation from a “person” to a “patient.” Sometimes the patient is perceived by physicians as a mere “case,” stripped of personality, representing an interesting disease to be studied, or a valuable research tool. Hospitals and the medical staff are supposed to care for the patients, but sometimes, especially in research hospitals, it seems that the reverse is the case: patients are in hospitals for the beneﬁt of the medical staff. The shift from a “person” to a “patient” to a mere “case” betrays human dignity. The preservation of one’s dignity involves, inter alia, listening to the patients’ complaints, helping patients cure their diseases or at least assisting them in controlling their pain, responding to their distress and anxieties, making an effort to relieve them, demonstrating sensitivity to the physical indignities that occur in severe illnesses, and making the patient sense that she is a human being and not an infant, a case study, or, worse, a body that occupies a bed and consumes resources. Patients can feel vulnerable because their self-respect is undermined by their deteriorating condition. Maintaining the patient’s dignity requires physicians as well as the patient’s loved ones (those around the patient’s bed who are important to the patient, who truly care for the patient, and who want her best interests) to help patients retain at least some of their self-respect. The aim is to secure digniﬁed living in severe health conditions.
Respect And Concern
According to Kant (1785), to respect a person is to treat her as an autonomous human being acting in accordance with moral law. The assumption is that humans are moral and Kant’s demand is that people act in accordance with the categorical imperative. In formulating his deontological categorical imperative, Kant recognized that each person had an inviolable and inalienable dignity, which was the reason for respecting persons. Kant (1785) wrote “Act on maxims that can at the same time have themselves as universal laws of nature as their object”; that gives us the formula for an “absolutely good will.” The categorical imperative refers to the will itself, not to anything that may be achieved by the causality of the will (Guyer 2005).
People respect others as autonomous human beings who exercise self-determination to live according to their life plans; we respect people as self-developing beings who are able to expand their inherent faculties as they choose, that is, to develop the capability they wish to cultivate, not every capability that they are blessed with. In turn we respect people in order to help them realize what they want to be. Each individual is conceived as a bearer of rights and a source of claims against other persons, just because the resolution of the others is theirs, made by them as free agents. To regard others with respect is to respect their right to make decisions regardless of our opinions of them. We assume that each course of life has intrinsic value, at least for the individual, and we respect the individual’s reasoning, so long as she does not harm others. Respect for a person means perceiving of the other as an end rather than as a means to something. As Kant explains (1785), persons are not merely subjective ends whose existence has an effect on our actions; instead people exist as ends in themselves. An objective end, Kant maintains, is one for which there can be substituted no other end, for otherwise nothing of absolute value would be found anywhere.
Kant’s line of reasoning is supplemented by our emphasis on the notion of concern. People not only respect people but also care for them. Kant wanted to base his reasoning on logic, attempting to exclude emotional worries, but we acknowledge that persons’ acts are often dictated by emotions. Human nature enables us to rationalize but it might be inﬂuenced by emotional drives. Thus it is not sufﬁcient to speak only of respect (Cohen-Almagor 2001).
The notion of “concern” signals the value of well-being: we ought to show equal concern for each individual’s good. “Concern” does not demand giving equal weight, utilitarian fashion, to the welfare of a stranger as to the welfare of a person’s children (Grifﬁn 1986). Instead, it means giving equal weight to a person’s life and autonomy.
Yet again, the debate revolves around the importance assigned to a person’s independent decision making. Those who endorse the Respect for Others Argument in objection to the “sanctity-of-life” model understand this argument in more speciﬁc terms that relate primarily to the autonomy of the gravely ill patients. The defense of personal liberties is founded on the assertion that we ought to respect others as autonomous human beings who exercise self-determination to live according to their life plans; in turn we respect persons in order to help them realize what they want to be. That is, respect for human beings involves the presupposition that others should be allowed to make their own decisions, based on their conception of what is good and just. Accordingly, each person is viewed as speaking from that person’s point of view, having perceived interests in her own way. We may be asked to give our opinions or decide to express our views anyway; nevertheless, in many instances we recognize the other’s right to make choices. This notion of autonomy is crucial in our considerations. The medical profession is required to respect the wishes of certain incurably ill patients.
Quality Of Life And Suffering
Advocates of the autonomy model say that the consideration of human dignity might lead us to think at times that life is no longer an attractive option. A theme that is frequently reiterated in this discussion is “quality of life” (Harris 1985; Kuhse 1987). The lack of some standard of quality legitimizes, even necessitates, so it is claimed, allowing patients the option of forgoing life if they so wish. Life qua life is not that important but rather what one does with one’s life. Life in earnest is important, not just the mechanical processes that deﬁne life in the superﬁcial meaning of the term. That one’s heart is beating and that one is able to breathe are not sufﬁcient reasons to maintain life.
The phrase “quality of life” has many positive connotations when used in a general social context. For instance, we speak of improving the quality of lives by various means including diverting public transportation away from crowded neighborhoods and making efforts to decrease air pollution. People seek to promote their quality of life by purchasing newer and bigger houses, cultivating their gardens, going abroad, and engaging in leisure activities. People use the phrase “quality of life” when describing the different ways they promote their comfort, their status, and their tranquility. Likewise, in medicine, the phrase “quality of life” has positive connotations, for example, in rehabilitation, cosmetic treatments, psychiatry, and psychology. However, when dealing with end-of-life issues, ethicists who support euthanasia apply “quality-of-life” considerations in a negative sense more often than in a positive one, meaning that they do not seek to improve the patient’s life but to end it (Kuhse and Singer 1985). They refer to certain patients and categories of patients, arguing that their lives lack signiﬁcant measure of quality and therefore should not be maintained. The terms “quality” and “life” in this context are contradictory and competing, designed to justify the termination of life.
Quality of life does not constitute a single criterion upon which we judge a person’s deeds. The criminal law does not address the quality of life. Different penalties do not exist for a murderer, based on the quality of the life of the victim. One would be appalled if a murderer argued in her defense that “this guy was a useless creature, led a dull life, and was miserable; therefore, no great loss had occurred.” Similarly, we would be deeply disturbed if a physician would claim that “there is little point in investing resources in patient A because she is 75 years old, and her prospects of leading a valuable life are slim.”
That is to say that quality of life is a subjective term. What is important is not how we assess the patient’s condition but how the patient assesses her own condition. Neither the medical team nor the patient’s family can decide that “her life is not worth living.” This call should be reserved only to the patient. Similarly, suffering is a subjective term. It may stem from multiple existential, physical, mental, and spiritual sources such as pain, depression, distress, hopelessness, dependence, loss of control, loss of sense of dignity, and anxieties of burdening others. What one may consider as unbearable suffering might be considered by another as bearable. When patients perceive their condition as dehumanizing, humiliating, degrading, painful, and beyond their abilities to endure and when patients believe that their condition is not worth living, physicians and others should not coerce them to continue living. This kind of medical paternalism cannot be justiﬁed. As we should not coerce physicians to do something that is contrary to their conscience, we should not coerce patients to live when they wish to die. Coercion qua coercion is morally repugnant. Physicians should not desert patients when they need them the most.
Research has shown that the majority of patients dread death. Most patients prefer to cling to life. However, for some patients death is not the worst thing that can happen to them. Suffering is. Upon experiencing refractory, intractable, irreversible physical and/or mental suffering that they deem unacceptable, they realize that the end-of-life is nearing and may lose the zeal to continue living. Concern and care for the patient dictate that physicians should not ignore the patient’s wishes.
Fear Of Abuse
The question of how we can (or should) protect a patient’s autonomy is of major importance. People who believe that rational patients should have the right to arrange their own deaths, with the help of willing physicians, often appeal to autonomy as justiﬁcation. But those who object to this idea claim that people who really want to stay alive might be killed, maintaining that leaving the decision in the hands of the patient’s family and/or medical team might negate the patient’s autonomy. All agree that it is of utmost importance to maintain trust between physicians and patients, but while some accentuate that trust means also depositing life in the hands of the physicians for them to end it at the patient’s request, others assert that once such deposit is granted to physicians, the trust between them and their patients might be undermined. Physicians are in the healing profession, not killing.
Physicians might abuse the power they possess. Such fears can be avoided by paying careful attention to the ﬁne details when formulating concepts and regulations and by using explicit wording that does not allow abusive interpretations. The fear of abuse and the desire to grant patients with control over their lives until the very last moment are good reasons to restrict assistance in dying to physician assisted suicide (PAS). From Belgium, the Netherlands, Switzerland, and Oregon, we learn that the majority of patients who opted for death were cancer patients. It can be assumed that they were capable of activating a lethal needle administered by a qualiﬁed physician.
At the same time, a voice of extra caution is raised in conducting mercy killing, criticizing death campaigns such as those of “Dr. Death,” Dr. Jack Kevorkian (1991), a pathologist who had no qualiﬁcations to examine the medical ﬁles of those who approached him for aid-in-dying. Kevorkian celebrated patient’s autonomy to the extreme without the necessary safety valves and control mechanisms. Upon becoming a missionary for his cause, Kevorkian killed patients who could have been cured. Aid-in-dying is a very risky business when those promoting it become missionaries of their cause.
At the end-of-life, the fear of abuse is very tangible. If physicians were allowed to assist gravely ill patients to die, pressure might be exerted on old and weak patients whose relationships with their families are not close. Appropriately, UNESCO Universal Declaration on Bioethics and Human Rights (2005) has emphasized the physician’s requirement to respect the patient’s personal integrity and the need to protect vulnerable populations. With lax standards of due care, the delicate framework of trust between patients and physicians would crack and practically be replaced by a completely different set of norms. Patients would no longer believe that physicians and nurses would do their best to help them stay alive. Explicitly or implicitly, physicians and nurses might communicate that they expect special gratitude for assisting patients to live. Patients might feel obliged to seek assistance to die in order to avoid further burdens on their beloved people as well as on the medical staff. There is also the fear that the right to die, accorded to patients who are able to decide, will – at some point – be expanded to patients who are not able to decide for themselves.
Sanctity Of Life
Fear of abuse leads many people to oppose any quality-of-life considerations in treating patients at the end of their lives. Many scholars fear the effects that entertaining physician aid-in-dying might have on the medical profession, changing its culture and norms in a way that would undermine the patient’s best interests. Some of these scholars promote ideas related to the sanctity of life (Novak 1989; Pellegrino and Faden 2000). Often times, their reasoning is based on religion.
The monotheistic religions uphold the belief that God created life and death and we must not take His place (Cohen 1998). It is not a proper or appropriate role for medical staff to end human life that had been given and sanctiﬁed by God. The proper role for medical staff is to save life and not to destroy it (Gill 1998; Misbin 1992). The Christian tradition emphasizes the following pertinent guidelines:
(A) Life is a God-given gift. It is given to people “in trust.” Hence people do not own their lives. Life is a gift over which we are to exercise stewardship, not dominion. That stewardship demands that we be responsible for life – its protection and enhancement. We will in turn be held accountable before the Creator not only for how we protected and developed our individual lives but for all life. Man cannot do with life as he wills (Wallace and Eser 1981).
(B) All human life is equal because every human creature is a creation of God.
(C) Because God created human life, even the most miserable of lives is worth living (Pellegrino and Thomasma 1996).
(D) Life is holy per se. God granted the respect, value, and sanctity of the human being to people, and they are not subject to human measurement. Life is not sacred because of something it includes and because of its content. Rather life is sacred because God created it: God is holy, and He has sanctiﬁed life. Human life has worth because Christ died to redeem it, and it has meaning because God has eternal purpose for it. According to Islamic law, God is the author of life and “owns” us. Since we do not own our lives we cannot take them (Charlesworth 1993).
(E) The life which God gives man is quite different from the life of all other living creatures, inasmuch as man, although formed from the dust of the earth, is a manifestation of God in the world, a sign of His presence, and a trace of His glory. Man has been given a sublime dignity, based on the intimate bond which unites him to His Creator: in man there shines forth a reﬂection of God himself. Life is the Lord’s image and imprint, a sharing in His breath of life (Ramsey 1950).
(F) Life is indelibly marked by the truth of its own. By accepting God’s gift, man is obliged to maintain life in this truth, which is essential to it. To detach oneself from this truth is to condemn oneself to meaninglessness and unhappiness, and possibly to become a threat to the existence of others, since the barriers guaranteeing respect for life and the defense of life, in every circumstance, have been broken down.
(G) People must not “play God” by determining when someone should die (O’Rourke and Boyle 2011).
There are many similarities between the Christian and the Jewish points of view (Pellegrino and Faden 2000). Both Judaism and Christianity afﬁrm creation as the necessary background for their respective revelations. Both share beliefs about the sanctity of human life, the integrity of the family, and the right to a variety of individual and cooperative achievements. One of the basic theological afﬁrmations that is shared by the Judeo-Christian ethic is that persons are created by God for the primary purpose of being related to God (Novak 1992; Holwerda 1976). The Judeo Christian ethic integrates the virtues of faith, hope, and charity, with principles of medical ethics, based on beneﬁcence, justice, and the best interests of the patient. The notion of a person includes not only the soul, spirit, and cognitive and intellectual capacities but also a living body. Human life is intrinsically good and valuable, and society is obliged to respect a living body irrespective of the person’s cognitive capacities. Notice that when speaking of intrinsic values we do not speak of interests. Life qua life is valuable, without paying attention to the person’s interests. In this view, taking one’s life by one’s own hands (or with the help of others) is considered to be wrong in itself. Even if people have deliberately chosen to die, it is nevertheless bad for them to do so. Euthanasia is perceived as an insult to the sanctity of human life. It is also an insult to God, usurping His authority (Cohen-Almagor and Shmueli 2000; Dorff 2004).
My independent research has shown that in Jewish and Catholic hospitals, most of the patients cling to life and do not ask physicians to assist them in dying. This issue is simply not part of the hospitals’ culture. Patients who may wish such help are more inclined to seek assistance in Protestant hospitals where sanctity-of-life considerations are weighed against patient’s autonomy and quality-of-life considerations.
Physician-Assisted Suicide, Not Euthanasia
In euthanasia, the control lies with the physician who administers the lethal injection and kills the patient. In physician-assisted suicide, the control lies with the patient. Ordinarily, the physician prescribes the lethal medication, mixes it in a pudding or a yogurt, and then the patient takes the last act and kills herself. To prevent abuse and to ascertain that the patient’s right to die does not open the road for medical paternalism where physicians may play God, it is suggested to limit aid-in-dying to physician-assisted suicide (Cohen-Almagor 2001). Below is a set of guidelines which reﬂects the general state of the art concerning the right to die. This set integrates some of the pertinent guidelines that were adopted in Oregon, where physician-assisted suicide is legal, in the Netherlands and Belgium where euthanasia is legal, in Switzerland where assisted suicide is practiced, and in the Northern Territory of Australia, where physician-assisted suicide was legal for a short period of time.
Specific Guidelines For Physician-Assisted Suicide
- Physicians are best equipped in terms of knowledge and expertise to provide aid-in-dying. It is the only profession that could come to aid patients who insist on their right to die. The medical profession is in ﬂux. The rapid scientiﬁc and technological progress, the rise of chronic disease, the ability to keep chronic patients alive for many years, and the democratization of knowledge are all important in the shaping of medicine. The medical profession should be attentive to wishes of all patients and strive to accommodate their wishes.
- Physicians should not suggest assisted suicide to the patient. Instead, it is the patient who should have the option to ask for such assistance. Any reluctance shown by patients regarding this issue should be honored and respected. Initiation by the physician might undermine the trust between patients and physicians, conveying to patients that the doctor is giving up on them. Such an offer might undermine the will to live and to explore further avenues for treatment. The GP may present before the patient the range of available options without manipulation and with due respect for the patient’s life and wishes.
- The request for physician-assisted suicide should be voluntary and come from a competent adult, 18 years of age or older, who suffers from an intractable, incurable, and irreversible disease. The decision should be made by the patient and not the family or as a result of family pressures. Some families can make the decision to end life because they feel overwhelmed by the patient’s illness. Many people cannot cope with the fact that their loved one is dying. For these reasons, the PAS decision has to be reached without any pressures. The patient should state this wish repeatedly over a period of time. This recommendation is similar to the one invoked in laws and guidelines in Oregon, the Netherlands, Belgium, and Australia.
- It is the task of social workers to examine to what extent the patient is affected by external pressures. The decision-making process should include a second opinion in order to verify the medical diagnosis and minimize the chances of misdiagnosis, as well as to allow the discovery of other medical options.
A specialist who is not dependent on the ﬁrst physician should provide the second opinion. It is advisable that the identity of the consultant be determined by a committee of specialists who will review the request for physician-assisted suicide.
- At times the patient’s decision might be inﬂuenced by severe pain, and therefore the role of palliative care can be, and is, crucial (LaPorte Matzo and Witt Sherman 2009). The attending physician should inform the patient of all feasible alternatives, including comfort care, hospice care, and pain control.
- The patient must be informed of her situation, the prognosis for recovery or escalation of her disease, and the degree of suffering that may be involved. There must be an exchange of information between physicians and patients. The laws in Belgium and Oregon contain these provisions.
- Sometime prior to the performance of PAS, a physician and a psychiatrist should visit and examine the patient. They will verify that this is the genuine wish of a sound mind person and that the individual is not depressed, being coerced, or inﬂuenced by a third party to end her life. The conversation between all physicians and the patient should be recorded and held without the presence of family members so as to avoid familial pressures.
- The patient must be able to rescind her decision to pursue physician-assisted suicide at any time and in any manner, as it was the case in Australia and is the case in Oregon and in Belgium.
- PAS may be performed only by a physician in the presence of another physician. Family members should not be allowed to administer assisted suicide (or euthanasia) as this might lead to abuse. The decision-making team should include at least two physicians and a lawyer who will examine the legal aspects involved and ensure there is protocol in place which will prevent possible abuse. Perhaps a public representative should also be present. This extra caution should ensure that the right to die with dignity does not become a duty. It will contribute to reporting of cases.
The physician who provides aid-in-dying should be the one who knows the patient best, having been involved in the patient’s treatment, taken part in the consultations, and veriﬁed through the help of social workers, nurses, and psychologists that PAS is the true wish of the patient.
- Physician-assisted suicide may be conducted in one of three ways, all of which should be discussed openly and decided upon by the physician and the patient: (1) oral medication; (2) self-administered, lethal intravenous infusion; and (3) self-administered lethal injection. Some medication may be difﬁcult or impossible for patients to ingest because of nausea or other side effects of the illness. The only exception in which the physician would be allowed to administer the lethal injection would occur in the event that medications have been provided and the patient’s dying process is lingering on for long hours. Euthanasia may be allowed only after the failing of physician-assisted suicide or if the patient cannot physically administer the medications to herself.
- Physicians may not demand a special fee for the performance of physician-assisted suicide. There must be no ﬁnancial incentive to perform or assist with the procedure since the motive for PAS is humane. There should be no special payment that might cause commercialization or promotion of such procedures.
- There must be extensive documentation in the patient’s medical ﬁle, including the disease diagnosis and prognosis by the attending and the consulting physicians, attempted treatments, the patient’s reasons for seeking PAS, the patient’s request in writing or documented on a video recording, documentation of conversations with the patient, the physician’s offer to the patient to rescind her request, documentation of discussions with her beloved people, and a psychological report conﬁrming the patient’s condition. This meticulous documentation is meant to prevent exploitation of any kind – personal, medical, or institutional. Each report should be examined by a coroner following completion of the physician-assisted suicide.
- The drugs required to end one’s life are known.
As a control mechanism, pharmacists should be required to ﬁle a report every time lethal medications are sold. Then it would be possible to track down the medication to the physician and keep track of how many times physician-assisted suicide was performed.
- The practice of medicine should be deontological rather than utilitarian. Physicians have certain duties to fulﬁll, including relieving patient’s suffering, respecting patients, and caring for them. Patients should always be regarded as ends in themselves, never as means. Patient’s autonomy and preferences : should be respected as much as possible. At the same time, physicians should not be coerced into taking actions that conﬂict with their conscience. No coercion should be involved in the process.
- A medical association committee should be established to investigate underlying facts of reported cases, to explore whether there were cases which did not comply with the guidelines, and to inquire whether there were unreported cases. Signiﬁcant sanctions should be taken to punish health-care professionals who violate the guidelines, fail to consult with other physicians or to ﬁle reports, or engage in involuntary termination of life without the patient’s consent or with incompetent patients. Physicians who fail to comply with the guidelines should be charged, and procedures to sanction them should be enforced by the medical disciplinary tribunal. The sanctions should be signiﬁcant and include revocation of the physician’s medical license.
- An annual report should be published documenting all cases of aid-in-dying. The reports should be made available to the public. Discussions and debates about their ﬁndings should be promoted and encouraged.
People, as autonomous moral agents, deserve to be treated with dignity. To treat a person with dignity requires respecting her choices and life decisions. If a person who suffers from an incurable disease decides that her life is no longer worth living, we should respect that decision. The medical profession should not rush to end life, but upon careful examination and upon satisfying certain criteria, physicians may provide aid-in-dying.
There may come a point when the belief in the importance of human dignity may lead to the conclusion that physician-assisted suicide should be considered an option. Most people ﬁnd some meaning in their lives even when they are severely impaired, bedridden, limited in movement, and in constant need of help. An independent, active, and energetic person with desires and ambitions, who becomes in her own eyes dependent upon others and who reaches the conclusion that her life has become a burden to herself and the people she loves, might lose her sense of humanity as well as her self-respect, and this might lead her to lose interest in life and to choose death.
People should give equal consideration to the interests of others and grant equal respect to a person’s life objectives so long as they do not deliberately undermine the interests of others by interfering in a disrespectful manner. This line of reasoning should be supplemented by our emphasis on the notion of concern, which is seen as the value of well-being. We should give due weight to a patient’s autonomy and decisions at the end of one’s journey.
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