Physician-Assisted Suicide Must Be Legalized
Sheryl Tello
GEN 499
Prof. David Ward
March 14, 2014

Physician-Assisted Suicide Must Be Legalized Imagine that you just received a phone call from your physician’s nurse and she told you that the doctor wants to see you right away. When you ask her what is the problem; she tells you that it would be best if you came into the office as soon as possible. You tell her that there is no way that you can come in until next week; she asks if you can hold for a minute while she relays the message to your doctor, and the next thing you know your physician is on the phone and tells you that he wants to see you today. You try to rationalize everything that your physician could possibly tell you. Then you tell yourself that it cannot be too bad because you have always taken good care of your body, you eat right, you get plenty of exercise, and you see your doctor once a year. At the doctor’s office, the doctor informs you that there is no easy way of telling you that a large amount of cancer cells have been found in your blood work. As you try to speak, he continues to inform you that the cancer cells have completely taken over your blood and have migrated to your vital organs. As you try to speak again, he interrupts you one more time, however, this time it is to deliver the final blow; you only have six weeks left to live, which you will surely spend in extreme pain and unremitting suffering as your body goes into complete organ failure. Would you not want the option to end your pain and suffering and die with at least a little dignity? This is what physician-assisted suicide (PAS), if legalized, would offer terminally ill patients. The strongest argument made on behalf of the legalization of PAS is that it, like abortion, it is a choice issue. Proponents continue to argue that PAS is the ultimate civil right, and to deprive mentally competent, terminally ill people who want to end their suffering of a peaceful aid in dying is to fundamentally disrespect their right to personal autonomy. Proponents also argue that legalizing PAS is necessary to insure that no one dies in painful agony and unremitting suffering. Advocates contend that there is very little difference between PAS and pain control since both use strong drugs and a patient’s death may be unintentionally hastened as a side effect of the narcotics used in palliative care. They also claim that doctors commonly engage in PAS surreptitiously and promote legalization as a way to protect vulnerable patients from abuses inherent in current unregulated practice. By acknowledging the worries over potential abuses, advocates assure that protective guidelines would be put into place that would protect the vulnerable from wrongful death while still allowing the terminally ill who are eligible for PAS to obtain a desired, peaceful death with dignity. Proponents also claim that opposition to PAS is primarily based in religion and therefore the laws prohibiting the practice are unconstitutional because they violate the division between the church and the state (Bonin, 2012). Opponents on the other hand believe that the legalization of PAS would surely lead society down a dangerous slippery slope that will eventually permit the legalized killing of the disabled, the elderly, and people who are depressed, as well as the mentally incompetent. They say that protective guidelines will not protect these people. Opponents also argue that the economics of modern medicine will promote PAS as a form of health care cost containment, noting that the drugs used in PAS are a lot cheaper than the cost of providing palliative care to the terminally ill. Opponents also note that more than 44 million Americans do not have any form of health insurance; and that medicine is sometimes practiced in a discriminatory manner against certain minorities. It is for this reason that opponents argue that the last people to receive medical treatment will be the first people to receive PAS. They also deny that there is widespread surreptitious PAS practiced in medical clinics, and urge that hospice care along with the proper medical treatment provide a morally acceptable answer to the pain and suffering that is sometimes associated with the process of dying (Pereira, 2011). While these arguments continue with no end in sight, more and more of the terminally ill cry out in agony, for the right to end their suffering. Terminally ill patients do not have a lot of options when it comes to ending their pain and suffering. The addition of just one more option can contribute to the psychological comfort of a terminally ill patient. In the article, Physician-Assisted Death in the United States: Are the Existing Last Resorts Enough? Timothy Quill outlines several aspects of PAS, specifically the fact that the terminally ill need as many options as they can possibly get. The whole time terminally ill patients are enduring tremendous suffering; they know that eventually they are going to die. Quill (2008), states that there are “several last resort options, including aggressive pain management, forgoing life-sustaining therapies, voluntarily stopping eating and drinking, and sedation to unconsciousness to relieve otherwise intractable suffering, could address many of these cases” (para.2). While it is not ordinarily acknowledged, but the last resort options are ethically and clinically and are just as complex as PAS (Quill, Lo, & Brock, 1997). For example, with voluntarily stop eating and drinking (VSED), a patient who is otherwise physically capable of eating and drinking decides to stop all oral intake of foods and fluids and then is gradually allowed to die, primarily of dehydration or some intervening complication. “Depending on a patient’s preexisting condition, the process will usually take [one] to [three] weeks or even longer if the patient continues to take in some fluids” (Quill, Lo, & Brock, 1997, p.2099-2100). This method raises the question of whether or not it is fair to ask a patient who is already suffering chronic pain to add to their suffering by means of voluntarily stop eating and drinking. Sedation to unconsciousness on the other hand puts the patient into a comatose state until they die. However, this method “is only appropriate for terminally ill patients as an intervention of last resort to reduce sever, refractory pain or other distressing clinical symptoms that have not been relieved by aggressive symptom-specified palliative care” (Levine, 2006, p.3). When a patient is sedated to unconsciousness other potentially life-prolonging treatments such as food and fluids are usually discontinued at the same time” (Quill, 2008, para.16). While this method eases the suffering of the patient, it tends to extend the suffering of the family. Aside from these last resort options, to forgo life-sustaining therapies seems to be no better. If a patient is currently undergoing palliative care to treat the symptoms that are causing them to suffer, why stop the treatment and increase their suffering instead of ending it once and for all? Why not give the terminally ill one more option when they have so few options now? Some patients will need a way out, and the withholding of just one option from patients whose options are already so limited seems unfair. Most terminally ill patients will want a way out; not necessarily a way out of life itself, but a way out of the unremitting suffering. There are very few options for terminally ill patients suffering with chronic pain, because relief is so hard to come by for someone who is dying. PAS is just one of these options, and it is an option that must not be overlooked. For some patients, just knowing they have the option of PAS; “gives them the freedom and reassurance to continue living; all the while knowing they can escape if and when they choose” (Quill, Lo, & Brock, 1997, p.2100). This is a powerful quote, as it brings forth the fact that legalizing PAS does not mean that a large number of terminally ill patients are going to choose PAS over palliative care options. The vast majority of terminally ill patients simply want the reassurance that if all other options are exhausted, they still have the possibility of a final escape; never actually needing to use it, as long as palliative care and hospice suffice in controlling their symptoms. These examples allow us to see how important the legalization of PAS is to those who are suffering on a day-to-day bases. Giving the terminally ill just one more option, when they have so few to choose from, will give terminally ill patients the reassurance that they still have some control over their lives. PAS should be considered as a last resort option; denying terminally ill patients a final escape, when all other options have been exhausted, is just unfair. Now that we have established how much the terminally ill would benefit from just knowing that they have access to a final escape; let us talk about the reasons why a terminally ill patient would actually resort to using PAS. The reason most terminally ill patients would ever think about ending their life, would be to put an end to their suffering. However, we already know that palliative care has been put into place to help ease the pain and suffering of the terminally ill. But when has a terminally ill patient suffered too much; and who has the right to decide when enough is enough? Quill (2008) states that, “there will always be a small percentage of these cases where the suffering will sometimes become unacceptably severe” (para.17). Even though the terminally ill suffer constantly, their degree of suffering is never the same; sometimes their suffering can be controlled with palliative care and/or aggressive pain management. However, there will be times when the suffering cannot be controlled, and there is a point when it becomes unacceptable. It is at this point that the patient needs to start thinking about last resort options; looking for a way to end their suffering. For example, a patient living with terminal cancer is, without a doubt, suffering daily. Palliative and hospice care programs have been put into place with no intention of helping the terminally ill; other than to alleviate their pain and suffering. However, according to Cassell,
Human suffering is a state of severe distress associated with events that threaten the intactness of the person. It occurs when a person perceives the impending destruction of themselves, and is associated with a loss of hope. It effects the individual’s physical, psychological, and spiritual well being. (as cited in Ledger, 2007, p.81)
However, according to Reich,
Also recognized the harmful consequences of suffering on a person; however, he argued that suffering was associated with anguish rather than distress. He stated that there was a difference between suffering and experiencing pain. Reich recognized that acute and chronic pain could cause physical, mental, or emotional distress. He argued that this distress was not necessarily associated with physical pain, but could be due to mental agony caused by a number of factors including feelings of injustice, powerlessness, victimization, dependency, shame, and fear of obliteration following death. (as cited in Ledger, 2007, p.81-82)
These descriptions of human suffering, each in their own way, state that the facing of one’s own mortality is not easy for anyone to do. Just the thought of not being able to stop your own demise can cause you great suffering. It is the ongoing, unrelieved suffering that gives rise to loss of hope and despair. “The patient whose symptoms have not/cannot be adequately controlled may ask for [PAS] to escape their suffering and/or restore their dignity” (Ledger, 2007, p.82). From 1997 to 2004, 208 individuals died under the provisions of Oregon’s Death With Dignity Act (DWDA), which only accounts for one in 1,000 deaths among Oregonians. “Interestingly, about 36 per cent of patients who obtained a lethal dose of barbiturates from a doctor never used it, suggesting that all these patients sought was control over the manner and timing of their deaths” (Dahl & Levy, 2005, p.335). However, the number one reason given by those who used PAS was the loss of autonomy. For one to loss their ability to control their life can be psychologically devastating; not just for the patient but for their family as well. The loss of dignity and the ability to enjoy one’s life came in very close to the loss of autonomy as the reason for wanting death as a final escape. When palliative and hospice care cannot sufficiently ease the pain that a terminally ill patient experiences on a daily bases, last resort options must be made available to the patient. When the chronic pain of a terminally ill patient takes away their ability to enjoy life, takes away their dignity, and takes away the human right of autonomy, the option to end their suffering once and for all must be made available. Even the terminally ill deserve to maintain some semblance of their former selves and be allowed to die with as much dignity as possible. Opponents of PAS have a valid argument, there are always other options to ease one’s suffering and control their symptoms. Palliative and hospice care are both viable options in the case of terminally ill patients. Palliative and hospice care programs have come a long way in helping the terminally ill cope with their illnesses. According to Hearn & Higginson (1998),
Palliative care, including pain and symptoms control, delivery of coordinated services, psychosocial and spiritual care, and support for the patient and family, is important at the end of life, because of its contribution to improve the quality of life of terminally ill patients. (as cited in Jansen-Van Der Weide, Onwuteaka-Philipsen, & Van Der Wal, 2006, p.399).
Palliative and hospice care programs have improved in ease of access, and are becoming more available to patients through reimbursement programs. Palliative and hospice care have not only becoming more easily accessible to terminally ill patients, but their mode of delivery has become more efficient; nurses can now come to nursing homes, hospitals, even a patient’s home, in order to provide care specific to each patient’s needs. While these programs continue to improve the quality of care that they provide, they continue to remain the standard of care for the terminally ill; and their implementation does not leave any room for more drastic options (Meyer, 2012).
However, with such great programs already in place and so easily accessible; the topic of PAS could actually lead into a discussion about other end-of-life options. Physicians can use a terminally ill patient’s request for a prescription as an opportunity to explore the patient’s fears and wishes about end-of-life care; all the while making the patient aware of their other options. This means that when a terminally ill patient believes that their pain and suffering requires a more direct and aggressive plan of action, perhaps PAS should not be the first option discussed. The patient must be made aware of all other options before they ever consider ending their life. Talks about PAS have shed a new light on the palliative care option. For example, “suicide prevention, when needed, is [now] an essential part of the package, crucial to fulfilling a hospice’s call to value the lives and intrinsic dignity of each patient until the moment of natural death” (Smith, 2008, p.85). Advocates for PAS argue that palliative and hospice care programs are well aware of their patients suffering, and realize that a number of patients who are already enrolled in their programs are contemplating PAS. Suicide prevention is actually one of the many services offered by palliative and hospice care programs. This service is offered because palliative and hospice care programs are suppose to make the patient as comfortable as possible while their lives end of natural causes. There are several good arguments for why the terminally ill should choose a long (or short) term care program over PAS; for one, these programs have been set up to control pain and other symptoms. Palliative and hospice care programs have improved a lot over the several years, and are now able to provide the terminally ill with better care; reimbursement programs are also available, as palliative and hospice care have become an accepted form of end-of-life care among the terminally ill. While both palliative and hospice care programs are excellent, and offer the terminally ill relief from most of their symptoms, these programs seem to do very little to overcome the underlying issues that are causing the terminally ill to desire a final escape. One of the biggest issues with the expanding of palliative and hospice care programs is their lack of manpower. There are just not enough skilled palliative care clinicians and nurses to meet the growing needs of the terminally ill. This is definitely a major problem with both palliative and hospice care programs which continue to rapidly grow. With programs such as Medicaid being willing to reimburse terminally ill patients who truly need palliative or hospice care, a lot more patients who are actively dying will be enrolling in these programs. However, if these programs are not fully prepared and staffed to meet the growing needs of their clientele, there is not going to enough nurses available to treat these patients (Kirchheimer, 2005-2014). Even if a terminally ill patient is fully educated on palliative and hospice care options, enrolled, and is being treated by a nurse, this is not necessarily a reason to rule out PAS. All last resort options, including PAS, only make sense if the patient is already receiving excellent palliative or hospice care. This argument directly refutes the opposition’s view that palliative and hospice care programs are acceptable alternatives to PAS. If a terminally ill patient is already enrolled in a palliative or hospice care program and an aggressive pain management system has been implemented, what should be the next step if he continues to suffer? It is at this point, once palliative or hospice care has failed to control the patient’s suffering, PAS should be an option that is considered. While opponents claim that PAS has corrupted palliative and hospice care programs, proponents refute this claim by pointing out that approximately 86 percent of people who died by PAS under Oregon’s law were receiving either palliative or hospice care at the time they took the lethal dose. This makes it clear that the alternatives to PAS are not doing a well enough job of keeping the terminally ill’s suffering to an acceptable minimum. In Oregon, one of the few states were PAS is legal; the majority of terminally ill patients who take advantage of this option have already tried the alternatives. Palliative and hospice care may work for a while, but when the suffering of the patient continues to become worse while the patient is receiving treatment to control their symptoms, there is always one more option left. While palliative and hospice care programs are designed to control the pain and suffering of a terminally ill patient during their last moments, they are not the absolute answer. Remember, pain is not the only thing causing a terminally ill patient to suffer.
No matter how much you agree or disagree with the legalization of PAS, people who want to die are going to die, either with the assistance of others or by themselves in a messy, horrifying, and traumatic way. Many believe that the highest suicide rates are in teenagers, when in fact the truth is there are actually more suicides committed by the elderly each year. Most elderly people believe there is nothing left ahead of them, except loneliness and pain. So if these people are going to end their lives, which do you think would be better, a controlled, compassionate PAS, or a clumsy attempt like taking sleeping pills, jumping from the top of a building, or firing a bullet into their head? Which one do you think would be more traumatic to one’s family; coming home to find their loved one’s brains splattered all over the wall from a bullet, or being able to say good bye to their loved one in a hospital or at home?
In January of 2011, while her husband of over 30 years lay in their bed sleeping, a loving mother and a good friend, Patsy Alex of Sheridan, Texas took her own life. She had battled cancer on two different occasions and when her physician told her the cancer was back, she could not take it anymore. She had no other choice, because PAS is not legal in Texas, she shot herself in the head. Her husband, who was awakened by the gunshot found his wife in their garage dead. This was no way for a loving mother and wife to have to end her life. The last memory her husband has of his beloved wife, is seeing her with her brains splattered all over the side of their pickup. If PAS would have been legal, Patsy and her family would have had the opportunity to say good bye to one another, instead Patsy had to hide how she was feeling, and had to commit suicide, alone in a cold dark garage. I wrote this shortly after Patsy took her life and sent it to my Senator in the hope that Texas would legalize PAS and/or euthanasia. No family should have to endure the loss of a loved one in this manner.
If that case is not bad enough, there has been case after case fought in U.S. courts, over the terminally ill wanting the right to end their pain and suffering. Take the case of Terri Schiavo for an example. Terri Schiavo, in 1990 was diagnosed by physicians as being in a persistent vegetative state (PVS), and a year later was considered to be in a permanent state of vegetation. Her husband, Michael, after various failed attempts at therapy, petitioned the courts in 1998 to have her life sustaining measures discontinued. However, Terri’s parents objected do to their ethical and religious beliefs. This set in motion a long legal battle in which various courts upheld Michael Schiavo’s petition, but were appealed. The U.S. Supreme Court denied the Schindler’s petitions, but not before the Florida legislation, the Florida Supreme Court, the President, and Congress had become involved in various ways. Terri Schiavo finally died in March of 2005. An autopsy was performed and found that the brain damage Terri originally suffered was both extensive and irreversible; it had affected almost all parts of her brain (Mosser, 2010, p. 189).
Even though the debate over whether or not to legalize PAS has gone on since the beginning of medicine, and will continue far into the future, there must be a way to ease the suffering of the terminally ill. While modern day medicine and technology continue to pull people from the brink of death, more and more people will be asking for the right to end their lives; this is because extending the length of life will allow the time needed for more people to become terminally ill. Almost everyone wants their loved ones to remember them as they once were, not as what they have become in the years following the diagnosis of a terminally illness. Why in a country that is supposed to be free, is it not our fundamental freedom to choose the right to die? Nowhere in the constitution does it state or imply that the government has the right to keep a person from committing suicide. As long as all parties involved agree that it is the best option, why should someone have to suffer? Besides, who else are they hurting anyway?
Terminally ill patients who have lost most of their control over the time they have left deserve to at least maintain their dignity in death. The legalization of PAS will give these patients this control over their final moments of life. Terminally ill patients do not have a lot of options left when their prognosis is death, and the list of options are not the best either. When a clinician suggests that a patient voluntarily stop eating and drinking or are sedated into permanent unconsciousness, it seems more unfair to deny that patient the option of PAS. Even though palliative and hospice care programs have come a long way, there are still many aspects of pain and suffering that they cannot control. Pain is just one symptom of a terminal illness. The loss of autonomy, loss of dignity, and the inability to enjoy life are the number one reasons why terminally ill patients begin to discuss PAS. While the arguments against PAS make some good points, the fact remains that denying a terminally ill patient one last chance to control their life is just not fair. When these patients have lost the ability to enjoy what life they have left, have lost the sense of control over their own destiny, having the option of PAS is comforting to them. If you found out that you only have six weeks left to live, which you will surely spend in extreme pain and unremitting suffering as your body goes into complete organ failure. Would you not want the option to end your pain and suffering and die with at least a little dignity? This is what physician-assisted suicide PAS, if legalized, would offer terminally ill patients.
References
Bonin, A. (2012, February 20). Human euthanasia, the debate: The arguments for both sides. The Examiner. Retrieved February 24, 2014, from http://www.examiner.com/article/human-euthanasia-the-debate-the-arguments-for-both-sides.
Dahl, E. & Levy, N. (2005, July 27). The case for physician assisted suicide: How can it possibly be proven? J Med Ethics, 32(6), 335-338. Retrieved from PubMed.
Jansen-Van Der Weide, M.C., Onwuteaka-Philipsen, B.O., & Van Der Wal, G. (2006, August 27). Requests for euthanasia and physician-assisted suicide and the availability and application of palliative care options. Cambridge University Press, 1479(9515), 339-406. Retrieved from ProQuest database.
Kirchheimer, S. (2005-2014). End-of-life care inadequate. WebMD. Retrieved February 24, 2014, from http://www.webmd.com/healthy-aging/news/20040106/end-of-life-care-inadequate.
Ledger, S.D. (2007, Summer). Euthanasia and assisted suicide: There is an alternative. Ethics & Medicine, 23(2), 81-94. Retrieved from ProQuest Central.
Levine, M.A. (2006). Sedation to unconsciousness in end-of-life care. Council of Ethical and Judicial Affairs, 5(8), 1-8. Retrieved from ProQuest database.
Meyer, T. (2012, April 28). Palliative care vs. physician assisted suicide. Ignitum Today. Retrieved February 24, 2014, from http://www.ignitumtoday.com/2012/04/28/palliative-care-vs-physician-assisted-suicide/.
Mosser, K. (2010). Philosophy a Concise Introduction. San Diego, Ca. Bridgepoint Education, Inc.
Pereira, J. (2011, April). Legalizing euthanasia or assisted suicide: The illusion of safeguards and controls. National Center for Biotechnology Information, 18(2), e38-e45. Retrieved from PubMed.
Quill, T.E. (2008). Physician-assisted death in the United States: Are the existing last resorts enough? The Hastings Center Report, 38(5), 17-22. Retrieved from JSTOR.
Quill, T.E., Lo, B., & Brock, D.W. (1997, December 17). Palliative options of last resort: A comparison of voluntarily stopping eating and drinking, terminal sedation, physician-assisted suicide, and voluntary active euthanasia. Health Law and Ethics, 278(23), 2099-2104. Retrieved from ProQuest database.
Smith, W.J. (2008). Assisted suicide and the corruption of palliative care. Human Life Review, 34(2), 85-86. Retrieved from EBSCOhost database.