The Role of the Doctor in Physician-Assisted Suicide

A diagram illustrating the countries where physician-assisted suicide is legal. https://euthanasia.procon.org/view.resource.php?resourceID=000136

Physician-assisted suicide, whereby a physician assists a patient in the ending of one’s life, has long been an ethical debate both in the United States and around the world. The idea of a physician assisting a patient in the termination of one’s life concerns not only the ethics of the practice, but has scientific and cultural ramifications as well. Physician-assisted suicide is currently legal in seven countries and in seven states within the United States, with other countries and states currently debating legalizing it. [1] In 2006, the United States Supreme Court ruled that physician-assisted suicide cases should be left up to the individual states. [2] Oregon was the pioneer in this arena with the “Death with Dignity” act, and many states are now considering similar measures.  This controversial issue will remain a hotly contested topic with people having passionate opinions about it on both sides of the debate.

A map of the United States illustrating the states where physician-assisted suicide is legal and illegal. To this date, only 7 states have legalized physician-assisted suicide. https://euthanasia.procon.org/view.resource.php?resourceID=000132

Physician-assisted suicide, once considered taboo, is now making its way into mainstream society. Fairly recently, states such as Oregon, have made physician-assisted suicide legal, and many other states are now voting on legalizing the practice as well. These discussions bring into focus the debate of whether it is ethical for a physician to knowingly and intentionally provide a person with either the knowledge, the means, or both, that will enable one to successfully commit suicide when faced with a terminal disease. Over twenty years ago, Dr. Jack Kevorkian, also known as Dr. Death, rose to prominence as an outspoken proponent of physician-assisted suicide; claiming to have helped more than 130 terminally ill patients end their life. He was arrested, convicted and ultimately served eight years in prison for assisting patients in ending their life. He continually defended his ideas stating that “dying is not a crime” and presented a platform for his beliefs and ideals. [3]

Dr. Kevorkian explaining his “suicide machine” and the right to die movement.

Decades after Dr. Kevorkian first came to prominence, the debate continues to rage on, with arguments both for and against the idea that a physician can assist a patient in terminating his/her life. A key element of the debate focuses on the ethics of this practice, stating that a physician is compelled to do no harm, and helping a patient to terminate his/her life is the very definition of harm. The “do no harm” argument stems from the Hippocratic Oath; and although the words “do no harm” never actually appear in the Oath, the concept exists throughout the oath that is taken by almost all physicians.  However, what does this concept mean in relation to today’s advancements within medicine? The Oath was written in the 5th century B.C. [4] Both medicine and ethics have changed considerably over these past centuries, yet the idea of a physician doing no harm remains integral in the practice of medicine. What does “do no harm” actually mean in an ethical sense? If a terminally ill patient is in pain with no chance of survival, is it ethical to let him/her suffer if he/she wants to end his/her life? This is the essence of the ethical dilemma that exists, and the one that states are currently debating.

The Hippocratic Oath that doctors recite at their White Coat Ceremony. https://www.alamy.com/stock-photo-hippocratic-oath-1938-135089098.html

The Hippocratic Oath is often used as leverage in the argument opposing physician-assisted suicide. The Hippocratic Oath specifically states, “I will not give a lethal drug to anyone if I am asked nor will I advise such a plan.” [5] This statement is unambiguous in its message and is a powerful argument for those against a physician assisting a dying patient in committing suicide. Taking this oath in its literal text would seem to prove the point that it is unethical for a physician to provide a patient with either the knowledge or lethal prescriptions, that would allow that patient to terminate his/her own life. Yet, the Oath also states that there is an “art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife.” [6] If warmth and sympathy are to be given to a dying patient who requests that he/she be allowed to die, how is a physician denying this request deemed to be ethical?

In addition to the Hippocratic Oath, a second central ethical issue raised regarding physician-assisted suicide revolves around the medical ethics adhered to by doctors. Medical ethics are what establish the duties of a physician to his/her patient, perhaps even more than the law. There are a few principles that a physician must follow including beneficence, acting in the patient’s best interest; nonmaleficence, avoiding or minimizing harm; autonomy, a patient has the right to control what happens to his/her body; and justice, the need to try and be as fair as possible. [7] It is crucial to examine these ethical principles in order to determine whether it is ethical or not for a doctor to aid in physician-assisted suicide.

Autonomy is the right for a person to make his/her own decisions. Regarding autonomy, medical ethics support a patient’s right to refuse treatment, even if it is lifesaving treatment. [8] Some may argue that a physician aiding his/her patient in assisted suicide is an act of compassion as he/she is respecting the choice that his/her patient has made. However, others argue that respect for autonomy is not the only ethical principle that should be followed; and it must be balanced with beneficence and nonmaleficence. [9] Although both proponents and opponents of physician-assisted suicide agree that a patient’s autonomy is important and needs to be respected, it is also important to note that it is not absolute. Those in favor of a physician being able to assist in suicide claim that it is an act of compassion and respect a patient’s choice and therefore fulfills the obligation of non-abandonment. Those in favor further their argument stating that physicians are indeed assisting in patients’ suicide even when it is not legal, and the legalization of this act would result in standardization, monitoring and more transparency. [10] Contrary, those against also use medical ethical principles to further their argument claiming that it would require physicians to breach specific prohibitions such as nonmaleficence and beneficence. Breaking these prohibitions is not what the role of a physician, or healer is. Much like most controversial subjects, both proponents and opponents of physician-assisted suicide, can and do cite ethics as the reason for their beliefs in what is the ethical choice.

The ethical perspective of physician-assisted suicide certainly presents an intriguing angle on such a contentious topic. However, the ethical perspective does not consider the principles certain societies hold. Analyzing physician-assisted from a cultural perspective permits a true understanding of the way a society’s unique culture dictates formal legislation regarding the legality of physician-assisted suicide. Japan and Belgium provide useful cultural insight because their stances are on opposite ends of the debate spectrum. Japan is particularly interesting because they lack a firm stance on physician-assisted suicide and euthanasia. Legislature in Japan is largely based on a cultural concept called ikigai. This roughly translates to a “life worth living”. To put this idea more plainly, writers have described ikigai as “joy and a sense of well-being from being alive” and of realizing the value of being alive”. One cohort study conducted in Japan found that lack of ikigai contributed to increased risk of all-cause mortality [11]. These are the principles that guide medical professionals and legislators in Japan when it comes to physician-assisted suicide. However, they have been unable to formalize anything because of the considerable distrust surrounding medical professionals in Japan. Interview accounts have found that many people in Japan carry the sentiment of doctors being untrustworthy. The phrase “I wa kin Jitsu Nari” is used because it describes medicine as a money-making scheme[12]. This cultural distrust surrounding physicians has prevented people from accepting physician-assisted death as a reasonable course of action [13]. Other countries have made changes concerning the legality of physician-assisted suicide, but Japan has yet to present a concrete point of view.

Graph highlighting an increase in Euthanasia cases since 2003. https://d3i6fh83elv35t.cloudfront.net/newshour/app/uploads/2015/01/euthanasiabelgium.jpg

Japan’s conservative culture contrasts Belgium where principles of physician-assisted are exceedingly liberal. The  Belgian Act on Euthanasia of May 28, 2002, legalized euthanasia and physician-assisted suicide for competent adults. A more recent in 2014 act even opened physician-assisted suicide to those under 18 if they suffered from “constant and unbearable physical or mental suffering that cannot be alleviated” [14]. Such liberal laws reflect a culture that accepts physician-assisted death as a viable path for people to take. Despite these laws, there is not necessarily complete agreement in support of physician-assisted death. A recent documentary from PBS provided an account of several cases where physician-assisted death was utilized in Belgium. The first instance involves a young woman who suffers from chronic depression and took advantage of the assisted death laws. Doctors highlight the simplicity of the act of requesting euthanasia. The only necessary step is to provide “their name, the date, and why they want euthanasia”[15]. Belgium was the first nation to give children access to physician-assisted suicide. This liberal culture does not come without controversy. Belgium provides people considerable autonomy. This eliminates any chance for fellow family members or friends to have a say in the decision. The documentary describes a situation where an older woman has chosen physician-assisted suicide. However, her son does not believe she is in the right state of mind to make such a decision. Clearly, this is where a liberal culture may backfire. Another study conducted found that restrictive policies on physician-assisted death is not in the best interest of the patient. In Belgium, where there is very little restriction on physician-assisted death, doctors openly discuss the drugs used and the process with the patient [16]. This open communication about assisted death allows for a smoother process that retains patient autonomy.

 Japan and Belgium were specifically described because they represent two countries that stand at opposite ends of the assisted suicide debate. The Japanese are skeptical about the medical profession and this distrust seeps into physician-assisted death laws. Meanwhile, in Belgium, doctors have comfortable conversations with their patients who can completely determine when they wish to participate in physician-assisted death. Evidently, unique culture amongst regions and people motivate how policy is enacted and how people perceive sensitive topics such as death.

In order for physician-assisted suicide to be considered as an option, a patient must fulfill certain requirements. [17] They must be in the right state of mind, the request must be voluntary and in no way can they be coerced into making the decision, and the life expectancy needs to be six months or less.  The condition must also be determined to be terminal by at least two physicians. After all of the requirements have been met, the patient is able to receive medication to help them end their life.  

There are specific medications that are used in order for this procedure to occur.  [18] In a study conducted in the Netherlands, where physician-assisted suicide is legal, they looked at what kinds of drugs are used in the life-ending procedure.  In the majority of cases where euthanasia was intended, a barbituate to induce a coma was given first, and then a neuromuscular relaxant was given. In most of the cases of euthanasia in the Netherlands, a physician was the one who administered the drugs.  A physician was also continuously present for the majority of cases in the study.

Many scientific questions arise when it comes to physician-assisted suicide. [19] One of the first questions that comes up is how is assisted-suicide compatible with medical practice?  All medical doctors take the Hippocratic Oath and are required to do no harm to others. By helping hasten death, wouldn’t they be going against this Oath?  In the states that have legalized physician aid in death, there are accommodations that allow physicians to opt out of this practice if they do not want to do it.  Another question that arises is does this practice devalue human life? When looking at data collected from the annual reports of the Oregon Death with Dignity Act, it shows that patients are primarily motivated by dying with dignity and retaining their self-respect.  These answers shift from social decisions to that of the individual.

There have also been many studies that were conducted to see how “vulnerable” groups would be affected by physician aid in dying.  [20] One of the studies focused on different socio-economic groups, which consisted of women, elderly, poor, and different races.  Some people feared that physician-assisted suicide would target these vulnerable groups. The study concluded that there was no evidence that the law would be abused.  

The last scientific question to be brought up is the effects physician-assisted suicide has on family members of the patient who is seeking life-ending medication.  [21] Although assisted suicide has been legal for a while in Oregon, there is little known about the effects on the family members.  In the survey that was conducted, families’ mental health was looked at after the death of the family member. Families of patients who died of lethal injection and families of patients who died from cancer were both surveyed.  When comparing the family members of those who did and did not request aid in dying, there was no difference in primary mental health. The study showed that when a person requested aid in dying, the family felt more prepared to accept the death of their loved one.  The study concluded that there are not negative effects on family members, but that the opposite might occur. They have greater acceptance of death.

Physician assisted suicide has been an ongoing debate for decades. This contentious debate has ethical, cultural and scientific ramifications concerning whether a physician should be allowed to aid a terminal patient in the ending of his/her life. Many states are contemplating whether they should legalize physician assisted suicide, but due to the controversial nature of the subject, there will continue to be strong opinions both for and against the idea. After the Death with Dignity Act was legalized in Oregon, other states have been able to follow and adopt the model that was successfully implemented there. This has resulted in an increase in the number of states that are now considering the legalization of physician assisted suicide, such as Washington, California, Colorado, Montana, and others. As medical technology advances, the medical community is going to have to address these difficult topics. The question cannot just be how our society prolongs a life, but also how our society deals with the inevitable end of a life, and honors the wishes of the patient.

Pod 2: Katie Somosky, Karan Ravi, Sydney Beck

Footnotes

[1] “Euthanasia and Physician Assisted Suicide around the World,” chart, accessed April 1, 2019, https://euthanasia.procon.org/view.resource.php?resourceID=000136.

[2] Kate Pickert, “Assisted Suicide,” Time, last modified March 3, 2009, accessed April 3, 2019, http://content.time.com/time/nation/article/0,8599,1882684,00.html

[3] Monica Davey, “Kevorkian Speaks After His Release from Prison,” The New York Times, accessed April 1, 2019, https://www.nytimes.com/2007/06/04/us/04kevorkian.html.

[4] “Modern Hippocratic Oath Holds the Underlying Values of Medicine in a Digital World,” last modified July 13, 2018, accessed April 1, 2019, https://medschool.ucla.edu/body.cfm?id=1158&action=detail&ref=1056.

[5] Amal Ababneh, “Physician Assisted Suicide for Terminally Ill Patients: An Argumentative Essay,” Journal of Palliative Care & Medicine, [1], https://www.researchgate.net/profile/Amal_Ababneh/publication/327266188_Physician_Assisted_Suicide_for_Terminally_Ill_Patients_An_Argumentative_Essay/links/5c51df8ea6fdccd6b5d4ef9f/Physician-Assisted-Suicide-for-Terminally-Ill-Patients-An-Argumentative-Essay.pdf.

[6] Peter Tyson, “The Hippocratic Oath Today,” PBS, last modified March 27, 2001, accessed April 1, 2019, https://www.pbs.org/wgbh/nova/article/hippocratic-oath-today/.

[7] Ababneh, “Physician Assisted,” [2].

[8] Lois Snyder Sulmasy and Paul S. Mueller, “Ethics and the Legalization of Physician-Assisted Suicide,” Annals of Internal Medicine, October 17, 2017, https://annals.org/aim/fullarticle/2654458/ethics-legalization-physician-assisted-suicide-american-college-physicians-position-paper.

[9] Lois Snyder Sulmasy, “Ethics and the Legalization of Physician-Assisted Suicide,” Annals of Internal Medicine, June 5, 2018.

[10] Sulmasy and Mueller, “Ethics and the Legalization,”

[11] Sone, Toshimasa, Naoki Nakaya, Kaori Ohmori, Taichi Shimazu, Mizuka Higashiguchi, Masako Kakizaki, Nobutaka Kikuchi, Shinichi Kuriyama, and Ichiro Tsuji. 2008. “Sense of Life Worth Living (Ikigai) and Mortality in Japan: Ohsaki Study.” Psychosomatic Medicine70 (6): 709–15. https://doi.org/10.1097/psy.0b013e31817e7e64.

[12] Lock, Margaret. 1995. “Contesting the Natural in Japan: Moral Dilemmas and Technologies  of Dying.” Culture, Medicine, and Psychiatry19 (1): 1–38. https://doi.org/10.1007/bf01388247.

[13]  Kai, Katsunori. 2010. “Chapitre 10. Euthanasia and Death with Dignity in Japanese Law.” Journal International De Bioéthique21 (4): 135. https://doi.org/10.3917/jib.214.0135.

[14] Watson, R. 2014. “Belgium Extends Euthanasia Law to Children.” Bmj348 (feb18 6). https://doi.org/10.1136/bmj.g1633.

[15].  NewsHour, PBS. 2015. “The Right to Die in Belgium: An Inside Look at the World’s Most Liberal Euthanasia Law.” YouTube. YouTube. January 15, 2015. https://www.youtube.com/watch?v=eo8Hn0DEcpw.

[16] Inghelbrecht, E., J. Bilsen, F. Mortier, and L. Deliens. 2009. “Nurses’ Attitudes towards End-of-Life     Decisions in Medical Practice: a Nationwide Study in Flanders, Belgium.” Palliative Medicine23 [1](7): 649–58. https://doi.org/10.1177/0269216309106810.

[17] Rurup, Mette. “When Being ‘tired of Living’ Plays an Important Role in a Request for Euthanasia or Physician-assisted Suicide: Patient Characteristics and the Physician’s Decision.” Health Policy. February 05, 2005. Accessed April 05, 2019 https://www.sciencedirect.com/science/article/pii/S0168851005000072.

[18] Groenewoud, Johanna. “Clinical Problems with the Performance of Euthanasia and Physician-assisted Suicide in the Netherlands.” ProQuest. February 24, 2000. Accessed April 05, 2019. https://search.proquest.com/docview/223932584/fulltextPDF/5D87F33976BE40A6PQ/1?accountid=14244.

[19] Gostin, Lawrence. “Physician-Assisted Dying A Turning Point?” UNC Chapel Hill Libraries. January 19, 2016. Accessed April 05, 2019. https://jamanetwork-com.libproxy.lib.unc.edu/journals/jama/fullarticle/2482336.

[20] Preston, Robert. “Physician-assisted Suicide-a Clean Bill of Health?” OUP  Academic. July 13, 2017. Accessed April 05, 2019. https://academic.oup.com/bmb/article/123/1/69/3958775.

[21]Ganzini, Linda. “Mental Health Outcomes of Family Members of Oregonians Who Request Physician Aid in Dying.” Journal of Pain and Symptom Management. September 24, 2009. Accessed April 05, 2019. https://www.sciencedirect.com/science/article/pii/S0885392409007076.

4 Comments

  1. Caroline Vincent

    April 20, 2019 at 12:23 pm

    In some ways, power and autonomy are given to the patient; however, a license to kill is given to the doctor. Doctors have a lot of power already, and many are said to have a “god complex.” Doctors given the power to kill could cause more issues on their feelings of power, and it could create cognitive dissonance in their sense of morality. It would be interesting to see if doctors that have performed physician-assisted suicide have a significant difference in patient outcomes (excluding the suicide patients) than doctors that do not participate in physician-assisted suicide.

  2. I enjoyed reading this post because it was thoroughly well-organized and I knew when each perspective (cultural, scientific, and ethical) was being discussed. As a Christian, I have always struggled with this topic. Part of me believes people should have autonomy over their own body and medical decisions but part of me also struggles with someone ending their life or having a doctor help them end their life. I relate to the ethical debates mentioned in this post because I have them with myself daily, especially since taking this class. I wonder as time moves on and if more states in the U.S. legalize physician-assisted suicide, if my stance will change. Will the normalization of this act change the overall stigma surrounding it? These questions have not been answered yet, but could easily be answered in the next few years depending on what happens.

  3. I really like how you talked about the idea of physician assisted suicide in other countries, particularly Japan and Belgium. The fact that these two countries are on complete opposite sides of the debate, really shows how highly controversial this topic is. I also think this paper did a good job explaining everything that is debated with this topic, specifically I think the use of the ethical principles was very effective. Also, you all did a really good job explaining both sides, as even I do not fully agree with one side in particular. I think people should be able to choose when to end their life, (when they are going to die anyway), especially if it can prevent pain and suffering, however it is God’s decision when someone has fulfilled their purpose on Earth.

  4. I appreciated the analysis of the Hippocratic Oath as it’s something most people have heard of, from movies or TV, but often haven’t read. It’s interesting to know that the oath officially doesn’t say “do no harm.” So I would argue that the oath should be taken as a medical professional but also interpreted in various scenarios which you presented. However, as you mentioned, this is undercut by the oath specifically stating “I will not give a lethal drug to anyone if I am asked nor will I advise such a plan.” However, the oath should hold its ideas of compassion over specific action.

    Your comparison and analysis of assisted suicide from other nations was very enlightening, as I was surprised that Belgium’s policies even applied to those under 18 with conditions causing “constant and unbearable physical or mental suffering that cannot be alleviated.” Does this policy require parental permission from those under 18, and if so, I cannot imagine the ethical complexities of a parent signing their child’s right to die.

    Your post was very well organized and had a great flow between concepts. While this is a very polarizing topic, your presentation was refreshingly objective and very well written. Thanks!

Leave a Reply

© 2019 Death & Dying III

Theme by Anders NorenUp ↑