Physician Assited Suicide: A Policy And Analysis Essay, Research Paper

Policy on Physician Assisted Suicide

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St. Wildes Medical Center, Georgetown University

Washington, D. C.

Submitted By Elinor Bazar & G. Konrad Brown

April 11, 2000

Introduction

The mission of this hospital is rooted in our emphasis on the individual, and directed toward providing the highest level of autonomy, beneficance, comfort, healing, privacy and respect for the dignity of the patient. With these as our guiding principles, we evaluated Physician Assisted Suicide (PAS) as a possible treatment option at this institution. We have concluded that PAS can be a viable treatment option after making the following considerations: 1. Defing the elements of justified PAS, 2. Consideration of moral justifications, 3. Why personal autonomy is important, 4. Informed consent, and 5. The benefits of the approach of causitry to issues of biomedical ethics. The elements of PAS are an agreement between a physician and the patient on the treatment option after consideration of all other options, (informed consent) conditions consistant with the Oregon state law and the asurance of the agent choosing this course of action in an autonymous nature. Moral arguements question the validity of PAS as an option. We make the determination that PAS can indeed be considered equivelent to other medical decisions regarding whether or not continue treatment in cases where the prognosis is immenent death, or prolonged intense suffering followed by death. If for example, a patient with a terminal illness such as lung cancer has a choice between hospice care, and being made comfortable, or PAS, we can not say that the two approaches are inconsistant with eachother. A patient who refuses treatment and accepts death as a consequence has the right self determination by law. If this action is acceptable under law, it is not unfair to consider PAS as an equivelent means to the same end. Therefore, there will be cases where PAS is most certainly a valid option for the patient. To reach our decision, it is important to understand our view of personal autonomy. We will elaborate on it’s relevance and worth in addressing PAS. Finally, criteria for PAS candidates is intricate, and established. Though we justify PAS as a viable treatment option, we do not take issue with the legal criertia established by the state of Oregon.

Personal Autonomy

Personal autonomy can be characterized as self-determination or the the extent to which an individual actively participates in in how his or her life is lived. Autonomy, therefore, requires some elements of control and choice. Defining autonomy in a being that is both rational and passionate can prove complex and problematic. A differentiation of first and second order volitions will help us conclude the what the exact nature of what defines autonomy. First-order desires are those passions to which the agent is subject to as a living being. The desire to live, procreate, feel secure and content are some examples of these desires. While they are certainly expressions of human passions, they do not account for man’s rational capacity, a fundemental facet of human nature. Second-order desires are wants about wants, or the desire to have certain desires. We will focus, however, on second order volitions, which differ from second order desires. Second order volitions involve the wish of an individual that certain first-order desires will motivate him to action. It is the rational choice of the agent which characterizes this, and therefore we will conclude that second-order volitions represent contemplation of a choice by the agent, which leads to a choice that by virtue of this process, is an indication of his true-self. Therefore, it is through these second-order volitions that we exercise autonymous action.1 The expression of rational choice in relation to a first-order desire is what we will define as the main component of an autonymous action.

There are those who would oppose this view in lieu of other moral considerations. If the agent has a lack information, or choices, the action in relation to the first-order desire is then no longer autonymous. Therefore, we will require that another dimension to autonomy is the range of options availible to the agent. In order to promote autonomy, it is absolutely essential that informed consent is a focal point of treatment. It is the concept of autonomy which is our guiding force in our formulation of a policy on PAS.

PAS as a treatment option has no universal application. In Oregon, where it is legal, two patients with the same doctor, the same illness and the same prognosis can make opposite decisions regarding treatment. If one patient simply chooses to wait for death to occur after stopping treatment, and the other chooses PAS, both of these autonymous actions are therefore equal. They have the same end, and individual considerations of quality of life, and an array of potential first-order desires explain the difference in choices. Therefore, it is the execution of the choice by the informed agent which constitutes the autonymous decision. With personal autonomy as the primary consideration, the patient then has the right to PAS as a treatment option, and denial is deprivation of self-determination. (Indeed this constitutes deprivation of freedom, which is intrinsically wrong, and contrary to the patients natural right to self determination.

PAS in a Clinical Setting

In relation to PAS, the agent must act “1) intentionally, 2) with understanding, and 3) without controlling influences that determine their action.”2 As an institution concerned with autonomy as a central right of the patient, we are supporters of requested withdraw of treatment (as well as PAS,) as there is no difference in the matter of allowing to die and killing. Killing is any form of “deprivation or destruction of life”, and allowing to die is “intentional avoidance of causal intervention so that a natural death is caused by a disease of injury,”3 which in itself is deprivation. Therefore, there is no distinction between allowing to die and directly intervening to bring about a patient’s death.

Moral Jusifications

Compassion is a focal virtue in our practice. Compassion is defined as a feeling of profound sympathy and sorrow for another who is affected by misfortune, accompanied by a strong desire to ease the suffering. Sometimes in healing the terminally ill suffering from profound pain, assisting the patient in suicide is the only means of alleviating his/her suffering. Those who oppose PAS are not subject to judgement or coercion. PAS is a matter of choice and is not an alternative to be suggested by the physician. It is a procedure which is only regarded among request and acute investigation thereafter. Patients are protected from non-voluntary euthanasia because, again, physicians will only address the option of PAS upon the request of the patient and the physician cannot physically be the cause of the death (euthanasia). No actions will act out of accordance with such, especially in situations of life and death.

It is clear that opposition to PAS is rooted in the execution of normative judgements, which object to the action unequivically and universally. This view neglects the secular and universal standard of self-determination and autonomy in patient care. This is not a criticism of religous institutions which find PAS intrinsically wrong. The standard which we adhere to leaves these considerations in the hands of the agent and physician.

Central to the hypocratic oath is the principle of beneficance, which holds that the physician is obligated to act in the agents best interest. As technology has increased and advances have been made, what constitutes beneficance in any given action is becoming trivial; quality of life issues and painful but successful treatments have clouded what constitutes beneficance to the point that the 1960s saw the emergence of Biomedical Ethics as a field. Indeed it is difficult to simply decide whether or not PAS should be considered universally a medical treatment or universally suicide. Rather than make this judgement, we hold that it is not a black and white issue, and that right action through policy requires consideration of all applications and scenarios. We further offer that causistry, or the evaluation of correct choice on a case by case basis, is essential to any approach hoping to yield just results.

Requests to Withdrawl Treatment

“[Any] person who is above [18 years old] and of sound mind has the right to exercise control over his/her body.”4(p.279). This implies a right to refuse medical treatment even if the deprivation of treatment results in death. The right to refuse treatment is fundamental to principles of autonomy such as privacy. Therefore, this rule is not conditional, and all requests for treatment withdrawal are honored upon completion of an informed consent. This particular type of informed consent acts independent of any previous informed consent (particularly ones such as advanced directives which will be spoken about in the next section) and only pertains to the task at hand. The document affirms that the physician and the patient had a discussion about the consequences and benefits of withdrawing from treatment as well as those with proceeding of treatment. It will also affirm that the physician told the patient all possible alternatives to the situation and all the patient’s questions were answered and understood. Most importantly, the patient has a sufficiently clear understanding of the situation in its entirety.

Upon association with our hospital, all competent persons are encouraged to fill out an advanced directive indicating “treatment directives (documents such as a living will stating the person’s treatment preferences in the event of future incompetence), proxy appointments (documents such as a durable power of attorney appointing a proxy decision maker), or both.”5 This hospital makes a continuing effort to educate patients about directives and, most importantly, to educate physicians in their obligation to honor them. Because there is room for interpretation and the advanced directives are not always case sensitive, a decision regarding treatment withdrawal will be one that proceeds from a collaboration of the proxy’s views and the patient’s preferences stated on the advanced directive. In cases of incompetence where no advanced directives exist, the legal right of the patient to consent to any procedures is handed over to the next of kin. If there is no next of kin, the attending physician will use his sound judgement to assess the situation.

Continuing Treatment When There is No Hope For Recovery

It is the belief of this institution that mere quantity of life does not eventuate in quality of life. The desire to continue treatment when there is no hope for recovery is indicative of fear in the patient. Healing is key to the mission of our hospital. Therefore, diminishing fears in our patients, particularly fears involving such natural processes as life and death, is of surmounting importance. In such cases, we will do everything possible through palliative care to assess the spiritual, emotional, and mental needs of the patient while we continue to respect the autonomous decision of the patient to continue treatment when there is no hope for recovery. In cases where the individual is deemed incompetent, the advanced directive of the patient should be honored if one exists. Otherwise, the decision will be handed over to the next of kin. This will be treated similarly to the previous competent-patient-decision process in that if the decision is fear-based then palliative care will be appropriated to ensure the most accurately desired procedure. A beating heart or a pair of working lungs does not assert an individual among the living, rather consciousness is what distinguishes an individual as alive. Lawrence O. Gostin assesses the Cruzan case stating that, “when asked, very few people would choose to be kept physically alive when all conscious life is over.” Particularly in cases of perpetual vegetative state (PVS), where all consciousness is gone, our hospital does not agree with life prolonging procedures and therefore will perpetuate palliative care among decision makers, whether it is the next of kin, or the attending physician. Although each case is different and should be assessed individually, the general view of the hospital stands.

REQUESTS FOR PHYSICIAN ASSISTED SUICIDE (PAS):

In accordance with The Oregon Death and Dignity Act, terminally ill adult Oregon residents are permitted to request drugs from their physician with the intent to end his/her life. This act ensures the removal of any criminal penalties for qualifying physician-assisted suicides. All of the following strict guidelines are pertinent to a qualifying PAS:

1) physicians predict patient’s death within 6 months;

2) the patient makes 3 requests for PAS, 2 oral, and 1 written;

3) 15-day waiting period after requests;

4) second physician’s opinion; and,

5) counseling if either physician believes that the patient has a

mental disorder or impaired judgement from depression.

It is our view that meeting this criteria, PAS has a stong case for legitimacy as a medical procedure and treatment option.

Conclusion

Implementation of PAS as a legal medical treatment in Oregon aroused the passions of so many. As the public debate continues, and as other initiatives work their way through state legislatures, it is clear that their is no answer that will apease both sides of this very difficult issue. As caregivers, it is essential to take a much longer consideration. In order to find what we believe to be the right approach to PAS by an institution, it was inevitable that we had to make a clear decision regarding what principles were to guide us. Compassion and beneficance are required. They are also desired; every caregiver wants to help his patient, deliver treatment with excellence, compassion, and with the intent of beneficance. These principles in and of themselves require us to consider their purpose: the benefit of the agent. With this, we hold that autonomy is the expression of the human self. It is the manifestation of human rationality, and therefore, should be held in the highest regard. The right to self determination is the key to this. As we hold this as our central virtue, it follows that beneficance in any action is contingent upon upholding personal autonomy. Violation of this constitutes deprivation of freedom, and is in turn, intrinsically wrong.