Assisted Suicide

[Whitney]

I view legalization of assisted suicide as the morally appropriate stance in so far as it is only allowable for those who have incurable illnesses that can not be sufficiently treated through current methods.  Allowing individuals the right to have access to assisted suicide, when adequate treatment for end of life care is not available, is a humane act.  Individuals should not be forced to suffer simply because their aliment cannot be sufficiently managed through modern and alternative methods.  Accordingly, it is equally important to continue searching for improved methods for managing pain and suffering.  

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The following is and final exam essay I had to write on the issue.  It outlines both sides of the argument then lastly I give my assessment (view) of the issue; which is pretty much what I stated above.  When it refers to "BV" it's talking about a book:

Tom Beauchamp and Robert Veatch, eds., Ethical Issues in Death and Dying, 2nd. ed. (Prentice Hall,
1996). [BV]

The "yes" and "no" arguments are handouts which we were instructed to put into our own words.  If anyone really wants to read the full articles I can try and find the sources in my notes.

Should Physicians Be Allowed to Assist in Patient Suicide?

   Assisted suicide has become a prominent issue within the medical world as well as society.  Due to this fact, it is important to look at the standpoints surrounding the topic to reach an informed stance.  This paper will outline the major ethical issues involved with assisted suicide to allow the reader to develop an informed stance on the issue.  The paper is divided into four parts:  â€˜Yes’ Argument, ‘No’ Argument, BV Arguments, Argument Assessment, and Position Statement.

“Yes” Argument
   Marcia Angell argues in favor of legalizing physician assisted suicide beginning with two starting points as justification for the moral correctness of allowing the practice.  The first premise holds that respect of patient autonomy is a major ethical principle in medicine.  This principle should always take priority if a conflict occurs with other principles.  Accordingly, the medical profession should be morally compelled to respect competent patient requests for assistance with suicide.  The second premise recognizes that death is seldom fair and often it is not possible to relieve all symptoms associated with the dying process.  Additionally, dying sometimes takes away dignity and causes existential suffering.  
   The following arguments are intended to support the legalization of physician assisted suicide.  Angell believes that active/passive distinctions are too doctor oriented and should be considered in light of the patient’s role.  Because euthanasia can be performed while the patient is passive, Angell opposes its legalization.  However, since physician assisted suicide requires the active role of a patient it is not the doctor who kills but the patient.  It is illogical to draw a parallel between allowing physician assisted suicide and less commitment in providing comfort care.  Additionally, to prevent the availability of physician assisted suicide is asking patients to pay for the current shortcomings of end of life care.  The voluntary nature of physician assisted suicide is its best protection from a slippery slope scenario and reports from the Netherlands, where physician assisted suicide is legal, have not indicated this problem.  It is possible that some cases could occur where overstrained families or frugal doctors could encourage a patient to choose physician assisted suicide; however there is no evidence of there being widespread abuse associated with removing life-sustaining treatment, so the same can be assumed regarding physician assisted suicide.  

“No” Argument
   Kathleen Foley constructed a moral argument against physician assisted suicide based on it being contrary to standards for palliative care.  Blurring the lines between allowing a patient to die and hastening death is not in keeping with the foundations of palliative care.  The purpose of a physician is to care for patients, not to cause their deaths.  The main focus of palliative care is to relieve suffering with utmost importance placed on improving quality of life.  Placing attention on the quantity of life by allowing physician assisted suicide is outside the scope of palliative care.  Furthermore, permitting physician assisted suicide puts the terminally ill patient at greater risk of being devalued and creates a reason for society to be less concerned with providing adequate care for terminally ill patients.  The use of physician assisted suicide should not be considered until the medical community is able to attend to the shortcomings of end of life pain and suffering management.  
   Foley’s following arguments create a case against the legalization of physician assisted suicide based on the inability to ensure patient autonomy and construct regulatory methods.  Studies have indicated that patients have a tendency to be influenced by the physician’s opinion in choosing end of life care options.  Accordingly, the variables which affect a physician’s stance on physician assisted suicide can easily affect the patient.  Since weight of the doctor’s opinion seems to play a factor in patient decision making, the autonomy of a patient who chooses physician assisted suicide is questionable and thus the practice is difficult to regulate.  Additionally, physicians are inadequately trained to manage the multiple factors which are associated with patient requests for physician assisted suicide.  Studies focusing on cancer and AIDS patients indicate that the desire for death is a result of contributing factors such as inadequate pain management, depression, and the absence of social support.  If these barriers to proper pain and suffering management can be relieved, there would be no desire for patients to request assistance with suicide.

BV Arguments
   Edmund Pellegrino offers a different view of how an individual maintains dignity.  Suffering, pain, and other physical issues associate with illness do not affect a being’s dignity.  An individual’s dignity is imbedded within his or her humanity.  Dignity is not lost due to physical ailments but is simply perceived to be lessened due to the opinion of society.  A person who fears loosing dignity does so based in relation to how society reacts to the processes involved in viewing the dying patient’s treatment and loss of previous abilities.  In this way, when an individual claims they have lost dignity, the person really means that they feel shameful for being in their condition.  Feeling shame is a central cause of suffering and anything that promotes the view that a person’s dignity is lost only furthers this suffering.  Advocating physician assisted suicide as a means to maintain dignity does not relieve suffering but acts as a means of escaping from the problem.  
   Additionally, Pellegrino calls the autonomy of chronically ill patients into question.  Dying patients are often in a state of lowered emotional quality due to pain, suffering, and a negative difference in how they are viewed by society.  This state places the patient in a position to be susceptible to the slightest indications of being unworthy made by friends, family, and medical care providers.  If those surrounding the patient hint towards physician assisted suicide as being a dignified means of dealing with dying, the patient could easily pick up on this suggestion in an effort to regain dignity and overcome shame.  The issues which can compromise autonomy, such as pain, suffering, shame, and other adverse physical problems, should be dealt with prior to considering assisted suicide as an option.  Accordingly, if these problems are removed it has been shown that patients will not request suicide.
   Timothy Quill believe that it is important to exhaust all efforts to provide a patient with quality care and comfort, however there are some cases where patients will experience intolerable situations despite the best efforts of physicians to provide relief.  Quill believes that it is the physician’s obligation as a comfort care provider to fully investigate patient requests for assisted suicide and that aid should be allowable if circumstances fall within their proposed criteria.  Additionally, access to physician assisted suicide allows the patient to be free from worry of future pain thus allowing for a more a fulfilling end of life.  Dignity for the dying patient can be found in the patient’s ability to have control of current or future pain through access to assisted suicide.  The following criteria should be used in assessing and carrying out patient requests for suicide.  First, the patient must have an incurable illness that can not be acceptably relieved through further treatment and be fully aware of the prognosis and other options which may be available.  Second, the doctor must be certain that all alternative efforts have been attempted or considered and should never use assisted suicide as a means to avoid having to find alternative care methods.  Third, the patient must be the one who makes the request for assistance with suicide and must do so on multiple occasions.  Additionally, the physician should not be overly willing to comply with the request but at the same time should not force the patient to plead for assistance.  Fourth, the physician must know that the patient is competent and autonomous in making a request for suicide and should seek outside evaluation if inappropriately trained to make such an evaluation.  Fifth, the physician must have a personal relationship that is lasting enough to provide the doctor with a full view of reasons for the patient’s request for assisted suicide.  If a physician is not willing to assist with suicide, aid in finding another doctor should be provided.  Sixth, the patient and primary physician must consult with another physician in order to ensure the autonomy of the patient’s decisions and accuracy of previous diagnosis.  Finally, the assistance should be accurately documented and the patient should be recommended, but not forced, to notify family.
   Through these criteria, Quill and his colleges hope to provide a framework through which assistance with suicide can be permitted without endangering patient autonomy or access to comfort care.  Additionally, by creating a regulated system for assisted suicide, patients who are unable to receive effective comfort care due to the limitations of pain control will not feel fear being abandoned by their care providers if the choice for assistance with suicide is available.  Furthermore, regulating the practice will allow physicians to openly consult their peers about associated methods, thus making the practice safer and removing chances for abuse which could occur more frequently within a closed system.

Assessment of Arguments
   A detailed assessment of the issues is necessary to reach a position on this issue.  I will conduct this analysis by separating the arguments into manageable sections.  The main arguments outlined in this paper can be divided into four main categories:  Palliative Care, Dignity, Patient Autonomy, and Medical Ethics.  
   Palliative Care:  Foley holds that legalization of physician assisted suicide will take away emphasis from the importance of finding better end of life pain and suffering management practices.  Removing emphasis from advancements in palliative care is definitely and issue for concern.  However, by disallowing assisted suicide only on these grounds, the medical profession is asking patients to unnecessarily suffer on account of the current shortcomings of end of life care practices.  Additionally, through the proper management of assisted suicide, a diminished societal emphasis on increasing the effectiveness of palliative care practices will be protected from occurring.  A means of providing this management was outlined by Quill who does not view assisted suicide as a replacement for palliative care, but as an option for those who cannot be sufficiently relieved of suffering through other means.  The ability of medicine to relieve all aspects of end of life pain and suffering is not currently available and there is little indication that a fully acceptable means will ever be developed.  
   Dignity:  Pellegrino believes that dignity is found within the individual, but can be damaged by the individual’s perception of the views held by friends, family, and caregivers.  Indeed, self-respect can be damaged through the way one is viewed by others.  However, societal views are not the only means through which an individual gains self-worth.  Throughout one’s life a person becomes accustomed to associate themselves with various activities.  When illness takes away the ability to participate in actions which previously defined the person as an individual, the self becomes damaged and dignity is diminished or lost.  It is important to aid the patient in gaining as much dignity as possible.  However, if the person is no longer able to enjoy the activities which defined their lives it may not be possible to restore their dignity to a tolerable level.  
   Quill views assisted suicide as a means of allowing a patient to find fulfillment and at least some dignity towards the end of life.  If a patient is diagnosed with an incurable condition that is associated with end of life pain and suffering which the individual find abhorrent, the patient can find comfort simply in knowing that assistance with suicide is available.  This knowledge allows the individual to be relieved of unnecessary worry over future discomfort and allows freedom to enjoy the remaining time with friends and loved ones.  It is possible that the patient may not decide to use assisted suicide, but the ability to have that option allows for a sense of self control during a time which the body has become out of their control.  
   Patient Autonomy:  Pellegrino is concerned that issues, such as pain and suffering, associated with chronic illness can compromise autonomy and the removal of these issues will also remove the patient’s desire for assisted suicide.  As outlined in the section on palliative care, it may not be possible to relieve all pain and suffering.  Furthermore, accessing the point at which pain and suffering affects autonomy can be difficult.  Due to this, we cannot assume each individual’s autonomy will be affected in the same manner.  It is possible that many individuals are able to maintain their ability to make informed decisions while suffering and experiencing pain.  Additionally, by being in stressful situations associated with end of life issues, Pellegrino holds that a patient is more susceptible to the will of others and this can compromise the individual’s autonomy.  Although this may be true for some individuals, this cannot be maintained as a general assumption because it adds the problem of dying patients feeling less dignified.  There are multiple important decisions that a patient must make during the end of their lives in which their autonomy is not normally questioned.  To hold that all patients who are experiencing pain and suffering also have lost their autonomy has implications that go further than affecting their ability to make a decision concerning assisted suicide.  To determine the autonomy of a patient a qualified physician must access their psychological state rather than the degree to which the patient is experiencing pain and suffering.  A patient should be assumed to be autonomous unless there is a reason to believe otherwise.  
   Quill believes that the autonomy of patients can be safeguarded by regulating assisted suicide.  The framework outlined by Quill for regulating physician assisted suicide provides a means for the autonomy of patients to be reasonably protected.  The most important aspect of these regulations in regard to autonomy is the inability of the physician to be able to suggest suicide as an option.  Additionally, with the legalization of assisted suicide following Quinn’s criteria, a patient is required to seek a separate medical opinion and evaluation prior to receiving assistance with suicide.  Furthermore, since the lethal does is self-administered in assisted suicide, the patient is left with the final decision.  The patient being required to finish the process combined with a full disclosure of options provides a means through which autonomy can be reasonably protected.
   Medical Ethics:  Foley believes that the role of physicians in palliative care is solely for the purpose of easing suffering and should not cross the boundary into providing death.  Foley’s stance calls for a strict view of what relieving suffering includes.  If the suffering of a patient cannot be relieved through current methods, it seems appropriate for the role of palliative care to extend to providing assistance with suicide.  The role of palliative care is to relieve suffering, so when the only means to relieve suffering is hastening death assisted suicide becomes a palliative care method.  It is contrary to the intentions of palliative care to forgo allowing an option which can relieve suffering which cannot be effectively remedied by other methods.  Therefore, Foley’s basis is unjustified in claiming that assisted suicide crosses an ethical boundary created by palliative care.  Conversely, Angell maintains that respect of patient autonomy is a major ethical principle in medicine and should always take priority if a conflict occurs with other principles.  Justification for this view has precedent in a patient’s ability to forgo life sustaining treatment.  In this way, there does not seem to be a conflict with the ethical principles of medicine and assisted suicide.  

Position Statement
   After an assessment of the above standpoints and associated issues, I view legalization of assisted suicide as the morally appropriate stance in so far as it is only allowable for those who have incurable illnesses that can not be sufficiently treated through current methods.  Allowing individuals the right to have access to assisted suicide, when adequate treatment for end of life care is not available, is a humane act.  Individuals should not be forced to suffer simply because their aliment cannot be sufficiently managed through modern and alternative methods.  Accordingly, it is equally important to continue searching for improved methods for managing pain and suffering.  Quill’s framework for regulating physician assisted suicide offers a means through which the practice can be allowed in the medical community without compromising the autonomy of the patient or placing the doctor in legal jeopardy.  Therefore, assisted suicide should be legalized according to similar guidelines.

[MikeyV]

As a nominal libertarian, I don't know why this issue is even a topic of debate.

To make someone hang on when they want to check out is barbaric, we don't even do that to our pets.

Of course, like many of our laws (phobias), it is religion and fear of god that keeps laws like these on the books.

[Asmodean Prime]

I live in the only state that a referendum has been passed by the citizenry on the matter, twice, and contrary to the predictions, assisted suicide has been used sparingly.  Freedom is only a word, unless you allow individuals to exercize it.

[MommaSquid]

Laetus thanks for the topic.  

Here's a link to the Oregon physician assisted-suicide page:

http://www.oregon.gov/DHS/ph/pas/

Seems like you have to jump through a lot of hoops just to die with dignity.  

[Whitney]

Seems like you have to jump through a lot of hoops just to die with dignity.  

Unfortunately, yes.  The rules are put in place to protect people from themselves more or less.  They want to make sure that anyone asking for assistance is psychologically sound and not being influenced by their doctor or family.  In my opinion we should be able to assume that the person is acting on their own authority unless it is suspected otherwise.  But, at least this makes the availability of assisted suicide more favorable in the public's eye.  Until the practice can be established as something acceptable everywhere I don't see a different way of handling the process.

In all reality, assisted suicide is being offered even where it is not explicitly allowed by law.  The doctors simply run a risk of being caught doing what they think is humanitarian service.  As far as I know, to this day no doctor has been convicted of assisting someone with suicide (this of coarse is recognizing the difference between assisted suicide and euthanasia).  At least the Oregon law allows doctors to be open about offering assisted suicide so people don't have to search underground for one or wing it on their own through information such as provided by the hemlock society (now called End-of-Life Choices). I couldn't find their web page they seem to have merged with another group here is that web page http://www.compassionandchoices.org/ .

[Asmodean Prime]

As far as I know, to this day no doctor has been convicted of assisting someone with suicide

Jack Kevorkian, still in prison.
http://en.wikipedia.org/wiki/Jack_Kevorkian

An extended biography and discussion of the subject.
http://www.pbs.org/wgbh/pages/frontline ... index.html

[Whitney]

Kevorkian was convicted of active euthanasia but let off of previous charges for assisted suicide.  Basically, if he hadn't activly administered the lethal dose to that patient he may have not been convicted.  

Kevorkian didn't seem to exercise very good discresion in who he helped.  The Wantz case mentioned in link two is an example of why Oregon has set up their laws to protect the individual from themselves and their doctors.  A responsible doctor would make sure the patient was actually suffering from an incurable medical problem before providing assistance with suicide.  Proper psychiatric care could have allowed Wantz to recover and live a fulfilling life.

[Big Mac]

I love how people were saying that it was unnatural to let Terri Shiavo starve to death when she was already dead. Her brain was fucking half the mass of a healthy women her weight, age, height, and mass!!! How the fuck can you believe she'd ever recover? Not to mention parading the poor woman on camera to the world. Is there no shame in people? Not to mention her own vanity brought about her demise. She was bulemic (excuse my spelling, I'm getting hammered right now, thanjsk to a friend hwo just hit the big 21!) and was vain. Her husband had already used up the insurance on making sure she was comfortable and the woman he married was who he met after she had collapsed. He wasn't being selfish, he was being a loving, compassionate spouse.

If I ever marry, I'd tell my wife to give me about 5 years, and if nothing comes from it, let me go in peace. I give it five years because it's just what I feel would be a good number. Not a full decade but enough to show that I am not on a road to recovery. Fortunately I know my mother wouldn't fight it, she believes if she is in PVS, she'd rather go. I'm glad I have such a reasonable matriarch.

[Jassman]

It should be a choice for any human to opt out of life at any time for any reason. No one asked to be born, but most are glad they were. However, if you don't want to exist, why should anyone else be allowed to stop you?

I find it absolutely insane that if I wanted to kill myself, there would be people halfway around the world telling me that I can't. What difference can it possibly make to them?

[Big Mac]

It should be a choice for any human to opt out of life at any time for any reason. No one asked to be born, but most are glad they were. However, if you don't want to exist, why should anyone else be allowed to stop you?

I find it absolutely insane that if I wanted to kill myself, there would be people halfway around the world telling me that I can't. What difference can it possibly make to them?

Well I have a few reasons:

1.) Because you're white...

2.) Because you didn't accept Jebus as your Dominatrix.

3.) It's the hair, dude, totally the hair.

4.) Control issue over other people. Just like people who ban guns, restrict vices such as smokes and drinks, and make pornography hard to find, it's all about controlling other people for a perverse motive.

[MommaSquid]

It should be a choice for any human to opt out of life at any time for any reason. No one asked to be born, but most are glad they were. However, if you don't want to exist, why should anyone else be allowed to stop you?

I find it absolutely insane that if I wanted to kill myself, there would be people halfway around the world telling me that I can't. What difference can it possibly make to them?

I would miss you, Jassman, but I would respect your decision.  

If we truly are in charge of our own destiny, then why shouldn't that include deciding the how, when and where of our deaths.

[Big Mac]

Because Gawd is vengeful!!! I mean he punishes a six-year-old with cancer but let's Jerry Falwell and Jack Chick's fat asses live in luxury. Vengeful to sinners!!!!

[Whitney]

It should be a choice for any human to opt out of life at any time for any reason. No one asked to be born, but most are glad they were. However, if you don't want to exist, why should anyone else be allowed to stop you?

I find it absolutely insane that if I wanted to kill myself, there would be people halfway around the world telling me that I can't. What difference can it possibly make to them?

I agree.  However, I think the person who wants to commit suicide should think about those s/he will be leaving behind.  For instance, I know my dad has contemplated suicide before because we have talked about it.  And if he had gone through with it he would have left my sister and I with just our mother for immediate family.  Back during this time my mother wasn't much to lean on for emotional support so we would have basically been left young and alone.  It's just and example and all cases are different.  I also can't claim to have a decision over that of another human...in the end an individual should be allowed to make the choice.  I just know that if it was me going through a situation where I wanted to kill myself I'd also think about the repercussions affecting those who love me.  

But, it is insane that there would be people who don't know me who would want to try and prevent me from going through with such a decision.  Just to be clear, I am being theoretical, even if I wanted to kill myself I'm too big of a baby to go through with it.  Pain scares me.  I would only be willing to kill myself if I were already in pain and that's where assisted suicide comes in.  

I personally think that the role of a doctor should be kept to healing and the prevention of suffering.  That is why I don't advocate the extension of assisted suicide past that of helping those who are already dying or suffering incurable chronic pain.  I guess there could be those who are suffering from currently incurable psychological problems who may also wish to die.  But, I don't know enough about the field of psychology to know how feasible it is to help people in such a situation.  I have, a possibly idealist view, that anyone suffering psychological problems can be helped if given proper attention or if the chose to help themselves.  

But, I also could understand that a person who sees no light at the end of the tunnel would want to kill themselves.  Yet again, through experience I know such times pass and it usually gets better.  But, how can I know what it would be like to be in such a situation, maybe for some it doesn't get better and I have been lucky.  I've never really wanted to kill myself so I can't begin to imagine such a situation. (going back to my example situation, my dad was surprise and glad when I said I never really wanted to kill myself even thought he through had briefly passed my mind at times).  But that still doesn't really shed some light on why someone would see that as the only way out.  

My thoughts aren't really put together on how I view those who do successfully commit suicide.  I feel sorry for them and feel that somehow they were failed by society.  I view it as one of those "if only" situations.  I have a classmate who killed himself sophomore year of college.  I didn't know him very well but have this feeling that maybe if more people befriended him maybe he wouldn't have wanted to kill himself.  What was going through his mind hours or minutes before?  Did we fail him as as society, was his life really that bad, was he insane?  I don't know, and will never know.

Basically, although I think a person should have the right to take his or her own life (what is to prevent them anyway other than fear of pain or death), maybe such cases are preventable if the reason is only psychological or due to a bad situation.

This has gone off track with the original idea of assisted suicide, but I would like to hear the thought of others.  I bring this up because it is such a taboo topic.  Maybe if we are able to discuss why a person may decide suicide is the best option we will also be able to discover how to help those "see the light" (sorry for the religious phrase) that there is hope to make it through a bad situation.

[MommaSquid]

laetusatheos,

A few questions for you to help me understand your point of view (and maybe to help you understand it, too).

In your mind, who failed your classmate?  Did society fail him, his parents, or did he fail himself?

Did he have the right to end his life?  Or do you think he was obligated to continue down life's path if he had grown weary of the journey?

Should a person be legally obligated to prove that death is their best option before ending it all?

If we truly are in charge of our own destiny, then why shouldn't we be able to decide the how, when and where of our deaths?

Unexpected loss is unkind, no matter the cause.

[Whitney]

laetusatheos,

A few questions for you to help me understand your point of view (and maybe to help you understand it, too).

Good questions.  I wasn't very clear on some parts of my view before.  Let me know if some of my points of view still are unclear or if you think they are completely wrong.

In your mind, who failed your classmate?  Did society fail him, his parents, or did he fail himself?

I think the fault is society in general.  Not parents, friends, or the individual...just the way society is structured.  In the way that if society were more open about talking about individual's experience with suicidal thoughts and things of that nature the classmate would have had felt more comfortable discussing his thoughts with others.  Right now people in such a situation at most have a hotline to call.  Having to call a hotline to talk to someone about your thoughts just adds to the stigma that they are unnatural and bad.  Society also has this "If you tell us we will do all in our power to keep you from killing yourself" approach to suicide...so a person who is seriously considering suicide as a favorable option won't want that option to be taken away by talking to others about their thoughts.

Did he have the right to end his life?  Or do you think he was obligated to continue down life's path if he had grown weary of the journey?

He certainly had the right.  If a friend told me she wanted to commit suicide I would try to talk her out of it and offer to help with whatever problems she was experiencing.  But, I would also reluctantly respect her decision if she wanted to go through with it.

Should a person be legally obligated to prove that death is their best option before ending it all?

Not at all, I just think we should create a social network in which discussing such thoughts is not taboo.  Right now those who want to commit suicide seem to be falsely lumped into the insanity category.  I know that if I had suicidal thoughts I wouldn't tell anyone close to me...I don't care much for being institutionalized.  But, that's currently how our society works.

If we truly are in charge of our own destiny, then why shouldn't we be able to decide the how, when and where of our deaths?

We should be allowed to decide for ourselves as individuals, sorry for not making that clear in my previous post.  However, I do think that in a lot of cases people would decide against suicide if they were able to openly discuss their thoughts about suicide with others without having to worry about others looking down on them or being labeled as insane.

Unexpected loss is unkind, no matter the cause.

Indeed.

edit:  I just realized that I kinda contradicted myself between the two posts.  In the post prior to this I asked the question "was he insane" in relation to the classmate who killed himself.  In asking that question I didn't mean to connect insanity with suicide...just that there could easily be cases, although probably not that many, where a person would choose suicide because they are insane.  I guess an example of such a case would be a person who thinks that, for instance, ghosts living in their closet are trying to get them and take them to some bad place.  That person would obviously be insane and it would also be a good reason, in their mind, for why the person would want to kill themselves.  But, if a person really beleived that ghosts are out to get them and can't be convinced otherwise, who am I to say that they should be forced to live in such a scary reality.