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Robert Bober

Dr. Claudia Skutar

Intermediate Composition

16/11/2015

Euthanasia & Assisted Suicide: Death To Nursing Ethics

My name is Robert Bober, and I am currently a major in nursing science at the University

of Cincinnati Blue Ash. I have spent nearly two years seeing and interacting with various

patients with a multitude of backgrounds in my clinical experiences. From assisted living to the

psychiatric unit, I have met and spoken to the terminally ill, the mentally unstable, and even the

suicidal. I have met clients who wished to die because they either saw no hope in their

circumstances, or they felt as if life was a cruel game that they could never win. To these

patients, death may appear to be the only means of escape. In the recent past, a majority

healthcare providers around the world would provide that means in the forms of voluntary

euthanasia or assisted suicide. Throughout the centuries, nearly all forms of assisted suicide were

frowned upon, and many attempts to legalize euthanasia and assisted suicide nation-wide were

typically opposed. However, the ideation of providing the resources to end one’s life has still

remained prevalent in today’s society. Currently in the United States, five states have passed

legislations permitting physicians to partake in hastening a patient’s death. These states being

Oregon, Washington, Vermont, Montana, and most recently this year California (ProCon.org.

"Historical Timeline."). As a student nurse, I feel that euthanasia and all forms of assisted suicide

conflict with the code of ethics we as students have spent years learning and practicing. In this

presentation, I will discuss the hindrance assisted suicide provides for not only patients, but to

the registered nurse as well. We will begin by delving into the similarities and differences of

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euthanasia and assisted suicide and relate how a physician provides this treatment to his or her

willing patients.

Euthanasia and assisted suicide are typically considered as one and the same. However,

while they both have the same end goal, they are in fact two completely separate ways to carry

out that said goal. Article authors King and Jordon-Welch briefly define the two from their

article "Nurse-Assisted Suicide: Not An Answer In End-Of-Life Care":

“The American Nurses Association (ANA) (1995) published a position statement on

assisted suicide in response to the growing concern about the issue of nurses assisting in

suicide, euthanasia, and physician-assisted suicide. The statement clarified the definitions

used for the terminology of the issue. Assisted suicide was defined as “making a means

of suicide…available to a patient with knowledge of the patient’s intention” (p.3). Active

euthanasia was defined as to “act as the direct agent” (p.3) for the death of a patient. This

would be the actual administration of the pharmacological or mechanical agent that

caused the death of the patient. In active euthanasia, the agent administered would be for

the sole purpose of hastening the death of the patient and not for control of symptoms

such as pain or dyspnea. Also the patient would have given rational consent for the

action” (51).

We can see here how both have the same purpose, yet the common man may not realize

the difference between the two. Have the healthcare facility provide for you tool—in this case a

lethal dose—for suicide, or to have your physician do it altogether for you. Your choice.

Some may even say that providing the means for death is the same as acting it out

yourself. We could even go further and assume that “provision” could be in all forms. The act of

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providing could be physically handing the patient a lethal injection. Providing could also be

instructions to the patient in how to go about requesting this treatment. And who is typically

required to teach and instruct the patient? Enter the nurse.

The nurse and her ethical training is considered a separate entity. A nurse is to provide

care for their clients to the best of their ability. They are to promote healing, even if the disease is

terminal and death is certain. No matter what the scenario, she must uphold the ethical training

provided by the Code. Michael M. Mathes summarizes the Code as such: “The Code for Nurses,

published by the ANA in 1976 and revised in 1985 ("the Code"), serves to inform both the nurse

and the public of the profession's expectations and requirements in ethical matters. It offers

general principles to guide and evaluate nursing practice” (Mathes, 262). The Code is the

foundation which all nurses are required to promote in order to excel in their field of work and to

promote the health of society. When presented with the issue of assisted suicide, the Code

defines it clearly:

“In its Position Statement." Assisted Suicide, the ANA (1994) further expands upon the

meaning and ethical basis for the Code's proscription against "terminating the life of any

person." First, the ANA notes that the historical role of the nurse has been to "promote,

preserve and protect human life." It observes that the profession itself is built upon the

Hippocratic tradition of "do no harm" and moral opposition to killing another human

being. The ANA further states that the Code's prohibition against deliberately terminating

a life is grounded in the profession's covenant with society at large to respect and protect

human life. It therefore concludes that participation in assisted suicide is inconsistent

with the norms and attributes of the nursing profession as reflected both in the terms of its

covenant with society and in its relationship of trust with individual patients. The ANA

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also supports its moral objection to nurse participation in assisted suicide based upon

concern for the potential for serious societal and professional consequences and abuses”

(Mathes, 262).

Let us return to the provision of information. Nurses have roles which must be performed

in a healthcare setting. Important roles such as medication administration and interventions are

performed every day in hospitals and other healthcare facilities, but one requirement of nurses

that is usually overlooked is the obligation of teaching. Whether it be instructing how to self-

administer injections or proper wound care, nurses are required to provide the patient

information related to his or her healthcare needs. Therefore, if a client who is terminally ill asks

the nurse about the possibility of assisted suicide or euthanasia, how is the nurse supposed to

respond? How can she recommended and provide information to a patient who wishes to kill

himself when it goes completely against her training?

Currently, the number of nurses across the United States who have to face this sort of

problem are in the minority, but the question still remains, what should the nurse do in this

situation? Maria Anguita provides the nurse with some advice, “Stop, think, and listen. Do not

ignore patients who want to talk about ending their lives. This is how nurses should react when

patients tell them that they want to die and that they need their help…” (6). Ignoring the issue is

never an option, so how is the nurse supposed to respond? Authors such as Sophie Blakemore

reveal that one reason a client may opt for assistive suicide is that they simply do not have an

understanding of other potential options for care. Also, preconceived ideas of what palliative

care implies can cloud their judgement. Blakemore gives a reflection on this from three palliative

care specialists:

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“They (the specialists) reported that good palliative care can reduce patients’ desire for a

hastened death. One said: ‘Some patients are in the depths of depression because they’ve

come into hospital, they know their time is short, they might be troubled by lots of

symptoms and when we see them at their first assessment they say “I’ve just had

enough”. But that’s a reflection of where they are psychologically, and then you often

find that by being alongside them and helping with their symptoms, their mind

changes’” (7, parenthesis added).

Sometimes the patient is uninformed in both assisted suicide and possible alternatives. It

is up to the nurse to identify what information is lacking, or to clarify any preconceived ideas of

her client.

Many, including myself, believe that assisted suicide restricts the patient and their family

rather than freeing them. In cases involving physician-assisted suicide, many patients who are

viable candidates for assisted suicide are coaxed into believing it is the only alternative. Dutch

cardiologist Richard Fenigsen believes that physicians are primarily responsible for this type of

thinking, as quoted, “Physician-assisted suicide is more easily accepted by the public because it

is believed to be an arrangement in which the patient remains in full control. This is of course an

illusion” (241). Patients lean heavily on a doctor’s recommendations for treatments and

interventions. “It is the doctor who informs the patient on the diagnosis and prognosis, and,

unfortunately, in this country some doctors do it in a callous or brutal way that may destroy the

patient’s will to live” (241). This allows the physician to make very crucial choices for his client

with little consequences for himself.

Although repercussions are relatively low for a healthcare provider during the initial

discussions for euthanasia or assisted suicide, sometimes after the deed has been carried out

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consequences can arise via the deceased patient’s family. This can result towards long and

tedious legal repercussions which can be detrimental towards a healthcare professional’s career

and even lifestyle. One particular case involving life altering backlash involves Doctor Jack

Kevorkian. Beginning in the eighties, Doctor Kevorkian was involved in euthanizing several of

his patients. Hengameh Hosseini provides a detailed history in regards to the matter, “Dr. Jack

Kevorkian of Pontiac, Michigan (the son of Armenian refugees) began his Physician-assisted

suicide-related activities in the 1980s, when he built a machine that could administer a narcotic

followed by a lethal dose of potassium chloride to patients, ensuring a swift death” (204, 205).

Hosseini continues how Doctor Kevorkian was able to perform physician assisted suicide for

several of his patients with this technique up until 1999, when he administered a lethal injection

for a patient while videotaping the procedure after his residing state of Michigan passed a new

law banning physician assisted suicide. This video recording aired on 60 minutes, and within

days Doctor Kevorkian was charged with murder.

“1999, Michigan Judge Jessica Cooper sentenced the (then) 70-year old Dr. Jack

Kevorkian to 10-25 years in prison for the videotaped death of 52-year-old Thomas Youk

(who was suffering with Lou Gehrig's disease)… It is worth mentioning that

Dr.Kevorkian served only 8 years of that 10-25 years sentence. For, he was released on

parole on June 1, 2007 on the condition that he would not offer suicidal advice to any

other person. He died four years later in 2011” (Hosseini, 205).

We have now seen how euthanasia and assisted suicide diverge greatly from a nurse’s

ethical standards, as well as the potential repercussions both may have in the aftermath, but what

can be said about the candidates who could be considered viable for euthanasia? In 2006 at the

United Kingdom, a study consisting of interviews from terminally ill patients was conducted to

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discover their personal thoughts on assisted suicide. These patients were diagnosed with various

malignant and non-malignant diseases, and the overall result of these interviews can be summed

up as followed:

“A few people opposed a change in UK law (or were ambivalent), who represent

negative cases in the analysis.25 Apart from three people who appeared to be discussing

involuntary euthanasia, one said that people should trust God and that good could come

out of suffering, and another was anxious that people might ask for assisted suicide to

help careers rather than themselves” (Chapple, 709).

We can see in Chapple’s study that a percentage of terminally ill participants believed

that a change in law was necessary for qualified and willing patients to receive euthanasia or

assisted suicide. Many individuals varying from the common man to the healthcare professional

currently agree with these patients, since the availability of euthanasia and assisted suicide are

still prevalent in the United States today.

Clients may feel like euthanasia and assisted suicide could be a viable alternative to

treatment, but what qualifies a patient to become a candidate for physician assisted suicide? The

client must obviously be able to comprehend the situation, make an informed decision, and be

able to verbalize his or her choice, but authors Stewart, Peisah, and Draper warn that the tests

used for the mental capacity to be able to request for assisted suicide is not as clear as some may

think. The authors state that, “The test is context-specific. It focuses the patient’s ability to make

the decision at hand. It is not diagnosis-specific. The fact that a person may be suffering from

global deficits because of brain damage or mental illness is not determinative of the issue of

competence” (34). The requirements to make an informed decision are stripped down, without

taking in the possible effects the disease could have in the client’s decision making. With this

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mode of testing, as long as the patient can make logical choices, regardless of investigating any

underlying alterations through their disease process, the client can request assistance to kill

himself. These tests are also subject towards the practicing physician’s personal beliefs, as stated

by Stewart, Peisah, and Draper, “There is also lack of consensus in the scientific community in

regards to standards to determine competence to consent to assisted suicide. Views on the

threshold for competence vary depending on the clinician's ethical stance.” Physicians such as

the previously mentioned Dr. Kevorkian can use their prestige to enforce their recommendations

of physician assisted suicide, and since physicians have the final say so in the matter of

determining their patients to be competent enough to legitimately ask for suicide, their power can

potentially be abused. Nurses and Physicians can also potentially force a hasty decision, whether

it be intentionally or unintentionally. Finley and George summarizes Battin et al’s study related

to euthanasia and physician assisted suicide in Oregon. Battin’s findings reveal an interesting

fact related to chronically ill patients wishing for euthanasia and their depressive state. “Battin et

al state that "approximately 20% of requests for physician assistance in dying [in Oregon] came

from depressed patients but none progressed to PAS," that is one in five applicants for PAS in

Oregon was diagnosed as having depression and was not allowed to proceed” (84). This further

shows how the tests required to be a candidate for assisted suicide and euthanasia may not

account towards underlying roles such as depression.

To some, the act of assisted suicide is no different than allowing the patient to refuse

treatment. Hugh McLachlan reviews the moral theories of David Shaw, who present his own

counter argument towards assisted suicide. McLachlan quotes Shaw as follows:

“According to Shaw: 'If we regard the body of someone who requests VAE (that is

voluntary active euthanasia) or AS (that is assisted suicide) as providing unwarranted

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life-support, it is clear that there is no substantive moral difference between turning off a

ventilator (eg), and providing or administering a lethal drug’” (306).

Many individuals would agree with Shaw’s moral choices. Even McLachlan shares in

Shaw’s belief that switching off a ventilator is considered the same as administering a lethal

injection for a patient. However, I believe this is a poor way to defend for euthanasia by

comparing these two scenarios. One requires the healthcare professional to stop treatment, the

other demands the healthcare professional to implement a treatment. Both have the same end

goal—which is death—but the process in which these two scenarios are carried out are in fact

extremely different. Let us look at Shaw’s example of pulling the plug on a ventilator.

As a nurse, or any healthcare professional personally dealing with patients, treatments

can be refused by the patients. In any scenario where a client refuses treatment or interventions, a

nurse is to be an advocate for that client. Being a good advocate requires primarily two things.

For one, you as the nurse must advise your client on the potential and actual risks that can be

associated with refusing the treatment or intervention. Secondly, if the client still refuses, you

must respect your client’s wishes and notify his or her physician that they refuse this treatment.

In Shaw’s example, we have a client who wishes to die by ceasing the treatment—which in this

case is keeping him alive. This specific scenario presents itself quite frequently, and is carried

out as such all over the United States. The client would notify his nurse or his physician that he

wishes to refuse his current treatment. After being given the potential and actual outcomes this

decision would cause, including discussion with the client’s family, the client may still desire to

refuse being maintained on the ventilator. In this case, the physician and the nurse can implement

the client’s wishes in the best interest. The client has the right to refuse any form of treatment,

and the healthcare professionals involved in the care have the right to honor the patient’s wishes.

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The result is both parties having a mutual agreement which does not overstep either of their

ethics.

Now, let us compare the second example Shaw uses in his argument. Once again, Shaw

proposes that the processes used to inhibit further treatment—such as shutting off a ventilator—

are one and the same to that of administering euthanasia or performing physician assistant

suicide. Performing the act of euthanizing however, requires a different approach. Instead of

honoring the client’s right to refuse treatment, the physician or the nurse is placed in a difficult

position in order to carry out the client’s wishes. Instead of simply negating treatment, the

healthcare provider has to physically carry out the means to cause patient death, rather than

allowing the patient’s own fate to take its course. As previously mentioned, there can be a greater

risk of repercussions from the family during the aftermath, now that the physician is directly

involved in hastening his or her patient’s end. To say that pulling the plug and administering a

lethal dose are one and the same requires a mentality that patients are only a means to an end

instead of real people with real problems. Death is imminent for these individuals, and it is easy

to convince a chronically ill patient to be euthanized, but it requires persistence and a sense of

caring to be able to encourage your client to keep on their fight for their families and their loved

ones.

The interventions of euthanasia and physician assistant suicide have always had an air of

controversy surrounding both issues. While the general public and the individual physician can

have their own preconceived ideals towards these issues, nurses might face a dilemma between

their morals and their profession’s ethics. The nurse may have personal beliefs about assisted

suicide and voluntary euthanasia—and they have that right to have that belief. But to deny that

the acts of voluntary euthanasia and physician assisted suicide are illegitimate healthcare

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interventions is to deny The Code of Ethics provided by the American Nurses Association.

Healthcare providers, especially nurses, have a specific purpose. That purpose is to promote

health in the unhealthy, to provide professional care to the needy, and finally to prolong a

meaningful life and a sense of well-being. A patient has rights. The right of confidentiality, the

right to accept or refuse treatment, and the right to know their plan of care. Seeking death is not a

right, nor is it a requirement for the healthcare staff and facility to pursue. If we can understand

the value of what little time our patients have left, then perhaps we as nurses and healthcare

providers will not be so quick to offer a means to take that precious little time away.

Works Cited:

Anguita, Maria. "Nurses Given Unequivocal Advice On Assisted Suicide." Nursing Older People

23.10 (2011): 6-7 2p. CINAHL Plus with Full Text. Web. 13 Nov. 2015.

Blakemore, Sophie. "Assisted Suicide Debate Puts End Of Life Care In Spotlight." Nursing

Older People 24.1 (2012): 6-7 2p. CINAHL Plus with Full Text. Web. Nov. 2015.

Chapple, A et al. “What People close to Death Say about Euthanasia and Assisted Suicide: A

Qualitative Study.” Journal of Medical Ethics 32.12 (2006): 706–710. PMC. Web. Nov. 2015.

Fenigsen, Richard. "Other People's Lives: Reflections on Medicine, Ethics, and Euthanasia."

Issues in Law & Medicine 27.3 (2012): 231-359. ProQuest. Nov. 2015.

Finlay, G., and R. George. "37 J. Med. Ethics: Legal Physician-Assisted Suicide in Oregon and

The Netherlands: Evidence Concerning the Impact on Patients in Vulnerable Groups." Issues in

Law & Medicine Summer 2011: 83+. Expanded Academic ASAP. Web. Nov. 2015.

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Hosseini, Hengameh M. "Ethics, the Illegality of Physician Assisted Suicide in the United States,

and the Role and Ordeal of Dr. Jack Kevorkian before His Death." Review of European Studies

4.5 (2012): 203-9. ProQuest. Nov. 2015.

King, P, and M Jordon-Welch. "Nurse-Assisted Suicide: Not An Answer In End-Of-Life Care."

Issues In Mental Health Nursing 24.1 (2003): 45-57 13p. CINAHL Plus with Full Text. Web.

Nov. 2015.

Mathes, Michele M. "Assisted suicide and nursing ethics." MedSurg Nursing Aug. 2004: 261+.

Expanded Academic ASAP. Web. Nov. 2015.

McLachlan, Hugh V. “Assisted Suicide and the Killing of People? Maybe. Physician-assisted

Suicide and the Killing of Patients? No: The Rejection of Shaw's New Perspective on

Euthanasia”. Journal of Medical Ethics 36.5 (2010): 306–309. Web. Nov. 2015.

ProCon.org. "Historical Timeline." ProCon.org. 23 July 2013. Web. 17 Nov. 2015.

Stewart, Cameron, Carmelle Peisah, and Brian Draper. “A Test for Mental Capacity to Request

Assisted Suicide”. Journal of Medical Ethics 37.1 (2011): 34–39. Web. Nov. 2015.

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