The Right to Die: An Ethical Paradox
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Physician assisted suicide has strict eligibility requirements to ensure such a decision is determined voluntarily and competently. Arguments center on the ethicality of hastening death versus allowing illness to run its course. Reaching a decision to opt for physician assisted suicide as an end of life choice is done to avoid needless suffering or living in a hopeless condition. As the aging population of Americans increases, so does its demand for end of life needs. Nurses establish strong relationships with their patients, allowing for therapeutic dialogue and credible patient education. As legislation becomes enacted to protect physicians from legal action after fulfilling patient wishes, nurses ought to also receive legal protection. Inhibiting patient autonomy in end of life decision making constrains their personal freedoms. Use of advance directives is widely accepted when deciding to refuse life saving and life sustaining treatments, and could serve as a vessel to guarantee patient rights to dignified death are maintained.
The distinction between voluntary euthanasia and physician assisted suicide is that of administration. Physician assisted suicide requires that the patient self administers the prescribed medication, ensuring the patients intent and control in deciding to commit suicide (Harris, 2014, p. 2). Measures to legalize physician assisted suicide have been noted as far back as the early 1900s (Appel, 2004, p. 610). It wasn’t until 1997 that legislation was passed in the United States, legalizing physician assisted suicide through Oregon’s Death with Dignity Act (ORS127, 1997).
The Death with Dignity Act has specific terms that must be met to ensure legality. Before a patient’s eligibility requirements are reviewed, the patient must imitate the request verbally to a physician twice separated by at least 15 days and once in writing signed in front of two witnesses with no relation to the patient or their estate, the desire to obtain a lethal prescription with the intent to end one’s own life. To qualify, a patient must be over the age of 18, be a resident of California, Colorado, District of Columbia, Hawaii, Oregon, Vermont, or Washington, be declared mentally and emotionally competent by showing capabilities in communicating and decision making free of signs of depression, be diagnosed with an illness determined terminal leading to death within 6 months, and be capable of self administration of medication. Two physicians review and determine eligibility requirements. If either physician harbors concern about the patient’s motivations, such as through depression or coercion, the patient must be referred for psychiatric evaluation. Once requirements have been satisfied, either physician must inform the patient on options such as hospice or palliative care, as well as request the patient inform the next of kin of the lethal prescription request (‘Death With Dignity’, 2018).
The ethical tension surrounding the act of physician assisted suicide is nearly palpable, partially between patients and health care providers. Patients diagnosed with terminal illness face many difficulties. Pain and other physical symptoms, depression, powerlessness, and socioeconomic factors all impact what decisions patients make towards the end of their life. A concern of suffering through loss of independence and control over one’s circumstances minimizes one’s dignity. Many patients requesting death with dignity proclaim that there are some situations were a person’s suffering will only end with death (Gandsman, 2018). Health care providers and nurses in particular, harbor the heavy role of educating patients in end of life options. A nurse’s relationship with their patient and their effectiveness in communication provides the foundation to conversations regarding advanced directives, palliative care, hospice care, and death with dignity.
Ensuring patient rights and that care is centered on the patient is a key responsibilities of nurses. However, the right to die dilemma provides framework for debate on unnatural versus natural death. In opposition, many individuals proclaim the premise of playing ‘God’ while activists argue the right to die as a gift decided upon a rational individual deciding the right time to die. Ethical standpoints aside, both sides can agree that a request for physician assisted suicide provides a unique opportunity to open discourse to understanding the patient’s affliction. Such dialogue ought to aim to seek out what suffering and fears the patient is experiencing, thus minimizing feels of abandonment and maximizing respect for patient autonomy (Goligher et al, 2017).
Receiving a terminal diagnosis is earth shattering for patients and loved ones. Intense emotions as displayed in the five stages of grief are expected reactions. Many concerns about the future begin to surface, with fear and control being shared core issues. Most common fears in terminal patients include loss of independence, powerlessness, loss of dignity, pointless suffering, poor quality of life, and becoming a burden. Fearing the loss on control is centered in these worries. As individuals, patients have controlled the aspects of their entire lives, so naturally they desire controlling the circumstances of their own death. Minimizing suffering is the goal and maintaining meaningful life is a key aspect to health care. To fulfill the goal of minimized suffering during end of life is to achieve a good death. Death is recognized as good when preceded by a completed life and is allowed to occur voluntarily at the right time and place. A good death is peaceful, whereas bad death is resisted against and plagued with struggle (Gandsman, 2018).
At what point in a patient’s terminal condition does life’s positive feature become outweighed by the actual burden of living? Avoiding needless suffering or living in a hopeless condition is a necessary component to end of life decision making. When death is certain and imminent, those who elect for physician assisted suicide feel choosing death on their terms is more ethical than being obligated to wait and anticipate unpredictable suffering as their terminal condition progresses (Goligher et al, 2017). Respecting ones dignity in life ought to also translate to respecting ones dignity in life. In states without legal reform for death with dignity, a phenomenon of indirect euthanasia has emerged. During such circumstances patients are administered medications to reduce pain; both stated pain or perceived pain, with the understanding of the likeliness that these pain medications often hastened the dying process. This situation is rationalized by the notion of the doctrine of double effect which states that if something is done with intent of moral goodness but has a bad side effect; it is still considered ethically correct (Naro et al, 2017).
The population of Americans aged 65 and older rose from 8% to 12% between the years 1950 to 2000, and is expected to continue to rise to 20% by the year 2050 (‘Americans Are Living Longer’, 2015). As the average life expectancy in America continues to increase, America’s end of life needs also increase. Nurses are the on the frontlines when it comes to satisfying patient needs, and fill many roles in healthcare. Of these roles, patient educator is of the most crucial and impactful to the patient. Continued thoughtful interaction throughout patient care establishes strong nurse patient relationships, allowing nurses to serve as credible sources of patient education. As physician assisted suicide appears on more state ballots, nurses must be prepared to inform patients who begin inquiring about the right to die.
Physician assisted suicide discussions must be treated carefully, for initiation has the possible implications of coercion. Determining self awareness to personal beliefs on physician assisted suicide is essential for nurses to effectively discuss such difficult subject matter as terminal illness prognosis and progression. Chelsia Harris, a family nurse practitioner with a Doctor in nursing practice explored physician assisted suicide in her research, and suggests patients consider alternatives to physician assisted suicide. According to Harris (2014), ‘Empowering patients through education is key. Helping them create a living will and a durable power of attorney for healthcare can not only increase a patient’s autonomy and sense of control, but also improve quality of life’ (p. 3). Providing nonjudgmental education and compassionate care allows terminal patients the reassurance necessary to make choices they feel are best for what remains of their life.
Unfortunately nurses do face professional challenges in the physician assisted suicide process, that being nurses do not have a defined role. Legally dialogue occurs between physicians and patients once conversation is initiated by the patient, but not legal stipulations exist for nurses. Nurses have valuable assessment and interviewing skills allowing crucial collection of data to occur during the large amount of time nurses spend with their patients. Therapeutic, unbiased communication mixed with the physical presences of provided care fosters an environment of trust where patients can feel comfortable enough to discuss sensitive topics like end of life decisions. Often time’s nurses are the first to be approached about further health information, and nurses are typically the first to notice hesitation in decision making. Nurses continuously advocate for their patients, but it becomes difficult to support patients and properly educate when fear of legal repercussions loom (Julia, 2016).
Patient autonomy and decision making in treatment preferences and choices is thoroughly entangled with a person’s perception on their personal freedoms. Patients able to understand their diagnosis and its prognosis are in turn capable of making well informed, thoughtful decisions. (Gandsman, 2018). Informed consent is a key aspect to a patient’s individual freedom, and their right to decide the proper avenue of treatment per their own values. When treatment options are no longer curative, diminished suffering becomes the goal. Patients are encouraged when consenting to embark on palliative routes through passive plans of treatment towards end of life, however questioned when consenting on physician assisted suicide as an active route of treatment towards end of life.
Understanding what is personally important and valuable in one’s life is an essential component to making end of life decisions. It is the responsibility of health care providers to properly educate patients and loved ones on the choices available concerning end of life decisions. This enables patients to self reflect and evaluate what decisions are most appropriate to them. This patient centered care approach fulfills the specific needs and wishes necessary to achieve their desired health outcomes. To ensure a patients end of life decisions are carried through, many patients obtain an advance directive. Advance directives are helpful in that they include instructions on how to best carry out health care decisions if a patient is ever in a situation that inhibits their ability to do so. A living will is a type of advance directive that describes what medical treatments a patient does or does not want, such as dialysis, ventilators, or tube feedings (‘Types of advance directives’, 2016). Another aspect to advance directives is resuscitation code status. Patients can elect for a full code, all resuscitation attempts made, a chemical code, only pharmacological interventions are attempted, a do not intubate order, where all measures are taken but do not agree to intubation, and a do not resuscitate order, where no measures are taken.
Wide recognition and use of advance directives satisfies the voluntary requirement necessary in opting for physician assisted suicide. The autonomy allowed to refuse life saving and life sustaining treatments implies the right to choose assisted death. Advance directives offer a clear perspective to patient’s wishes and are written legally while still competent (Menzel & Steinbock, 2013). Patient desires are carefully considered when reviewing an advance directive, and provide clear, legal evidence to patient end of life wishes.
Words hold a heavy framework into how ideas are perceived. Suicide is riddled with negative influence and portrays a sense of hopelessness. By replacing the phrase physician assisted suicide, with physician assisted death, the emotion fiercely tied into the word suicide is loosened and becomes slightly less taboo. The actual act of committing suicide has been decriminalized, whereas physician assisted death performed where legislation has yet to be passed is a crime, thus assisting an individual to commit a legal act, in turn becomes illegal. Individuals electing suicide as a form of ending life commits to this act as an emotionally impulsive and irrational act. In comparison, physician assisted death has legal safeguards such as eligibility requirements, multiple physician evaluations, and mandated waiting periods, rationally considering current and future situations (Gandsman, 2018). As legislation becomes discussed and enacted, legislation must also exist for nurses. Continuing education classes would aid nurses in becoming prepared to properly inform patients and loved ones, and provide necessary strategies to such sensitive and challenging dialogue (Julia, 2016). The event of death is ultimately a private matter. If a patient decides that a faster death is necessary in the event of poor or unbearable quality of life, then it is the right of the patient to maintain one’s personal view of life and death. Ensuring individuals have the right to a dignified life implies they in turn have the right to a dignified death (Naro et al, 2017).