Who Should Assist in "Assisted Suicide": Doctor or Family?
Think about a chronically ill patient who is suffering, debilitated and can't seem to get relief. Think about the patient with an end-stage cancer who is not obtaining relief of suffering from established medical treatments. Suppose these patients ask their doctor to "help" them die and end their suffering.
In the United States, only two states, Oregon and Washington, permit, under restrictions, physician assisted suicide. Physicians can prescribe a lethal dose of pills that the patient can take by themselves at their own time if they desire. Despite the two states laws allowing physician assisted suicide, there is, I think, ethical reasons why physicians should not be doing this.
But what are the ethics of assisting a patient in their act of suicide? Should society really allow this generally as it has in the two states, by physicians and with requirements? But why physicians? By assisting in suicide, wouldn't they be violating professional principles? Wouldn't they be degrading the professional trust that society has expected from doctors? Wouldn't this lead to physician encouragement for suicide rather than the patient electing end-of-life palliative care?
Why not allow family to assist their suffering family member in the patient's own wish for suicide? The family members who assist have no professional oaths to uphold. Is there concern that family members who have attended and cared for the patient and now tire will have their own personal interest to accelerate the patient's death?
Any suggestions for the answer the question: Who should assist in "assisted suicide": Doctor or Family? ..Maurice.
posted by Maurice Bernstein, M.D. @ 4:12:00 PM
13 comments
13 Comments:
Aren't there ethical reasons against family assisting? There could be a conflict of interest as most heirs tend to be family members who might want to hasten the reading of the will. Also, what if the patient doesn't have a family, or even close friends?
Good point, Emily. There certainly could be a monetary conflict of interest for the family. Do you or others see any conflict of interest on the part of the physician to "assist"? What do you think about society setting up technicians (not doctors but permitted to write "deadly" prescriptions or to assist if requested in other ways)? ..Maurice.
Is it unethical for a veterinarian to put terminally ill sick dogs to sleep, because the duty of the veterinarian is to heal sick dogs?
I don't see what the difference is between people allowing abortion and allowing people to end their suffering and cathode licks decision to listen exclusively to voices in their head as to what others are allowed to do, but I once met a person who had a disease that was uncureable , where they felt as though their whole body was on fire and even they could not get any assistance in suicide, what has happened to the term "showing mercy".
Timothy Quill has gone over all the technical ethical issues regarding this, and I wouldn't presume to try to improve on his analysis.
My interest in this topic is the more general one.."who's life is it anyway?"
It seems clear that this country basically says.."Not just yours, mister!"
When you look for aid-in-dying, the system is set up to intervene vigorously against you. (eg, Kevorkian)
Why is society so interested in constraining autonomy in this area?
I think the answer probably lies in a vestigial religious impulse that still informs our so-called secular society. IOW,.. no, Sonny, that is not YOUR life, it is ultimately God's life (to give and take.)
This is nt a good thing,IMO.
What think you?
Andrew Loewy MD
Cincinnati.
I have an idea: no one should give the final medication... maybe there is another way to help... its called palliative care.
"Is it unethical for a veterinarian to put terminally ill sick dogs to sleep, because the duty of the veterinarian is to heal sick dogs?"
Quoted for truth. Dr. Bernstein alludes to the violation of ethical principles, but he doesn't say which ones.
"Wouldn't this lead to physician encouragement for suicide rather than the patient electing end-of-life palliative care?"
In practice, it's precisely the opposite. I went to med school in Oregon and doctors who are both pro and con on the law agree on one thing: pain management, palliative care and hospice are pursued much more aggressively by doctors at the end of life. The reason: no one wants their patient to come to them and ask for that script.
Oregon's law has only seen use a couple of hundred times in ten years. The far more widespread effect of the law has been the unintended consequence of IMPROVING palliative care.
The Tracker, thanks for the info about the increase use of palliative care concept by physicians in Oregon in apparent reaction to the permission for physician-assisted suicide.
The ethical principle which applies to assisting suicide by a physician is non-maleficence ("do no harm"). One may debate whether helping a patient meet their desire to die is causing harm for that patient. That could be debatable. However, the harm actually is regarding the trust in physicians by society. Simply consider what most people will think when they hear "Oh, doctors are allowed to help people die.." Out of distrust, they will next say "I hope they don't help me die when I get sick." ..Maurice.
I do not observe any distrust directed at doctors of veterinary medicine because they help their patients die. Rather, most people recognize this as a measure of last resort, undertaken in sorrow, in the fulfillment of the core obligation of physicians to relieve suffering.
The hospice movement, by allowing caregivers to focus on the relief of patients' suffering rather than the single-minded pursuit of the maximum number of minutes with a beating heart, has not undermined the trust between patient and physician. Just the opposite, in my opinion. People do not worry that their doctors are going to give up on them and stick them in hospice; they recognize that as a decision that comes from them.
As to why doctors should be involved, I've alluded to one reason; the relief of suffering. Pragmatically, though, we are also the only people with access to the tools of euthanasia, the only people who can say if an illness is terminal or not, the only people to screen for mental illness, and the only people who can insure that maximal palliative care has been provided so that the patient's burden of suffering and indignity has first been reduced to the absolute minimum possible.
I am not as optimistic about the attitude of the public towards physicians as The Tracker if physican-assisted suicide becomes more widespread. Look what happened in the past year or so about reaction to the so-called "death panels" attributed erroneously to the healthcare legislation. Of course, it was a political not a realistic description but look at what appeared to be a public response as reported by the media. What is one person's interpretation as relief of suffering is another person's claim of legal lethal execution. If there is no consensus, it may be unwise for physicians to assume the responsibility of participating in assisted suicide. ..Maurice.
One might draw a different lesson from the "death panels" meme, which started with a effort to give doctors compensation for visits spent planning and preparing an advance directive; that people so inclined are so vicious and unscrupulous in their distortions of fact that it is useless to try and appease them.
It seems that there are two separate issues: the ethics of assisted suicide, and the politics. So to tease out the one from the other, let my pose the following case as a thought experiment:
57yom with an aggressive stage four cancer metastatic to bone, lung, brain and bowel. The public is understanding of euthanasia, and has passed laws to that effect. Despite your best efforts, you are not able to bring the patient's pain under control with anything short of an opioid coma. They are confined to bed, intermittently delirious, and will shortly lack the ability to interact with your of their family. The patient, in agony, wants your help in administering a lethal dose of narcotics. This will shorten their life by days at the most; days that promise to be filled with confusion and extreme pain.
What is your ethical duty to that patient? (Putting aside how it looks or how it makes the public feel.)
Tracker, your scenario is not an unique one and represents a not uncommon situation facing the attending physician. The ethical duty of the physician is to attempt to relieve pain. A narcotic administered in a dose great enough to relieve pain and produce comfort for the patient is ethical even if the known but unintended effect might be the death of the patient if the criteria of the ethical principle of the Double Effect is followed.
As summarized in Wikipedia "the nature of the act is itself good, or at least morally neutral;
the agent intends the good effect and not the bad either as a means to the good or as an end itself;
the good effect outweighs the bad effect in circumstances sufficiently grave to justify causing the bad effect and the agent exercises due diligence to minimize the harm." ..Maurice.
"no, Sonny, that is not YOUR life, it is ultimately God's life (to give and take.)"
If a human life is God's life to give and take then any medical help, especially with potentially terminal diseases would be against God's will wouldn't it? Are doctors spiritually unethical by working against the will of God? In my mind God has no problem with doctors relieving the pain of his children, such as fixing broken bones or sewing up large cuts. But I wonder what he thinks about doctors that work against him to save the lives of people that God cursed with terminal illnesses. Sorry, I'm getting a little off topic.
I wouldn't count on either a doctor or my family to assist me with suicide. At many facilities even the mere mention of suicide will put a patient on suicide watch and at that point all decisions will be made for him, either by family or the doctors. The patient may even be restrained one way or another. Family, especially a religious family like mine will likely do everything possible to "save me from myself" to keep me from going to hell. I would be very suspicious of any family member who suggests or agrees to help someone commit suicide, because of life insurance or other death benefits that family member may receive.
I think the only way to kill yourself is to just do it without anyone else knowing. If someone can expect nothing more than pain in his/her future I see nothing wrong with suicide, but don't expect any help from your doctor or family.
Some patients want to show contempt for the doctors and nurses, like those that have a blatent disregard for a patient's moral beliefs, by killing themselves in the hospital. In that case the doctors and nurses will be the cause for the suicide, not the assistants.
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