Paliation, Hospice, and Autonomy in the Debate on Physician-assisted Suicide

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Introduction

It is with increasing frequency that physicians in the United States and throughout the world are asked to participate in ending the lives of their patients.  Abortion and physician-assisted suicide are two issues that illustrate the expectation that physicians will participate in intentional life-ending activities.  They differ, however, in the potentiality of the life in question.  In the case of abortion, the early life of the embryo or fetus is destroyed by the will of the mother, though if given the proper environment and there are no abnormalities, the child has potential for a full, productive life.  At the other end of life’s spectrum, an increasing number of states have enacted laws to permit physician-assisted suicide.

Stories of patients suffering with inadequate pain relief and fear of loss of one’s autonomy are drivers for support of physician-assisted suicide legislation.  The medical specialties of palliative and hospice care have transformed care for those with chronic and terminal illnesses.  Palliative care provides an excellent alternative to physician-assisted suicide to address concerns of the chronically and terminally ill.

A Biblical View of Illness and Death

 Scripture speaks to life and end of life issues and the value God places on those made in his image.  As Fedler explains, humankind made in the image of God is the central theme of biblical faith.[1]  The psalmist asks God the question, “What is mankind that you are mindful of them, human beings that you care for them?”  (Psalm 8:4 NIV).  The psalmist then exclaims, “You have made them a little lower than the angels and crowned them with glory and honor,” (Psalm 8:5 NIV).   God has given humankind high standing and is watchful over us.  The concept of God being “mindful” of man is further illustrated by the scripture, “…for whoever touches you touches the apple of his eye...” (Zach. 2:8 NIV).  The eye does not like to be touched, and many reflexes are in place to prevent this sensitive thing from happening.  Likewise, God is very sensitive to anyone “touching” one of those made in his image.

 Does the time of our death matter to God?   The earliest stories of man’s interactions with each other include Cain’s murder of his brother Abel.  Though Cain thought the act was done in secret, God’s response was, “What have you done? Listen! Your brother’s blood cries out to me from the ground,” (Gen. 4:10 NIV).  There are many verses that condemn one person putting another to death.  One of those is, “Anyone who takes the life of a human being is to be put to death,” (Lev. 24:17 NIV).  Our societal laws reflect the value of human life and severe consequences for taking another’s life.

 The despair associated with severe infirmity is illustrated in the book of Job.  One illustrative statement is, “…to those who long for death that does not come, who search for it more than for hidden treasure,” (Job 3:21).  Job expresses a wish for escape when he said, “…I prefer strangling and death, rather than this body of mine,” (Job 7:15).  Though he was great man of faith, he was suffering physically and psychologically.  His condition seemed endless and without hope, but he did eventually recover.  Even if he had not recovered, he was steadfast in maintaining his faith as evidenced by the statement, “I know that my redeemer lives, and that in the end he will stand on the earth, And after my skin has been destroyed, yet in my flesh I will see God;” (Job 19:25-26), so he had the moral courage to fight the battle of his illness.

The Hippocratic Heritage

 The Hippocratic Oath has been the foundation for understanding the role and duty of a physician from the time of the ancient Graeco-Roman world until today.  In the past decades, the principles of the Oath have come into question, specifically over the prohibition of participating in abortion and giving poison for taking one’s life.  As Cameron explains, the Greek culture was pluralistic, and the Oath outlined a specific philosophy in favor of life that Hippocratic physicians would adhere to.  It is also important to note that a standard was set that was different than marketplace demands.[2]  Some consider this paternalistic, as the physician was expected to stay true to the Oath, even if it contradicted the patient’s expectation.

 The Hippocratic philosophy is still very instrumental in defining expectations of physician behavior.  Though the oath establishes a sacred trust to maintain the patient’s secrets, it is understood that when a life hangs in the balance, protecting life trumps privacy.[3]  Examples include patients disclosing a plan for self-harm or for harm to another.[4]  The physician has an obligation to obtain care for the patient against the patient’s will or to notify authorities if someone is in harm’s way.  Though the confidence of the patient is sacred, protecting life is a higher obligation.

The Discipline of Bioethics

 There has been an evolution in medical care options since World War II.  Advances in antibiotics, medications for numerous conditions, organ transplantation, and life-sustaining technologies such as ventilators, dialysis and organ transplantation revolutionized the practice of medicine.  In the decades following the war, although physicians were able to treat the previously untreatable, the advances permitted those who would have died earlier to languish without cure.  Physicians were faced with excruciating decisions on how to allocate scarce resources.  Discussions on how to meet the new challenges in medicine included input from physicians, scientists, theologians, philosophers, legal experts and sociologists, and the discipline of bioethics was born.[5]

 Religious influence was important in the initial framework of understanding bioethics, but this was followed by an “enlightenment period,” when a secular approach to bioethics was developed and became more prominent than a theological perspective.  Ethical theories were primarily viewed from a deontological or utilitarian perspective and guiding principles were developed to address the types of situations faced by the medical community.  Four primary principles to use in biomedical decisions were identified as follows: 1) autonomy; 2) non-maleficence; 3) beneficence; and 4) justice.[6]

Arguments in Favor of Physician-Assisted Suicide

 The growing public support for physician-assisted suicide is evidenced by an increasing number of states that have passed or considered legislation permitting it.  Oregon’s Death with Dignity Act was the first of its kind in the United States, passed in 1997.  Patients must be able to ingest the medication themselves and qualify for consideration if they have a terminal condition with an estimated six months or less to live.  Euthanasia is not permitted.  Since then, the United States has a total of eight states with legislation permitting physician-assisted suicide, and one state that will not prosecute physicians participating.

 Autonomy is one of the most important arguments in favor of physician-assisted suicide.  Hollinger explains that for those who merely see physician-assisted suicide as a choice, morality is removed from the debate.[7]  For these individuals, autonomy the most important factor in a patient’s decision.

 The philosopher Peter Singer has written extensively on life and death issues.  He promotes personhood theory, believing that the value of human life varies[8] depending on their ability to interact with their world and their intelligence.  He believes there are animals that exhibit some characteristics of human beings more than some humans do, therefore should be considered persons and also have a right to life.[9]  Singer states, “The new vision leaves no room for the traditional answer to these questions, that we human beings are a special creation, infinitely more precious, in virtue of our humanity alone, than all other living things.”[10]  He believes we should respect a person’s desire to live or die,[11] so supports full autonomy of the patient.  He rejects the sanctity of human life arguments and believes there should be no reason to deny a request for physician-assisted suicide.

 On the question of the appropriateness to hasten death actively, Rachels makes the case that there is no substantial difference between acts of omission (to let someone die) than allowing acts of commission (to provide active euthanasia).  He states, “….once the initial decision not to prolong his agony has been made, active euthanasia is actually preferable to passive euthanasia, rather than the reverse.”[12]  His greatest priority is relief of suffering, and if active euthanasia provides relief, then it should be permissible.  Hulse agrees with the opinion that there are situations where killing someone is preferred over letting die, but only when the motivation of the physician (or those helping) is the good of the patient and not for the benefit of the “helper.”[13]

 Death with Dignity is an organization with a mission “to promote death with dignity laws based on our model legislation, the Oregon Death with Dignity Act, both to provide an option for dying individuals and to stimulate nationwide improvements in end-of-life care.”[14]    The organization objects to the term “suicide” being used for legislation regarding end of life options because, “Physician-assisted dying isn’t suicide legally, morally, or ethically.  Patients already are dying and therefore are not choosing death over life but one form of death over another.”[15]  The organization argues that semantics matter, and opponents to physician-assisted suicide agree on this point.

 Another organization promoting physician-assisted suicide is Compassion in Choices.  Their website makes this statement, “Medical aid in dying is a safe and trusted medical practice…”[16]  The website offers free consultations for patients exploring end of life options, and testimonials about why the authors or their loved ones have chosen or would have chosen to ingest a lethal prescription.  In addition to physician-assisted suicide, it offers information on advanced directives and understanding end of life treatment options.

 Both websites feature stories of patients who had intractable suffering at the end of their lives, or felt they were more aggressively treated than they would have wished to have been.  Clearly, giving patients appropriate informed consent and having physicians who are ready to admit when care is futile is important to adequately care for patients with terminal illness.

Physician-Assisted Suicide: What Professional Medical Organizations Have to Say

 Though proponents of physician-assisted suicide call it “safe” and “trusted”, most physicians will define safe medical practices as those which promote health and well-being, and unsafe practices those that lead to increased patient morbidity and death.  It is not conceivable to declare a “safe practice” one that precipitates a patient’s death, nor does a conscientious physician “trust” a practice that causes loss of life. 

 The American Medical Association(AMA)reaffirmed its physician-assisted suicide policy at the AMA House of Delegates meeting in 2019, which includes this statement:  “Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.”[17]  The largest organization representing physicians in the United States, the AMA, remains opposed to the concept that facilitating death at the end of life is medical care. 

 Physicians spend many years and untold hours learning about the human body, dedicating themselves to promoting health and curing disease.  It only takes minutes to learn how to write a lethal prescription to end a patient’s life.  What qualifies physicians, in their training, to determine when it is appropriate for a patient to take their own life?  Physicians are trained to fight disease and extend life, not to help determine the right time for a patient’s death.  If one suggests that the patient should be the sole determiner of the time of their death, then why is the physician needed at all?  If the physician is a contractor obligated to comply with the wishes of the patient under the principle of patient autonomy, then the many years of medical training to determine the best course of treatment are unnecessary.  To call writing a lethal prescription “medical care” runs contrary to multiple millennia of medical tradition.

 In 2017, the American Osteopathic Association (AOA) reviewed a resolution to change the Osteopathic Oath, which contains the phrase, “I will give no drugs for deadly purposes to any person, though it be asked of me.”[18]  The resolution addressed a concern that osteopathic physicians may be asked to decide between following the Osteopathic Oath (not providing lethal prescriptions to terminal patients), or to follow laws of the states that permit physician-assisted suicide.  The resolution to change the phrase to “I will give no illegal drugs though it be asked of me,” was defeated.[19]  Official policy of the organization maintains the original phrase in the oath against the administration of deadly medications.

 Both the AMA and the AOA, the professional organizations representing physicians with unlimited licenses to practice medicine in the United States, have recently taken action to reaffirm opposition to the practice of physician-assisted suicide as part of medical care. 

A Case for Palliative Care

 Hospice and Palliative Care are relatively new subspecialties in the practice of medicine, having received approval from the Accreditation Council on Graduate Medical Education (ACGME) to develop fellowship training programs in 2006.[20]  Palliative care is defined as care for patients and families to provide relief from pain and other symptoms, and support quality of life for those with serious advanced illnesses.  Hospice, on the other hand, provides palliative care to patients and families with limited life expectancy.[21]

 The goal of palliative care is to keep a patient living and able to enjoy those activities that mean most to them despite chronic or terminal disease, and is intended neither to hasten or postpone death.[22]  This includes excellent pain management and partnering with the patient to determine how much pain relief is needed without compromising the patient’s ability to participate in the most important activities to them.  Hospice’s more narrow focus of care during the last six months of a terminal condition may cause patients and families to resist committing to the services.  Palliation, on the other hand, does not carry the same stigma.

 Intractable pain is often used as an argument in favor of physician-assisted suicide.  Appropriately applied palliative care addresses adequate pain relief in most cases.  The use of opioids is considered appropriate and in doses higher than what would be acceptable in a non-terminal condition.[23]  Concerns of the addictive nature of the drugs is not an issue in the terminal patient, though patients may resist the medications for that reason.  Patient and family education to understand the appropriate use of analgesia is important.  Sedation can be employed for intractable pain.[24]  As the practice of palliative and hospice care continue to improve, and available services become better known, one would expect fewer people to choose physician-assisted suicide as their preferred option.

Autonomy:  An Absolute Right?

 The bioethical principle of autonomy is a central point of debate on physician-assisted suicide.  The State of Oregon has the longest record of physician-assisted suicide in the United States, passing their legislation in 1997.  The state produces an annual report of the characteristics of those participating.  It is noteworthy that in the most recent report the most commonly stated reasons to ask for a lethal prescription are:  1) fear of loss of autonomy (91.7%); 2) less able to participate in enjoyable activities (90.5%); and 3) loss of dignity (66.7%).  Fear of inadequate pain control was only 25.6%,[25] though it is frequently cited as the rationale for physician-assisted suicide.  Loss of autonomy is the single greatest driver of the request for a lethal prescription.

 Depression is a common finding in patients with chronic disease, and patients who are depressed are more likely to want to end their lives.  Depression is also common in the elderly, one article estimating the incidence between 34% and 38%.[26]  Of the patients who died under the Oregon Death with Dignity Act, the median age was 74, so it can be presumed that a similar percentage had depression.  The report tracks how many patients were referred for psychiatric evaluation.  During 2018, 249 prescriptions were written, and 168 patients died secondary to ingesting lethal medication.  Of those that died, only three were referred for psychiatric evaluation.[27]  Given the incidence of depression in the elderly and those with chronic diseases, one would expect the rate of those who had depression to be significantly higher than the number referred.  Patients with depression may have chosen another course had their underlying psychiatric conditions been appropriately treated. 

 The principle of liberty as understood by the United States founding fathers was not an unfettered right to do whatever one wants, but the ability to choose to do what is right, and that a liberal democracy can only function with a moral people.[28]  Today, autonomy has “run amok” as individuals exercise their rights as absolutes without consideration for the impact on society or what should be done for the greater good.[29]

Conclusions

 For those who believe humans were made in God’s image, that humans have inherent value for this reason, and that the timing of one’s last breath is in God’s hands, physician-assisted suicide has no place in patient care.  Death with dignity is always guaranteed, because all humans have dignity by virtue of having been made in the image of God, no matter what the circumstances of their last days.

 Excellent palliative care can relieve the despair that may overtake even those with deep reverence for and faith in God.  The modern practice of palliation allows access to pain relief and strategies that permit life to be lived to the fullest possible until the last natural breath.  This includes supportive strategies to help patients live while they are dying, and help families better support their loved ones.  Those who fear pain and loss of ability to enjoy life are less likely to choose physician-assisted suicide when excellent palliation is available.

 For those who connect human dignity to their physical appearance or activities, excellent palliation is not likely to give them the control they desire.  The temptation of original sin, “…you will be like God…” (Gen. 3:5) applies when individuals take upon themselves decisions that belong to God, like the timing of their own death.  These individuals may not realize or value the contributions they can still make to their loved ones and society despite their condition, and how their lives contribute to the greater good.  Advocates of physician-assisted suicide say that the term “suicide” is inappropriate, as one is just hastening inevitable death.  The definition of suicide does apply as it is the taking of one’s own life before natural death.  Giving it a different name does not change the intent or the action.  By promoting the philosophy that for those near death the remaining hours, days, weeks or months still available are inconsequential, a class of people is created that are as good as dead, or those who have “lives not worth living.”[30]  The desire for ultimate autonomy by those with this philosophy cannot be met with palliation.

 The utilitarian argument that one’s value is based on perceived contribution to society has wreaked immeasurable havoc in the past, as evidenced by the atrocities committed by Nazi physicians during World War II.[31]  As the 19th century philosopher Georg Wilhelm Friedrich Hegel stated, “But what experience and history teach is this, - that peoples and governments never have learned anything from history, or acted on principles deduced from it.”[32]  As our culture moves further down the path of utilitarianism in measuring the value of human life, and as autonomy becomes out of control, we would be wise to take a careful look at where this path has led before.

Bibliography

  • Cameron, Nigel M de S. The New Medicine:  Life and Death After Hippocrates. New Edition. Chicago & London: Bioethics Press, 2001.
  • Committee on Approaching Death: Addressing Key End-of-Life Issues. Dying in America:  Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: National Academy Press, 2015.
  • Fedler, Kyle D. Exploring Christian Ethics: Biblical Foundations for Morality. Kindle. Louisville, Kentucky: Westminster John Knox Press, n.d.
  • Hegel, Georg Wilhelm Friedrich. Lectures on the Philosophy of History /. London :, 1857. http://hdl.handle.net/2027/uc1.$b288580.
  • Hollinger, Dennis. Choosing the Good:  Christian Ethics in a Complex World. Grand Rapids: Baker Academic, 2002.
  • Jonsen, Albert R. A Short History of Medical Ethics. New York: Oxford University Press, 2000.
  • Kuhse, Helga; Schüklenk, Udo; and Singer, Peter. Bioethics. Third. West Sussex, UK: Wiley Blackwell, 2016.
  • Ozaki, Yaeko, Andrea Plácido Borges Sposito, Denise Ribeiro Stort Bueno, and Maria Elena Guariento. “Depression and Chronic Diseases in the Elderly” (2015): 5.
  • Rae, Scott B., and Paul M. Cox. Bioethics:  A Christian Approach in a Pluralistic Age. Wm. B. Eerdmans Publishing Co., 1999.
  • Singer, Peter. Rethinking Life and Death. New York: St. Martin’s Griffin, 1994256.
  • “A Framework for Generalizability in Palliative Care- ClinicalKey.” Accessed August 4, 2019. https://www-clinicalkey-com.proxy.pnwu.org/#!/content/journal/1-s2.0-S0885392408004387.
  • “About Us.” Death With Dignity. Accessed August 4, 2019. https://www.deathwithdignity.org/about/.
  • “H332 - AOA HOD Osteopathic Oath Resolution Defeated.,” n.d.
  • “Medical Aid in Dying Is NOT Assisted Suicide.” Compassion & Choices. Accessed August 4, 2019. https://compassionandchoices.org/about-us/medical-aid-dying-not-assisted-suicide/.
  • “Oregon Death with Dignity Act Annual Report 2018,” n.d. https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year21.pdf.
  • “Osteopathic Oath.” American Osteopathic Association. Accessed August 4, 2019. https://osteopathic.org/about/leadership/aoa-governance-documents/osteopathic-oath/.
  • “Physician-Assisted Suicide.” American Medical Association. Accessed August 4, 2019. https://www.ama-assn.org/delivering-care/ethics/physician-assisted-suicide.
  • “Privacy in Health Care.” American Medical Association. Accessed August 4, 2019. https://www.ama-assn.org/delivering-care/ethics/privacy-health-care.
  • “Terminology of Assisted Dying.” Death With Dignity. Accessed August 4, 2019. https://www.deathwithdignity.org/terminology/.

[1] Kyle D. Fedler, Exploring Christian Ethics: Biblical Foundations for Morality, Kindle. (Louisville, Kentucky: Westminster John Knox Press, n.d.), Kindle loc 1167.

[2] Nigel M de S. Cameron, The New Medicine:  Life and Death After Hippocrates, New Edition. (Chicago & London: Bioethics Press, 2001), 28.

[3] “Privacy in Health Care,” American Medical Association, accessed August 4, 2019, https://www.ama-assn.org/delivering-care/ethics/privacy-health-care.

[4] Kuhse, Helga; Schüklenk, Udo; and Singer, Peter, Bioethics, Third. (West Sussex, UK: Wiley Blackwell, 2016), 604.

[5] Albert R. Jonsen, A Short History of Medical Ethics (New York: Oxford University Press, 2000), 99–100.

[6] Scott B. Rae and Paul M. Cox, Bioethics:  A Christian Approach in a Pluralistic Age (Wm. B. Eerdmans Publishing Co., 1999), p 54-55.

[7] Dennis Hollinger, Choosing the Good:  Christian Ethics in a Complex World (Grand Rapids: Baker Academic, 2002), Loc 121.

[8] Peter Singer, Rethinking Life and Death (New York: St. Martin’s Griffin, 1994256), 190.

[9] Ibid., 202–206.

[10] Singer, Rethinking Life and Death, p. 183.

[11] Ibid., 197.

[12] Kuhse, Helga; Schüklenk, Udo; and Singer, Peter, Bioethics, p. 249.

[13] Ibid., pp 257-259.

[14] “About Us,” Death With Dignity, accessed August 4, 2019, https://www.deathwithdignity.org/about/.

[15] “Terminology of Assisted Dying,” Death With Dignity, accessed August 4, 2019, https://www.deathwithdignity.org/terminology/.

[16] “Medical Aid in Dying Is NOT Assisted Suicide,” Compassion & Choices, accessed August 4, 2019, https://compassionandchoices.org/about-us/medical-aid-dying-not-assisted-suicide/.

[17] “Physician-Assisted Suicide,” American Medical Association, accessed August 4, 2019, https://www.ama-assn.org/delivering-care/ethics/physician-assisted-suicide.

[18] “Osteopathic Oath,” American Osteopathic Association, accessed August 4, 2019, https://osteopathic.org/about/leadership/aoa-governance-documents/osteopathic-oath/.

[19] “H332 - AOA HOD Osteopathic Oath Resolution Defeated.,” n.d.

[20] “A Framework for Generalizability in Palliative Care- ClinicalKey,” accessed August 4, 2019, https://www-clinicalkey-com.proxy.pnwu.org/#!/content/journal/1-s2.0-S0885392408004387.

[21] Committee on Approaching Death: Addressing Key End-of-Life Issues, Dying in America:  Improving Quality and Honoring Individual Preferences Near the End of Life (Washington, DC: National Academy Press, 2015), 7.

[22] Ibid., 58.

[23] Ibid., 415.

[24] Ibid., 449.

[25] “Oregon Death with Dignity Act Annual Report 2018,” n.d., https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year21.pdf.

[26] Yaeko Ozaki et al., “Depression and Chronic Diseases in the Elderly” (2015): 5.

[27] “Oregon Death with Dignity Act Annual Report 2018.”

[28] Rae and Cox, Bioethics:  A Christian Approach in a Pluralistic Age, 201.

[29] Ibid., 198.

[30] Cameron, The New Medicine:  Life and Death After Hippocrates, 71.

[31] Ibid., 69–84.

[32] Georg Wilhelm Friedrich Hegel, Lectures on the Philosophy of History / (London :, 1857), p 6, http://hdl.handle.net/2027/uc1.$b288580.

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