The Effects of Physician Assisted Death on Physicians

Physician assisted death is a topic that has been debated worldwide for many years. According to the American Medical Association, physician assisted death can be defined as “when a physician facilitates a patient’s death by providing the necessary means and/or information to enable the patient to perform the life-ending act.”[1]In the United States, it is only legal in six states. When thinking about physician assisted death, many people directly jump to the effects it has on patients and their families – but what about the effects it has the on the doctors involved in the process?

Physicians are expected to do what is best when it comes to their patients, which should include taking the patient’s request into consideration. When a patient who is in their right mind and has less than 6 months to live asks to be given medications that will kill them, how should a physician respond? Some factors that determine their response is their own personal religion or customs or also even the medical community and the customs that lay within it.

Before becoming a doctor, you are sworn in on the Hippocratic oath, which says “I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan.”[2] Even though doctors must swear by this oath and stick to it their entire career, there are still some doctors that go against it and participate in AID (Aid in Dying) techniques. What the oath doesn’t encompass is how medical culture will change as time progresses, and what will become the new cultural norm in the new day and age.

50 years ago, if a physician was interviewed about their stance on physician assisted suicide, there would be an instant opposition. Likewise, 50 years ago medicine wasn’t as advanced as it is now and also didn’t have as many possibilities. Medicine was still heavily influenced by religion and personal customs that kept care to be as preventative and life saving as possible instead of trying to keep the person in control of their body and its care. Medical care has moved from only going to one doctor for all illness/sickness, to going to a different doctor per part of the body.[3]  When there is a separation in the different doctors and what they care for, there is also a divide in which doctors will support PAD (Physician Assisted Death) and which will deny a patient of this choice due to their own beliefs.[4]

Many physicians who are religious have a conflict with supporting PAD because in some religions, it has been declared wrong for any man to take another’s life and not suffer the consequences for it. In fact, the Roman Catholic church has completely disapproved of it and has stated that it would be better to live until natural death than to help someone die using medicine.[5][6]Most Christian denominations have followed suit and hold the same standards for their Christian physicians. The main reasoning for this is because “God has forbidden it” [7], meaning that any type of unnatural death (including murder and suicide) is “an attack on the sovereignty of God.”[8]Christian beliefs also state that “human life is special”[9], and to take another’s life using any method is wrong and devalues that life.

In eastern religions, such as Hinduism and Buddhism, mortal life is seen as a cycle living, dying, and being reborn again, with the ultimate goal being to be liberated from this cycle.[10] If a physician practicing either of these religions participated in PAD, they would have guilt from possibly interfering with another person’s cycle of life, but also from violating the principle of ahimsa.[11]This principle states that you should never harm a living being, even if they are asking to die. These two eastern religions also believe in karma, which would lead to the physician being negatively affected by satisfying their patient’s request to die.

 

The cycle of life in the Hindu faith

While physicians will or will not participate in PAD because of personal beliefs, there are some physicians that do participate in PAD because of the other options available to the patient. When a patient is terminally ill and has accepted their fate, there is most certainly a period of depression that follows due to their succumbing to the loss of their autonomy. A physician with the duty of palliative care is required to make the end of life process for the patient as pain free as possible. Physicians are also obligated to give the best care possible to their patients and give them the full range of options for their end of life care.[12]Physicians who decide to participate in PAD are going outside of medical norms and giving patients back their autonomy that they lost when they were diagnosed with a terminal illness. For some physicians, their decision to provide PAD is not only going outside of what their beliefs normally are, but also what can be seen as morally wrong by some in the medical community. From here it is important to look into the ethical problems faced by physicians.

As noted earlier, six US states, along with Washington D.C, have legalized PAD with ideas and arguments of autonomy. To emphasize the increasing moral issues at hand, there have been at least thirty-six other states that have also attempted to introduce this law and legalize PAD but without success.[13]

Physician assisted death is a fairly new technique that has not only recently been implemented in several U.S states, but among multiple other countries as well.[14]

Consequently, it is in these states and countries, with possibly many more to come, where physicians are faced with the moral and ethical dilemmas of following through with the aid in the death of their patient.

The main ethical/moral issue that arise through physician assisted death is that in which physicians cannot fulfil their traditional role as a healer and comforter. An immediate consequence of this dilemma is where a physician cannot maintain their trusting, professional relationship with the patients/surrounding community, ultimately destroying their ancient role in society.

As described by the first principle of medical ethics presented by the American Medical Association, a physician must be “dedicated” to giving every patient “competent care” while upholding all aspects of human rights.[15] Thus, by providing the drugs in a quantity that causes a patient’s death, an ethical paradox emerges. Instead of providing care for an individual, the physician is essentially facilitating a means of harm. Two alternatives are present that can avoid this ethical dilemma. One option being the forgoing of life-sustaining treatment and treatment through proper pain control as mentioned previously. It is through these alternatives, labeled as “human, legal, and morally proper”, that suicide can be ultimately avoided.[16] While the forgoing of a life-sustaining treatment system might seem equivalent to PAD, Lois Snyder Sulmasy points out that this is not intended to hasten death but instead points to an “acceptance” of death as a “natural” response to the disease.[17] Seen here, the intent of an action is critical in upholding the ethical concerns of physicians and an intent to kill contradicts their ethical duties of beneficence and nonmaleficence. Intent also parallels with the provision of pain control. It is in this provision where a doctor, while acknowledging that death may come sooner as a side effect, pledges to never intentionally hasten the patient’s death. Yang argues that PAD disregards the most “universal moral junction,” do not kill, by writing a prescription with the intent to kill the patient.[18]

Trust is essential for the physician-patient bond that is so important in our medical society today. In relation to palliative care, the ethical boundary against a physician intentionally causing the patient’s death is what allows patients to be able to request and accept pain medication without fear of an intentional overdose that would hasten their death. In addition, this gives physicians room to operate freely and distribute the medications as they see fit. Many professional organizations have taken the stance of opposition upon the legalization of PAD including the NHCPO, ACP, and AMA. Specifically, the AMA (the largest national doctors’ group) believes that this would cause societal problems as it is “fundamentally incompatible with the physician’s role as healer” and would be “impossible to control.”[19] To put it another way, the physician’s societal role as a healer with ethical responsibilities, could be diminished to that simply of a provider of services at the patients’ expense.

Physicians can lose their professionality and established role in society with the onset of physician assisted death. More so, they must disregard their ethical standards in which they would intentionally end a patients life, an action completely contradictory to a doctors morals. For these reasons it would be more ethical to, with the patient’s permission, practice palliative care or withhold/withdraw life-sustaining treatment.

In order to fully understand the effects of physician assisted suicide on doctors, the issue must be explored from the scientific perspective. Many physicians hold the value of the Hippocratic Oath close to their hearts each day that they go to work. When doctors are faced with the controversial method of physician assisted death, it can have lasting psychological impacts on them. This is an important issue to address because as it is stated in a study done in Washington State, “Patient requests for physician-assisted suicide and euthanasia are not rare.” [20]

In 2001, a study was done in the Netherlands investigating the emotional impacts physicians experienced after having performed euthanasia or having participated in medical end-of-life decisions. 42% of the physicians reported feelings of discomfort from participation in the event, 28% of which specifically reported feelings of guilt. However, after the death of the patient, 52% of the physicians felt comforted afterwards, 44% of which reported feelings of satisfactions and 13% reporting relief. After all was said and done, only 5% of participating physicians had doubts about their actions, and none had regrets. 95% said that they would perform the act again in a similar situation. Despite the fact that physician assisted suicide can be uncomfortable for the physician, after the fact it may provide physicians with “a feeling of having contributed to the quality of the dying process.” [21]

In 2007, Kenneth R. Stevens published an article in which he cumulatively analyzed data regarding the emotional and psychological effects of physician assisted suicide on doctors. 24% of the physicians surveyed in the United States reported that they regretted performing euthanasia or physician assisted suicide, which is significant compared to the 0% of physicians in the 2001 Netherlands study that stated that said they had regrets about their actions. 16% of the United States physicians stated that “the emotional burden of performing euthanasia or PAS adversely affected their medical practice.” [22] Many physicians stated that they felt hopeless, isolated, and even disappointed. Dr. Peter Reagan, an American doctor interviewed about his experience in participating in physician assisted death states, “I think the most important thing is for doctors to understand how huge of an experience it’s going to be for them and that they must have ways of dealing with it themselves.”[23]

Due to the strong psychological impacts of physician assisted suicide on doctors, many doctors choose to immediately dissociate with that patient if that is a path that they are considering. Even the mere suggestion of physician assisted suicide can be “so disturbing to some physicians that they disengage from or avoid their patients.” [24] However, not only can this lead to the patient feeling isolated, this can also lead to the physician feeling isolated. Additionally, physicians may even lose satisfaction with their work when they leave emotions unaddressed. An American doctor, who will be referred to as Dr. P, had a critical patient who suggested the idea of physician assisted death. Rather than helping the patient make an educated decision, Dr. P decided to stop seeing the patient because she couldn’t deal with the burden that would be put on her. Not only was the patient left in the dark, Dr. P was saddened and disappointed that she could not have done more.

In order to avoid situations like Dr. P’s, it is important to have a trusting doctor-patient relationship in which there is a mutual understanding of feelings. If the doctor shuts out the patient, the patient may be left unable to to make the right decision for themselves. The doctor can also seek peers for advice if they do not feel comfortable talking to the patient. The “importance of open discussions, both with patients and with others” [25] is a crucial part of the decision-making process for the physician. There is no way to avoid the negative emotions surrounding physician assisted death, but it better to talk through concerns rather than simply avoid addressing the situation. As stated by Dr. Peter Regan, “I did what I felt was right, given bad choices.” [26]

A diagram of the doctor-patient relationship with respect to physician assisted death. [26]

Of course, different physicians will react in different ways to the idea of participating in physician assisted death. Some doctors refuse to perform the act at all, while others have done it multiple times and would do it again if the circumstances called for it. When physician assisted suicide is performed, a strong, trusting doctor-patient relationship must be established in order minimize lasting psychological effects on doctors.

Through analysis of physician assisted death from an ethical, scientific, and cultural perspective, it is clear that physician assisted suicide significantly impacts doctors. In considering physician assisted suicide, physicians are faced with ethical dilemmas and choices that may go against cultural norms, as explained through religious beliefs. This can have lasting psychological impacts on doctors, proving the necessity for strong doctor-patient relationships.

Blake Matthews

Brianna Ramgeet

Katherine Acierno

 

[1].”Physician-Assisted Suicide.” American Medical Association. Accessed March 25, 2019. https://www.ama-assn.org/delivering-care/ethics/physician-assisted-suicide.

[2].”Greek Medicine – The Hippocratic Oath.” U.S. National Library of Medicine. February 07, 2012. Accessed April 06, 2019. https://www.nlm.nih.gov/hmd/greek/greek_oath.html.

[3].Henry Cha. “A Culture of Health Reaches Far Beyond the Doctor’s Office.” HCIactive. December 23, 2017. Accessed April 08, 2019. https://www.hciactive.com/a-culture-of-health-reaches-far-beyond-the-doctors-office/.

[4].Quill, Timothy E., MD, and Margarett P. Battin, MFA, PhD. “Physician-assisted Dying: Understanding, Evaluating, and Responding to Requests for Medical Aid in Dying.” UpToDate. Accessed April 04, 2019. https://www.uptodate.com/contents/physician-assisted-dying-understanding-evaluating-and-responding-to-requests-for-medical-aid-in-dying#H2168049655.

[5]”Ethics – Euthanasia: Religion and Euthanasia.” BBC. Accessed April 08, 2019. http://www.bbc.co.uk/ethics/euthanasia/religion/religion.shtml.

[6]”Religion and Spirituality.” Death With Dignity. Accessed April 04, 2019. https://www.deathwithdignity.org/learn/religion-spirituality/.

[7]”Ethics – Euthanasia: Religion and Euthanasia.” BBC. Accessed April 08, 2019.

[8]“Ethics,” BBC

[9]“Ethics,” BBC

[10]“Ethics,” BBC

[11]“Ethics,” BBC

[12]Buchman, Sandy. “Why I Decided to Provide Assisted Dying: It Is Truly Patient Centred Care.” Bmj, 2019, L412. Accessed April 8, 2019. doi:10.1136/bmj.l412. https://www.bmj.com/content/364/bmj.l412.short?rss=1&utm_term=1-B&utm_content=americas&utm_campaign=tbmj&utm_medium=cpc&utm_source=trendmd

[13]Wicht, Edward, Rohini Mehta, and Sarah Anne Kleinfeld. “PHYSICIAN AID-IN-DYING: UPDATES FOR GERIATRIC PSYCHIATRISTS: Session 100.” The American Journal of Geriatric Psychiatry 27, no. 3 (2019): S3. https://doi.org/10.1016/j.jagp.2019.01.137

[14]Radbruch, Lukas, Carlo Leget, Patrick Bahr, Christof Müller-Busch, John Ellershaw, Franco de Conno, and Paul Vanden Berghe. “Euthanasia and Physician-Assisted Suicide: A White Paper from the European Association for Palliative Care.” Palliative Medicine 30, no. 2 (February 2016): 104–16. doi:10.1177/0269216315616524

[15]Riddick Jr, Frank A. “The code of medical ethics of the American Medical Association.” (2003): 6-10. http://www.ochsnerjournal.org/content/ochjnl/5/2/6.full.pdf

[16]Kelly, David F. 1995. Alternatives to physician-assisted suicide. American Journal of Otolaryngology–Head and Neck Medicine and Surgery 16 (3): 181-5. https://www.sciencedirect.com/science/article/pii/0196070995900993

[17]Sulmasy, Lois Snyder, and Paul S. Mueller. “Ethics and the Legalization of Physician-Assisted Suicide: An American College of Physicians Position Paper.” Annals of Internal Medicine 167, no. 8 (2017): 576. doi:10.7326/m17-0938.

[18] Yang, Y. Tony, and Farr A. Curlin. 2016. Why physicians should oppose assisted suicide. Jama 315 (3): 247-8. https://jamanetwork.com/journals/jama/article-abstract/2482333

[19]”Physician-Assisted Suicide.” American Medical Association. Accessed April 08, 2019. https://www.ama-assn.org/delivering-care/ethics/physician-assisted-suicide

[20]Back AL, Wallace JI, Starks HE, Pearlman RA. Physician-Assisted Suicide and Euthanasia in Washington State: Patient Requests and Physician Responses. JAMA.1996;275(12):919–925. doi:10.1001/jama.1996.03530360029034 https://jamanetwork.com/journals/jama/article-abstract/399087

[21]Haverkate, Ilinka, PhD, Agnes Van Der Heide, MD, PhD, Bregje D. Onwuteaka‐Philipsen, PhD, Paul J Van Der Maas, MD, PhD, and Gerrit Van Der Wal, MD, PhD. “The Emotional Impact on Physicians of Hastening the Death of a Patient.” Medical Journal of Australia. November 01, 2001. Accessed March 30, 2019. https://onlinelibrary.wiley.com/doi/abs/10.5694/j.1326-5377.2001.tb143707.x

[22]Kenneth R. Stevens (2006) Emotional and Psychological Effects of Physician-Assisted Suicide and Euthanasia On Participating Physicians, The Linacre Quarterly, 73:3,203-216, DOI: 10.1080/20508549.2006.11877782 https://www.tandfonline.com/doi/pdf/10.1080/20508549.2006.11877782

[23]Kenneth (2006), 203-216

[24]Meier, Diane E., MD, Anthony L. Back, MD, and R. Sean Morrison, MD. “The Inner Life of Physicians and Care of the Seriously Ill.” JAMA. December 19, 2001. Accessed April 2, 2019. https://www.researchgate.net/publication/11612706_The_inner_life_of_physicians_and_care_of_the_seriously_ill.

[25]Jennifer R. Voorhees, Judith A. C. Rietjens, Agnes van der Heide, Margaret A. Drickamer, Discussing Physician-Assisted Dying: Physicians’ Experiences in the United States and the Netherlands, The Gerontologist, Volume 54, Issue 5, October 2014, Pages 808–817,https://doi.org/10.1093/geront/gnt087https://academic-oup-com.libproxy.lib.unc.edu/gerontologist/article/54/5/808/626967

[26]Kenneth R. Stevens (2006) Emotional and Psychological Effects of Physician-Assisted Suicide and Euthanasia On Participating Physicians, The Linacre Quarterly, 73:3,203-216, DOI: 10.1080/20508549.2006.11877782 https://www.tandfonline.com/doi/pdf/10.1080/20508549.2006.11877782

 

10 Comments

  1. The fact that many doctors allow their religion to dictate their practice is somewhat alarming. Should there be a divide in medical practice and religion like there is with church and state? Should the patients wishes overpower the doctor’s beliefs? After all, their role is to provide the best care for their patients. It would be interesting to see what happens when a doctor refuses to administer death-causing drugs, are patients left to find someone else? or should the doctor refer them to someone else? Overall this was a very interesting read.

  2. I really enjoyed reading this standpoint on Physician Assisted Death. I worked on a similar topic, and I too put the spotlight on the scientific community and their role in the process. I agree that, regarding the Hippocratic Oath, the world is constantly growing and evolving, so circumstances do change. Yes, a physician may break the oath, but to others it is just and the right thing to do. It is hard to imagine how it feels when the person you are supposed to be helping and serving requests death—do you turn them down and make them suffer, or break the oath and relieve him/her of his/her suffering? There is such a negative stigma around suicide, but it gets to a point when it is more costly and futile to the patient and his/her family to stay alive than to die on one’s own terms. Yes, there can certainly be a very detrimental effect that this action has on physicians, but it is the own individual’s wishes that are most important. Then again, it should also be a doctor’s right to be able to refuse. As in research, there are seven US states that allow PAD—if one physician refuses, there can always be another that will comply. The comment before me mentions the divide between medical practice and religion. What is more important? To me, I still believe that people—whether the doctor or the patient— have the right to choose.

  3. I enjoyed reading this article about the effects of assisted suicide on physicians. We naturally think of the effects that assisted suicide or euthanasia has on the patient and their families, however we do not often think about the doctors. Doctors have went through years of schooling and training to help save lives of those who are injured or sick, not to help someone in assisting with their death. However, our society is advancing and this comes with new medical practices such as euthanasia. I do believe that doctors should have rights when it comes to treating their patients, however their job is to take care of their patient in the way that is best for the patient. If the patient believes that their best outcome is assisted suicide, there should be a doctor readily available to assist in this process if it meets guidelines. I researched a similar topic, which is the modern stigma around euthanasia., specifically researching the cultural perspective. I found a lot of data in the Netherlands as well, but not from the actual physicians. I found data about the society and culture as a whole. I found this information interesting, as it revealed that almost half of the physicians reported feeling feelings of discomfort when assisting with physician assisted suicide.

  4. I really liked looking at this view on physician assisted suicide. It was interesting how religion was pulled into this discussion since many doctors have this as a reason for not aiding in physician assisted suicide. The other main reason for not assisting is because of the Hippocratic Oath and the role doctors have to save patients lives. I think in the end, the doctor has the right to refuse to help. I wonder if then the patient will go to another doctor or if the doctor that refused can refer them to someone that can help.

  5. Personally, I think this is one of the most touchiest subjects on the whole site and I give many props to tackling is the way you all have done, as I can assume during the creation of the post you have processed and considered your take on this. Overall, with physicians having a stressful job in itself, this is an added stress that can’t be ignored and could cause different problems and inflictions of mental health symptoms outside of their work that stems from grief and guilt. I think you all did a good job with pulling in major religious beliefs and how they affect the role of PAD in physicians and the patient’s life’s. I wonder how the idea of us being alive and having a purpose plays into PAD. To expand, regardless of illness the force we look to above us has us here a reason, disregarding pain that we may go through, so shouldn’t we power through and stick it out? I know that ethics, such as autonomy, definitely supports PAD in itself but being a religious person and a supporter of PAD due to ethics it is very contradicting. Can it also be seen as moral ethics for physicians to avoid PAD to support themselves and take a stance for their mental health and the damage agreeing to euthanasia can cause?

  6. The introduction captured my attention – what states allow this? Using religion to show the physicians decisions are being influenced by their beliefs strengthens this post. What exactly do the acronyms mean? From this article, I was able to learn that physicians have it difficult, in assisting death. Bringing in an article that was not American helps provide a global scale of this issue. I agree on the issue of the world constantly changing, especially in beliefs and how society views these issues. Usually, our first thought is the patient – what does the patient want? What will they go through? Doctors aren’t looked to what they believe so it was interesting getting this viewpoint and information.

  7. Given the research, it is evident that the psychological effects of PAD on the physicians are substantial. It is interesting to learn that the negative impact on doctors seems to stem from conflict with their religious ties or ethical concerns about the Hippocratic Oath, rather than the practice itself. This raises some questions for me: if the oath were to change, would the negative psychological impacts on doctors change as well? Aside from religious views, I think it would be interesting to analyze how societal norms around “assisted suicide” will be shifting in the near future as younger, more liberally-minded individuals take positions in politics, media, and medicine. I wonder if there will be more of a focus on the autonomy the practice gives to the patient. Personally, I believe that, although the goal of medicine is to preserve life, being able to help someone in need, even if that means the death of the patient, should be an option all doctors should provide.

  8. This point of view on physician assisted death is rather interesting. Typically, the point of view is from the patient looking at their access to physician assisted death based on physicians’ willingness to prescribe the drug. Often, the issue of morality and religion of the physician is considered when arguing about whether the physician should be required to prescribe the drugs or not. This post’s view of the issue from the perspective of how physician assisted death affects the physician is rather interesting. Tying this in with another post topic about the effect of patient death on physicians, physician assisted death amplifies that issue because not only do they watch their patient die, but they have a hand in accelerating the dying process rather than slowing it down.

  9. As society continues to develop, so do opinions about death and in particular, physician assisted deaths. Therefore, I think that the Hippocratic Oath serves as a gateway, a borderline to assess doctoral behavior. If a physician or a doctor wounded their patient unnecessarily, then they would be in violation of their oath and have caused harm to the patient. However, as people begin to take control of their own body, I believe that the Hippocratic Oath must be changed, or even discarded to support a new society.

  10. Great post. I appreciated how you all gave the historical background and emphasized different religions and cultural backgrounds and the impact that may or may not have on a physician’s support of PAD. It is amazing that almost 24% of physicians in the survey ya’ll site regret participating in PAD, and I really believe that that statistic alone deserves more attention and warrants more studies on the physician’s role in PAD and how it might impact him or her emotionally, spiritually, and at work where their main role is to prevent harm. This post does a good job of raising these key points, and I think PAD is one of the crucial ethical questions our society will have to deal with in the next few years. I also appreciated how this post delved into the complexities of the patient-doctor relationship.

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