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Chapter 5

Bioethics, Euthanasia,and Physician-AssistedSuicide

We all labor against our own cure;for death is the cure of all diseases.

—SIR THOMAS BROWNE, 1605–1682, URN BURIAL

ObjectivesAfter reading this chapter, you will be able toanswer the following questions:

• How do ethics and morality differ?• What is bioethics, and what is the role of

a bioethicist?• How do active and passive euthanasia differ?• What are the religious, legal, and social

views toward euthanasia?• What is physician-assisted suicide?• What is the current legal environment

regarding physician-assisted suicide?• How do issues of gender bias, pain relief,

and the voluntary nature of physician-assisted suicide factor into arguments forand against the practice?

Controversy continues to swirl around the issuesof legalized euthanasia and physician-assisted sui-cide (PAS). The controversy rests on differingviews of the ethics and practical morality of suchlegislation, what effect it would have on the prac-tice of euthanasia and PAS, who typically asks for

it, and on whether improving pain managementand palliative care would be a better first step.

What Is MedicallyEthical Behavior?Ethical behavior is defined by moral principlesor values based on concepts of whether somethingis good or bad. Moral behavior is based onsocially accepted codes or notions of right andwrong. Thus, ethics and morality are similar butnot identical.

Ethical decision making must balance the rightsof an individual to decide for him/herself, the viewsof society as a whole, and the desires and wishes ofa family and others close to the individual. Justiceinvolves making decisions to balance contendinginterests so that everyone is treated fairly.

These definitions are, perhaps unfortunately,hypothetical. They address the question, “Whatshould be done?” In reality, and in the bureaucraticsetting of a hospital or other healthcare institution,the question more often is “What can be done?” and

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38 Chapter 5: Bioethics, Euthanasia, and Physician-Assisted Suicide

the answer is “Do everything possible, even if it isnot always appropriate.” In times past, when notmuch could be done to prolong death, sympathyand efforts to manage pain were the norm. Now,with the enormous advances in techniques, equip-ment, and drugs, the imperative to treat and cure atall costs sometimes overwhelms compassion.

BioethicsThe growing difficulty and complexity (as well asthe dangers) of medical decision making have cre-ated the role of the bioethicist. A bioethicist is ahospital staff person who is educated in philoso-phy, psychology, religion, law, humanities, andthe social sciences (Guyer, 1998). This person’srole is to help the medical professionals, the fam-ily, and the patient make difficult medical deci-sions, especially for those patients at the end oftheir life. The bioethicist meets with the patient,his or her family, and medical staff, collecting thefacts and surveying the various views involvedbefore offering a recommendation regarding nextsteps for the patient. If one or more parties balk atthe bioethicist’s decision, meetings are held sothat all parties can talk over things. If these meet-ings fail to produce an agreed upon path of action,the hospital’s ethics committee reviews the caseand makes a ruling.

In principle, the bioethicist represents theinterests of the patient above all others. But the

inevitable influence of the institutional settingand interaction with hospital medical profession-als can erode the best of good intentions, and thebioethicist often comes to ally with the profession-als and their views on patient care (DeVries &Subedi, 1998)—or even subvert his of her role byselling cover ups for cost-cutting measures tomanaged-care insurance companies (Shalit, 1997).

The Doctor’s Oath of PracticeAll cultures have had guidelines in the form ofcodes, prayers, creeds, or oaths to guide their heal-ers. One of the earliest oaths comes from theChareka Samhita of ancient India. This oath callsfor the medical student to “follow a path of per-sonal sacrifice and commitment to duty.” InChina, ethical codes of conduct for physiciansappear from the Taoist writer, Sun Szu-Miao. Hiswritings stress the importance of “preserving lifeand serving the interest of the patient.” A widelyknown Judaic text is the Daily Prayer of aPhysician, attributed to Moses Maimonides, atwelfth-century Jewish physician in Egypt, butprobably written by Marcus Herz, a Germanphysician. This text first appeared in print in1793 (see box).

Codes from other cultures are similar to theHippocratic oath. Hippocrates, a Greek physicianwho lived from 466 B.C. to 377 B.C., is known asthe father of medicine. Even though not specifi-

Daily Prayer of a Physician

Almighty God, grant that my patients have confidence in me and my art and follow my direc-tions and my counsel. Remove from their midst all charlatans and the whole host of officious rel-atives and know-all nurses, cruel people who arrogantly frustrate the wisest purposes of our artand often lead Thy creatures to their death. Should those who are wiser than I wish to improveand instruct me, let my soul gratefully follow their guidance. Should conceited fools, however,censure me, then let love for my profession steel me against them. Imbue my soul with gentle-ness and calmness when older colleagues, proud of their age, wish to displace me or to scorn meor disdainfully to teach me. Let me be contented in everything except in the great science of myprofession. Never allow the thought to arise in me that I have attained to sufficient knowledge,but vouchsafe to me the strength, the leisure and the ambition ever to extend my knowledge.(Excerpts, translated by H. Friedenwald, 1917.)



What Is Medically Ethical Behavior? 39

cally spelled out in the oath, the implied messagefor doctors is “Above all, do no harm.” Membersof the American Medical Association (AMA) arebound by the Hippocratic oath in its modern ver-sion (Lasagna, 1964)[J1], in which the ideal ethi-cal behaviors for medical doctors are explained(see box).

Many physicians today believe that theHippocratic oath is outdated, because some oftoday’s issues were unheard of at the time the oathwas created. For example, years ago, no one hadheard of legalized abortion or test-tube babies.

Physicians’ Perspectives on Lifeand DeathCaring for dying patients is part of every doctor’straining and experience. Yet physicians’ perspec-tives regarding death differ. For example, most

doctors admit that patient deaths disturb themvery little. Others, although not as many, say thattheir patients’ deaths, even those they knew onlyfor a short time, are very disturbing. The mostcommonly reported grief symptom is “feelingupset when thinking about the patient”(Redinbaugh et al., 2003).

Medical Ethics and Capital PunishmentIn 1976, the U.S. Supreme Court legalized capitalpunishment. Because the Eighth Amendment tothe Constitution forbids cruel and unusual pun-ishment, the method of using lethal injections wasintroduced. To make sure the lethal injectionswere administered properly, courts required medi-cal personnel to attend executions (Gawande,2007). The American Medical Association balked

Hippocratic Oath (modern version)

I will apply, for the benefit of the sick, all measures required.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, andunderstanding may outweigh the surgeon’s knife or the chemist’s drug.

I will respect the privacy of my patients, for their problems are not disclosed to me that the worldmay know.

Most especially must I tread with care in matters of life and death.

I will remember that I treat a sick human being, whose illness may affect the person’s family andeconomic stability.

I will prevent disease whenever I can, for prevention is preferable to cure.

A Physician’s First Encounter with Death

As a new doctor assigned to the first of his clinical rotations on the Internal Medicine service, Dr.Sherwin Nuland helped an intern by agreeing to complete the admission workup on a new coro-nary patient who had just arrived. Before Nuland got far into the routine admissions work, thepatient died of a massive, and inevitable, heart attack. Alone in that room with the corpse,Nuland tried everything to save the dead man. Then, the door to the room swung open andNuland’s friend rushed in to see Nuland crying, out of control and begging the patient to live.His friend said, “It’s okay, buddy—it’s okay. You did everything you could . . . Shep, now youknow what it’s like to be a doctor.” (Nuland, 1995, p. 8.)




at this practice, resolving that “A physician . . .should not be a participant in a legally authorizedexecution” (Article 2.06 of the AMA Code ofMedical Ethics).

One doctor, a prison physician, has a differentview about attending executions. He feels obligedto attend inmates when they are about to die. Heviews executions as an end-of-life issue, a timewhen a doctor should make sure the person aboutto die is comfortable and does not have pain or suf-fering. Anti–capital-punishment activists havechallenged his medical license and AMA member-ship, but he believes that it is wrong to stopattending executions. He and his medical team arepaid quite well for their services; he donates hisshare of it to a children’s shelter (Gawande, 2007).

EuthanasiaThe ability to keep a dying person alive has raiseddifficult questions for the terminal patient, his orher physician, as well as policymakers and thegeneral public. Should a patient be allowed todie? Should the medical profession help a patientto die? (Weir, 1998).

In euthanasia, the physician takes some sort ofaction to end a patient’s life. When the physiciantakes direct action to do so, it is sometimes calledactive euthanasia, to distinguish it from passiveeuthanasia, which is simply withholding orwithdrawing the treatment needed to sustain lifeand allowing the patient to die. Physician-assisted suicide involves the physician supply-ing the means, usually medication, to a patientwho then decides and takes the necessary action toend his or her life.

When it comes to distinguishing betweenactive and passive euthanasia, proponents ofactive euthanasia argue that there are no impor-tant moral distinctions between the two practices,so both should be allowed. Opponents of activeeuthanasia, but who support the passive form,argue that, when life support is withdrawn, thecause of death is the underlying disease—notaction by the physician.

If it were legal, more than a one-third of U.S.physicians would be willing to offer active euthana-

sia with medication, and one-fourth would be will-ing to give a lethal injection (Meier, et al., 1998).An increasing number of people in the UnitedStates support the painless euthanasia of incurablyill patients—if they and their families request it(Blendon, Szalay, & Knox, 1992; Caddell &Newton, 1995; Rogers, 1996). This increasedacceptance is paralleled in other countries (Genuis,Genuis, & Chang, 1994; Singer, Choudhry,Armstrong, Meslin, & Lowy, 1995; Steinberg,Najman, Cartwright, MacDonald, & Williams,1997; Suarez-Almazor, Belzile, & Bruera, 1997;Van der Maas, Pijnenborg, & van Delden, 1995).

Knowing what makes euthanasia acceptablelikely would help guide those professionals—physicians, psychologists, lawyers, and medicalethicists—who help patients and their familiesmake end-of-life decisions, as well as those whomake healthcare policy. They then would knowwhat issues to discuss with patients and families,and policymakers likely would know how toshape guidelines, rules, and laws (Cuperus-Bosmaet al., 1999).

But what, specifically, might make euthanasiaacceptable? Acceptability, according to Frileux etal. (2003), depends mainly upon.

• the level of patient suffering in spite oftreatment;

• the extent to which the patient requestedthe life-ending procedure;

• the age of the patient; and• curability of the illness.

Karen Ann Quinlan and Terri SchiavoEthical questions about the “right to die” havebecome prominent since the landmark case involv-ing Karen Ann Quinlan in 1975. Because Quinlanwas in a persistent vegetative state (PVS), a comastate of wakefulness without detectable awareness,her parents asked for her respirator to be removed.After much controversy, the New Jersey SupremeCourt ruled that her respirator could be discontin-ued. Quinlan died in 1985.

A more recent case is the one involving TerriSchiavo. In 1990, Schiavo, then age 26, collapsed



Euthanasia 41

at her home in St. Petersburg, Florida, and neverrecovered. She entered a coma and was kept aliveby the tools of modern medicine. She had experi-enced respiratory and cardiac arrest and remainedin a coma for 10 weeks. She did not have a livingwill. After 3 years, she was diagnosed as being ina PVS. This condition of wakefulness persuadedher parents, Robert and Mary Schindler, that shecould recover.

In 1998, her husband, who was also her legalguardian, petitioned the state courts to removeher feeding tube, but her parents objected. Thecase generated intense media attention, involve-ment by politicians and interest groups, a series ofstate and federal court actions, and eventuallyattempted intervention by the U.S. Congress.

Despite these efforts, the state courts stead-fastly held that she was in a PVS and ordered thatshe should cease to receive life support. Her gas-tric feeding tube was removed (for the thirdtime), and she died 13 days later of dehydration,on March 31, 2005, at the age of 41 in a PinellasPark hospice facility.

The Schiavo case resulted in 14 appeals andnumerous motions, petitions, and hearings in theFlorida courts, all of which were denied, and fivesuits in Federal District Court, all of which alsowere denied. Also noteworthy is that a subpoena bya congressional committee was filed in an attemptto qualify Schiavo for witness protection as was fed-eral legislation (the Palm Sunday Compromise) andfour denials of the Supreme Court of the UnitedStates to review the appeals courts decisions.

The Palm Sunday Compromise, formallyknown as the Act for the Relief of the Parents ofTheresa Marie Schiavo, was an act of Congress toallow the case to be moved to a federal court. Thename “Palm Sunday Compromise” was inventedby House Majority Leader Tom DeLay, highlight-ing the mixture of religion and politics that over-shadowed the Schiavo case.

Religious Perspectives on EuthanasiaIn this age of life-prolonging medicine, the delib-erate decision to end a life generates a significant

amount of religious discussion (O’Connell, 1995).Ethical concerns from a religious perspectivelikely will become even more central when and ifeuthanasia enters the mainstream of medical prac-tice and society struggles to achieve consensus onthis issue.

The futility of medical treatment to sustain lifehas collided with religious ethics. In the case ofBaby K, an anencephalic infant, physicians con-cluded that Baby K’s life could not be sustainedand that continued treatment would be futile.The infant’s mother insisted that Baby K shouldbe kept alive because God might choose to per-form a miracle (Post, 1995).

In the mother’s defense, Post (1995) insistedthat religious beliefs should be taken seriously bymedical personnel and included in medical orsocial policies concerning futile treatment. Othersargued, however, that physicians should not becompelled to violate their own moral convictionsand professional standards to accommodate thereligious beliefs of others (Paris & Reardon,1992). Refusal to continue futile treatment “isnot abandonment of the patient; it is an assertionof professional responsibility” (Paris & Reardon,1992, p. 133). Before refusing to provide treat-ment, the physician should explain why the pro-posed treatment is futile, and, if possible, arrangea conference with the hospital ethics committeeor the pastoral care department. Often a consen-sus does emerge, thereby averting a break in thephysician–patient relationship.

Is Legal Availability ofEuthanasia Justified?People, in general, are becoming more receptiveto euthanasia. Advances in medical technologyoften cause people to worry about lingering, nastydeaths hooked to machines, unable to communi-cate, the modern equivalent of the seventeenth-and eighteenth-century fear of being buried alive(Daniel, 1997). But what are the arguments andjustifications, pro and con, for euthanasia?

Proponents of legalized euthanasia argue thatthe right to self-determination encompasses theright to choose how and when to die. The believe




that keeping a person alive who wishes to die is notonly an infringement of that person’s rights, but anirresponsible use of resources (McLean & Britton,1996). Treatment costs are high, for example, forAIDS and cancer, but very low for lethal injection.These proponents also argue that because euthana-sia is already taking place, it should be made legalso that it can be regulated. For instance, a doctorcan administer drugs to relieve pain knowing thathe or she might kill the patient. As long as the doc-tor’s intention is to relieve pain, this practiceshould be acceptable, and the death that ensuesshould be ruled accidental.

Many opponents to legalize euthanasia, how-ever, worry about an inevitable “slippery slope,”such as demonstrated by the case of a healthy 50-year-old woman who, distressed after her two sonsdied, was helped to die by her doctor. The doctorwas censured but not convicted of wrongdoing,thus establishing mental suffering as a valid reasonfor euthanasia (Keown, 1995). The decision tohelp a person end his or her life might be at first,but the more it is done the easier it might become.In other words, the line between what is and is notacceptable might become blurred (Daniel, 1997).

Many argue that palliative care—pain manage-ment, symptom control, and psychological andspiritual support—is the acceptable alternative to

euthanasia (George, 1997). Most doctors, how-ever, are in need of training in both palliative careand medical ethics (Keown, 1995). Also, a short-age of available beds and funds makes extensiveuse of palliative care difficult. Perhaps, ratherthan campaigning for legal euthanasia, doctorsand families of the terminally ill should bedemanding adequate palliative care (Nathanson,as cited in Daniel, 1997).

How Patients View EuthanasiaWhat might lie behind a patient’s requests foreuthanasia? Mak, Elwyn, and Finlay (2003)revealed that concerns are not always confined tophysical and functional decline. They also statedthat many patients experience hidden psychoso-cial and existential issues embedded in life expe-rience, fears about the future, and yearnings forcare and social connection. Many patients expressfears of pain or a painful death, lack of quality oflife, and lack of hope (Johansen, Hølen, Kaasa,Loge, & Materstvedt, 2007). Furthermore, theymight fear physical disintegration and loss offunction and loss of personal relationships, whichleads to a perceived loss of self and wholeness(Lavery, Boyle, Dickens, Maclean, & Singer, 2001)that gradually diminishes until they oftentimes

My Story: “Stop! Let Her Die”

I always have believed that doctors should do everything in their power to keep everybody alive.That was especially true for my grandmother. That was very clear for me.

Suddenly, my grandmother had a stroke. We were told that her stroke was too severe and thatshe probably would soon die. While she was in the hospital, only one family member at a timecould visit her—and then for only 5 minutes. I thought my turn would never arrive to get onelast visit. But it did.

I walked back to the intensive care ward to find two nurses working to get my grandmotherto breathe. Apparently, she had just quit breathing. When I saw them working so hard, Ithought, “How cruel!” Just as I thought it, I also was shocked at my reaction. What had changedthe way I previously had believed?

Then, I knew. I changed my beliefs when reality for me changed. I think I understood that adignified death isn’t about force; it’s about letting death take its course. I feel like I grew up a lotthat day.



Physician-Assisted Suicide 43

see a future worse than death itself (Mak, Elwyn,& Finlay).

The prospect of good quality end-of-life careand social connectedness might help patients seetheir reality differently and lead them to reevalu-ate the desire for death (Mak, Elwyn, & Finlay,2003). This reevaluation suggests that improve-ments in palliative care should precede considera-tion of legalized euthanasia.

Beyond assessing mental competence ordetermining legal guidelines, physicians andother healthcare professionals must acquire theskills for providing good end-of-life care, whichincludes the ability to connect with patients, todiagnose suffering, and to understand patients’hidden agendas through in-depth exploration.These skills are especially important for encour-aging patients’ feelings of hope and personalworth. Thus, to give physicians better communi-cation skills and attitudes, medical educationshould include medical humanities, experientiallearning, and reflective practice (Bolton, 2001;Vass, 2002).

Physician-Assisted SuicideMost people judge euthanasia to be less accept-able than physician-assisted suicide (PAS), theprocess in which the physician simply gives thepatient the means to end his or her life. WithPAS, the patient takes the action and can until thelast minute decide not to go ahead with the act(Rogers, 1996).

In the past, most people died relatively quicklyas a result of accident or illness. Today, despiteadvances in palliative care, death is too often pro-tracted, painful, and undignified. In the UnitedStates, 80% to 85% of people die in institutions,70% of those after a decision to withdraw orwithhold treatment, and the great majority areelderly (Fraser & Walters, 2000.)

Results from public opinion polls consistentlysupported PAS. In one poll, even 50% of Catholicvoters answered “yes” to the question, “Shall thelaw allow terminally ill adult patients obtain aphysician’s prescription for drugs to end life?”(Dietz, 1997). Some recent report results suggestthat attitudes to PAS become more positive withage (Littlejohn & Burrows-Johnson, 1996;Sedlitz, Duberstein, Cox, & Conwell, 1995).

In 2005, a majority (70%) of 1,010 Americanspolled favored allowing some form of PAS. Thispercentage is up from previous years, but less thanthe peak of 73% percent approving in 1993(Taylor, 2005).

PAS is controversial. This controversy, how-ever, is not new. Beginning in 1870 and continu-ing until the 1930s, there was widespread publicdebate in the United States over legalization ofPAS. World War II and the reactions to the Nazideath camps suspended further discussion until1971, when, in the Netherlands, a doctor whoadmitted administering a lethal dose of morphinewas given a 1-year suspended sentence. Theleniency of the sentence prompted a publicdebate, and, in 1984, the Royal Dutch Medical

Dr. Death

The most publicized advocate of PAS has been Dr. Jack Kevorkian (“Dr. Death”), a retiredMichigan pathologist. Despite arrests, imprisonment, and loss of his medical license, he helped130 people commit suicide.

Before finally being convicted of second-degree murder in 1999, he was tried four times,resulting in three acquittals and one mistrial. Kevorkian’s conviction came after he was shown ina videotape on the TV program 60 Minutes, helping 52-year-old Thomas York, who had LouGehrig’s disease, commit suicide. The judge sentenced Dr. Kevorkian to 10 to 25 years in prison.He was released in 2007, after serving 8 years.




Association offered guidelines to help the courtsdecide at what point euthanasia was a crime. In1990, the Ministry of Justice accepted these cri-teria, and, in 1993, the Dutch parliament votedin favor of this reporting system (Daniel, 1997).PAS has strong public support in theNetherlands, where it is monitored by the gov-ernment. In 2001,, about 0.2% of all deaths inthe Netherlands were the result of PAS (van derHeide, et al., 2007). Because people are livinglonger, the practice of PAS is likely to increase.

Oregon, which passed the Death with DignityAct, is the only U.S. state that allows PAS. InOregon, a physician must sign an AttendingPhysician’s Compliance Form, which is sent to theOregon Public Health Department to ensure thatthe physician has complied with the law. On thisform, the physician must attest to the following:

• The patient has requested the physician’sassistance in suicide three times, the lastin writing, with the statement is datedand signed by the patient in the presenceof two witnesses.

• The physician must wait at least 15 daysafter the initial oral request to the secondoral request and at least 2 days after thefinal written request before writing the pre-scription for the lethal drug. The patient’swritten request for medication to end his orher life is attached to the compliance form.

• Two physicians have determined that thepatient has a life expectancy of 6 monthsor less.

• The patient is not suffering from a psychi-atric or psychological disorder or depres-sion causing impaired judgment.

• At least one of the two witnesses to thepatient’s written request for the lethal pre-scription is a person who is not a relativeof the patient, does not stand to benefitfrom the estate of the patient, and is notan employee of the institution where thepatient is being treated.

The physician also must indicate on the form thatthe patient was fully informed about:

• his or her medical diagnosis;• his or her prognosis;• the potential risks associated with taking

the medication;• probable result of taking the medication; and• the feasible alternatives, including, but

not limited to, comfort care, hospice care,and pain control.

The patient has the right to rescind the requestfor medication to end his or her life at any time.

In 2003, 38 people (one-tenth of 1% of allOregon deaths) committed PAS. Twenty-one PASdeaths occurred in 2001, and less than half that in1998 (Lee, 2003). Most of those selecting PASpeople had cancer and were well-educated whitemales. The top three reasons they cited for want-ing to end their lives were:

• loss of the ability to make their own deci-sions (84%);

• decreasing ability to participate in activi-ties they enjoyed (84%); and

• loss of control of their bodily functions(47%) (Lee, 2003).

Physician-assisted Suicide and the LawIn the United States, the “liberty interest”—anindividual’s right of choice—is guaranteed by theFourteenth Amendment. Thus, the issue of PAS is

Questions & AnswersQuestion: Are any other states besidesOregon trying to legalize PAS?

Answer: In 2004, Arizona, Hawaii, andVermont introduced state bills to allow PAS.At the same time, John Ashcroft, then UnitedStates Attorney General, issued a directivemaking it illegal for doctors to prescribe con-trolled narcotics to help terminally ill patientsdie. In 2006, the Supreme Court ruled (6–3in Gonzales vs. Oregon) that Ashcroft had over-stepped his authority.




as much about control as about dying, andpatients, and possibly family, should have theright to participate in all end-of-life decisions.However, 34 states have statutes explicitly mak-ing it illegal for anyone to assist in a suicide.

One state, Oregon, as the result of a citizen ini-tiative ballot (Measure 16), passed the DeathWith Dignity Act, permitting PAS death undervery restricted conditions. Shortly thereafter,opponents of the law persuaded the lower house ofthe Oregon legislature to return Measure 16 tothe voters for repeal.

Some months earlier, the ninth circuit federalappeals court upheld Measure 16 but allowed astay until the Supreme Court ruled thatAmericans did not have a constitutional “right todie.” The Supreme Court, however, did not pre-clude states from passing laws establishing such aright (Savage, 1997).

In their decision to uphold Measure 16, theninth circuit judges said that the “liberty inter-est” should allow competent, terminally illpatients the right to choose the time and mannerof their death. They considered that adequatelyrigorous safeguards could be implemented in thedecision process to prevent abuse: “We believethat the possibility of abuse . . . does not out-weigh the liberty interest at issue” (Compassion inDying v State of Wash, 79 F 3d 790, p. 837).

Addressing the issue of physician-assisted sui-cide, the judges stated:

We see no ethical or constitutionally recogniz-able difference between a doctor’s pulling theplug on a respirator and his prescribing drugswhich will permit a terminally ill patient to endhis own life . . . . To the extent that a differenceexists, we conclude that it is one of degree andnot one of kind (Compassion in Dying v State ofWash, 79 F 3d 790, p. 824).

The judges also observed that “today, doctors aregenerally permitted to administer death-inducingmedication, as long as they can point to a con-comitant pain-relieving purpose” (p. 822).Physicians are aware of this double effect, a termthat “originates in Roman Catholic moral theol-ogy, which holds that it is sometimes morally jus-

tifiable to cause evil in the pursuit of good” (May,1978, p. 316).

Specifically, in medical usage, double effect can bedescribed as follows: The intent of palliative treat-ment of the terminally ill is to relieve pain and suf-fering, but the patient’s death is a possible sideeffect of the treatment. It is, therefore, ethicallyacceptable for a physician to increase pain-relievingmedication gradually, being aware that the medi-cation may depress respiration and cause death.

In November 1997, 60% of Oregon votersrejected the repeal of Measure 16. The appealscourt then lifted the stay. Both proponents andopponents of Measure 16 predict the adoption ofsimilar measures in other states (Murphy, 1997).

In Australia, The Rights of the Terminally IllAct went into effect July 1, 1996, in theNorthern Territory, but the legislation was short-lived. In March 1997, the federal parliamenteffectively repealed it by passing the EuthanasiaLaws Bill (Gordon, 1997). Draft legislation in thestate of South Australia, however, if passed, willchallenge it. Both the Oregon and NorthernTerritory laws had exhaustive provisions designedto safeguard the integrity of the legislation and toprevent abuse (Oregon Revised Statute 127;Cordner, 1995).

Has all the legal maneuvering about PASresulted in justice? To most people, medical jus-tice means the fair and equal treatment ofpatients. But the current situation seems unjust.For instance, terminally ill patients often are toodebilitated to take active steps to end their suffer-ing should they choose to do so.

Because it is illegal in most states for a personto assist a suicide, many terminal patients aredenied choices available to the more privileged insociety, because they are much more likely to havea relationship of trust with a medical practitionerwho will discreetly help to alleviate their suffer-ing. When commenting on the demise of his leg-islation, the former Northern Territory chiefminister observed that the senators who voted forrepeal belong to a privileged, wealthy group who,themselves, have access to voluntary euthanasia(Ceresa, 1997).




Religion is another factor inhibiting beliefsabout the suitability of PAS. In Michigan,approximately 30% of physicians who opposedassisted suicide did so primarily because of reli-gious conviction (Bachman, 1996). The principalopponents of both the Oregon and NorthernTerritory legislations held strong religious views.Results from a number of other studies suggestthat among the general population fervent reli-gious belief is an important predictor of opposi-tion to PAS (Bachman, 1996; Suarez-Almazor,Belzile, & Bruera, 1997; Ward, 1980). As theninth circuit judges stated:

Those who believe strongly that death mustcome without physician assistance are free to fol-low that creed, be they doctors or patients. Theyare not free, however, to force their views, theirreligious convictions, or their philosophies on allother members of a democratic society, and tocompel those whose values differ from theirs todie painful, protracted, and agonizing deaths.(Compassion in Dying v State of Wash, 79 F 3d 790,p. 839)

If both patients and physicians were free tochoose, patients could select a physician holdingviews on PAS or euthanasia similar to their own.

Another important matter is the impact of ter-minal illness on patients’ families. Currently, it isillegal to assist a person in committing suicide intwo-thirds of the United States. Consequently,people who are in unbearable pain often die alone(if they commit suicide), because they do not wantto put loved ones at legal risk. When consideringthe possibility of this kind of risk, the ninth circuitjudges observed that almost all who agreed to assistthe dying avoided prosecution, but would “likelysuffer pain and guilt for the rest of their lives. Thisburden would be substantially alleviated if doctorswere authorized to assist terminally ill persons toend their lives and to supervise and direct others inthe implementation of that process” (p. 836).According to Fraser and Walters (2000), it seemsthat a democratic society that observes justice andliberty should permit differing opinions and allowterminally ill people some freedom to decide forthemselves when and how they die.

Gender Bias and Physician-assisted SuicideProponents of PAS often offer a story or case studyto convince the reader or listener (Keenan, 1998).One such story (Vorenberg and Wanzer, 1997) isthe case of “Uncle Louis,” who is in constant painbecause there is supposedly no good pain man-agement for his type of cancer. After many thera-pies and surgery, he is definitely terminal. He hasdiscussed PAS with his physician, and he nowwants it. Proponents then ask if Uncle Louisshould be left to suffer.

The implication is that Uncle Louis has a rightto die. But how common is the case of UncleLouis? Is he really representative of the people ask-ing for PAS? In most cases, the person asking forPAS is usually a woman, not a man (Vorenberg &Wanzer, 1997). Why might the reason be? Manymore elderly poor are women, and women aretwice as likely to suffer from depression as men.Age, poverty, and depression are among the lead-ing reasons why people ask for PAS. The femalepatient also is more likely to be worried about hercondition’s impact on others. And a certain type ofwoman—depressive, self-effacing, and near theend of a life largely spent serving others—mightbe particularly vulnerable to the offer of PAS.

The case of Uncle Louis is about one man whohas tried every possible option, consulted physi-cian and family, and apparently faces unmanage-able pain. He has considered his decision, but heis unable to carry it out because laws prohibit it.The more likely case, however, is that of a womanwho, if she fears pain, fears it because her health-care providers do not properly manage it. Shechooses PAS because she does not want to burdenher family.

Gender inequality involving the wishes of thedying is found in the courts as well. After hearingfamilies testify about an incompetent patient’swishes to be removed from life support, judgesrule in favor of a male patient in 75% of cases, butonly 15% for females. In their opinions, it appearsthat most judges treat men’s decisions as rationalbut women’s as emotional and immature (Miles &August, 1990).




The irony of a case like Uncle Louis’ is that it isan attempt to persuade people to change the lawfor a rather small number of empowered persons.The cost of this persuasion is doing away withthose persons who already find themselves isolatedfrom society, family, and the healthcare industry.

Pain and PASA second questionable aspect of the Uncle Louis caseis the absence of pain relief medication (Keenan,1998). In 1994, the New York State Task Force onLife and the Law reported, “Taken together, modernpain relief techniques can alleviate pain in all butextremely rare cases. Effective techniques have beendeveloped to treat pain for patients in diverse con-ditions” (Martyn & Bourguignon, 1997). Yet, alltoo often, pain relief is not provided.

Actually, pain relief is a minor factor in themotivation of people who seek PAS, according tothe medical ethicist Ezekiel Emanuel (1997).According to Emanuel, “No study has ever shownthat pain plays a major role in motivating patientrequests for physician-assisted suicide or euthana-sia” (p. 75). Distress and dependency are the pri-mary concerns of PAS candidates.

How Voluntary Is PAS?How likely is it that most PAS candidates wouldenjoy the choice that Uncle Louis has? Of 3600Dutch deaths reported as PAS in 1994, about1000 were cases wherein the physician took thepatient’s life without an explicit request from thefamily or the patient (Keenan, 1998). Dutchstatistics on PAS, however, leveled off and thendeclined in the period 1995–2001 (Onwuteaka-Philipsen, et al., 2007).

Even more unsettling about the possibility ofinvoluntary PAS is that The Royal Dutch MedicalSociety and the Dutch courts have extendedmercy killing to infants and to psychiatricpatients. Regarding these developments, twoDutch lawyers commented that the increase ininvoluntary euthanasia and mercy killing in theNetherlands has gone unchecked, despite legalconditions that were designed to guarantee vol-unteerism (Keown, 1995). In response to these

concerns, in the Netherlands euthanasia requestsare assessed by the public prosecutor only afterbeing advised by a multidisciplinary committeeof medical, ethics, and legal specialists(Onwuteaka-Philipsen, et al., 2007). The rate ofPAS (1995 to 2001) has been level and accompa-nied by an increase in effective pain management.

Could a similar creep toward involuntary PAShappen in the United States? The Dutch are amore homogenous society, with universal healthcare. U.S. society is fragmented and economicallystratified, with a patchwork healthcare system.The likelihood of creep toward involuntary PAS,therefore, might be greater in the United States(Kaveny, 1997).

Hard Cases and Representative CasesReal cases like Uncle Louis’ exist (Kennan, 1998).Ethicists call them “hard cases,” meaning theyraise the question of whether a particular lawshould be absolute. For instance, an abused wifewho kills her husband might be morally excusedor even morally right, and, therefore, a judge andjury might be persuaded to “let her off.”Legalizing her action, though, might make it anacceptable alternative and jeopardize other, morecivil, methods for resolving domestic conflict. Ahard case like the abused wife as an exception tothe law does not justify creating a new law—norshould it be used to nullify an existing law.

Thus, in debating PAS legislation, it seems moreimportant to ask whether cases cited in defense orrebuke are representative cases or hard cases. DoesUncle Louis represent a large group for whom thelaw should be changed? If he is not representative,then it is exactly like the case of the abused wife.Hard cases depend not on legislators making newlaws, but on judges and juries interpreting existinglaws and precedents for a particular case.

If the one case of Uncle Louis is not represen-tative, what might be a representative case? Morelikely, it might be an isolated and depressedwoman who does not want to be a burden, whohas, at best, uncertain access to adequate healthcare, and whose own wishes are rarely solicited or




heeded. When this case is taken into account, itseems that the critical issue facing Americans incaring for the dying is not lack of autonomy, butthe inability to care properly for the dying. Inshort, the typical case is a reminder of a society’sfailure to the aging, to women, and to the poor.

What, then, would be the social effect of a lawthat permits PAS? Proponents for the case ofUncle Louis are only interested in the autonomousperson. But opponents of legalization try to per-suade others that the law that the friends of “UncleLouis” want invalidated is the same law that keepsthe person of more common instance from beingmarginalized to death.

SUMMARY

• Ethical behavior is defined by moral prin-ciples or values based on concepts of goodor bad.

• The growing difficulty and complexity (aswell as the dangers) of medical decisionmaking have created the role of the bioethi-cist, whose job it is to help medical profes-sionals and families make difficult medicaldecisions, especially for people at the endof life.

• All cultures have guidelines—codes, prayers,creeds or oaths—to guide their healers.Members of the AMA are bound by theHippocratic Oath. Even though not specifi-cally spelled out in the oath, the impliedmessage for doctors is “to do no harm.”

• In euthanasia, the physician takes an actionto end the patient’s life. When the physi-cian takes direct action to do so, it is calledactive euthanasia, distinguishing it from pas-sive euthanasia, which is simply withholdingor withdrawing the treatment needed tosustain life and allowing the patient to die.Physician-assisted suicide involves the physi-cian supplying the means, usually medica-tion, to a patient who then decides andtakes the necessary action.

• If it were legal, more than one-third ofU.S. physicians would be willing to offeractive euthanasia with medication. One-

quarter would be willing to give a lethalinjection. An increasing number of peoplein the United States support painlesseuthanasia of incurably ill patients—ifthey and their families request it.

• Proponents of legalized euthanasia arguethat rights to self-determination includethe right to choose how and when to die.

• Opponents of legalized euthanasia worryabout a “slippery slope” wherein ending alife might be a difficult decision at first,but then become easier the more it is done.

• Most people are more supportive of physi-cian-assisted suicide (PAS). In 2005, amajority (70%) of 1,010 Americans polledfavored allowing some form of PAS.

• In the United States, 34 states havestatutes explicitly making it illegal foranyone to assist in a suicide.

• Currently, Oregon is the only state thatallows PAS. In 2003, 38 people (one-tenthof 1% of all Oregon deaths) wereattributed to PAS.

• In Australia, The Rights of the TerminallyIll Act went into effect July 1, 1996, inthe Northern Territory, but in March 1997the federal parliament effectively repealedit by passing the Euthanasia Laws Bill.

• Women ask for PAS more often than men.• When debating PAS legislation, it is impor-

tant to ask whether cases cited in defense orrebuke are representative cases or hard cases.

ADDITIONAL RESOURCES

BooksShavelson, L. (1995). A chosen death: The dying confront

assisted suicide. New York: Simon & Schuster. Anargument for assisted suicide, this book is a portraitof five dying people who chose euthanasia.

Smith, W. J. (1997). Forced exit: The slippery slope fromassisted suicide to legalized murder. New York: Crown.A well-written argument against physician-assistedsuicide is presented in this book.

Woodman, S. (1998). Last rights: The struggle over the right todie. New York: Plenum Press. An examination of theright-to-die movement and the medical, ethical,legal, and social issues surrounding euthanasia areaddressed in this book.



References 49

MovieMillion Dollar Baby. (2005). Story of a fighter who fought

both to live and die.

CRITICAL THINKING

1. Was the removal of Terri Schiavo’s feed-ing tube active or passive euthanasia?Explain.

2. If you have a terminal illness, with a par-alyzed body but active mind, describethree good reasons for continuing to live.

CLASS ACTIVITIES

1. Interview a person who deals with ter-minal illness on a daily basis (e.g., aphysician or nurse) and report findingsto the class.

2. As a class, debate whether or not PASshould be legalized.

REFERENCES

American Medical Association (AMA), Council on Ethicaland Judicial Affairs (CEJA). (2006–2007). AMACode of Medical Ethics. Chicago: AMA.

Bachman, J. (1996). Attitudes of Michigan physicians andthe public toward legalizing physician-assistedsuicide. New England Journal of Medicine 334,303–308.

Blendon, R. J., Szalay, U. S., & Knox, R. A. (1992). Shouldphysicians aid their patients in dying? The publicperspective. Journal of the American MedicalAssociation, 267, 2658–2662.

Bolton, G. (2001). Reflective practice writing for professionaldevelopment. London: Sage.

Caddell, D. P., & Newton, R. R. (1995). Euthanasia:American attitudes toward the physician’s role. SocialScience and Medicine, 40(12), 1671–1681.

Ceresa, M. (1997, March 24). Others will follow. TheAustralian, p. 2.

Cordner, S. (1995). Reactions to Australian state’seuthanasia law. Lancet, 345, 1561–1562.

Cuperus-Bosma, J. M., van der Wal, G., Looman, C. W. N.,& van der Maas, P. J. (1999). Assessment ofphysician assisted death by members of the publicprosecution in the Netherlands. Journal of MedicalEthics, 25, 8–15.

Daniel, C. (1997). Killing with kindness. New Statesman,126(4347), 16–18.

DeVries, R., & Subedi, J. (1998). Of bioethics and society:Constructing the ethical enterprise. Upper Saddle River,NJ: Prentice Hall.

Dietz, D. (1997, March 11). Assisted-suicide debate splitsCatholics. The Statesman-Journal (Salem, OR), p. 2A.

Emanuel, E. (1997, March). Whose right to die? TheAtlantic Monthly, pp. 73–79.

Fraser, S. I., & Walters, J. W. (2000). Death—whosedecision? Euthanasia and the terminally ill. Journalof Medical Ethics, 26(2), 121.

Friedenwald, H. (translator). (1917). Daily prayer of aphysician. Bulletin of the Johns Hopkins Hospital, 28,260–261.

Frileux, S. C., Lelievre, M. T., Munoz, S., Mullet, E., &Sorum, P. C. (2003). When is physician assistedsuicide or euthanasia acceptable? Journal of MedicalEthics, 29(6), 330–336.

Gawande, A. (2007). Better: A surgeon’s notes on performance.Metropolitan Books: Henry Holt and Company.

Genuis, S. J., Genuis, S. K., & Chang, W. C. (1994). Publicattitudes toward the right to die. Canadian MedicalAssociation Journal, 150, 701–708.

Gordon, M. (1997, March 29). How euthanasia law wassunk. The Australian, Focus, 20.

Guyer, R. L. (1998, February 6–8). When decisions are life-and-death. USA Weekend, 26.

Johansen, S., Hølen, J. C., Kaasa, S., Loge, J. H., &Materstvedt, L. J. (2005). Attitudes towards, andwishes for, euthanasia in advanced cancer patients ata palliative medicine unit. Palliative Medicine, 19(6)454–460.

Kaveny, M. C. (1997). Assisted suicide, euthanasia, and thelaw. Theological Studies, 58, 124–148.

Keenan, J. F. (1998, November 14). The case for physician-assisted suicide? America, 14.

Keown, J. (Ed.). (1995). Euthanasia examined. New York:Cambridge University Press.

Lavery, J., Boyle, J., Dickens, B., Maclean, H., & Singer, P.(2001). Origins of the desire for euthanasia andassisted suicide in people with HIV-1 or AIDS: Aqualitative study. Lancet, 358, 362–367.

Lee, D. (2003). Physician-assisted suicide: A critique ofintervention. Hastings Center Report. Retrieved<DATE>, from http://findarticles.com/p/articles/mi_go2103?is_200301/ai_n7361257

Littlejohn, T., & Burrows-Johnson, J. (1996). Anattitudinal survey of euthanasia in Windward Oahu.Hawaii Medical Journal, 55, 265–269.

Mak, Y. W., Elwyn, G., & Finlay, I. G. (2003). Patients’voices are needed in debates on euthanasia. BritishMedical Journal, 327(7408), 213–215.

Martyn, S., & Bourguignon, H. (1992). Physician-assistedsuicide: The lethal flaws of the ninth and secondcircuit decisions. California Law Review, 85(2), 400.

May, W. (1978). Double effect. In W. Reich (Ed.), Encyclopediaof bioethics (p. 316). New York: The Free Press.

McLean, S., & Britton, A. (1996). Sometimes a small victory.Glasgow: Institute of Law & Ethics in Medicine,Glasgow University.




Meier, D. E., Emmons, C. A., Wallenstein, S., Quill, T.,Morrison, R. S., & Cassel, C. K. (1998). Nationalsurvey of physician-assisted suicide and euthanasia inthe United States. New England Journal of Medicine,338, 1193–1201.

Miles, S., & August, A. (1990). Courts, gender, and theright to die. Law, Medicine, and Health Care, 18,85–95.

Murphy, K. (1997, November 5). Voters in Oregon soundlyendorse assisted suicide. Los Angeles Times, p. A1.

Noppe, L. D., & Noppe, I. C. (1996). Ambiguity inadolescent understandings of death. In C. A. Corr &D. E. Balk (Eds.), Handbook of adolescent death andbereavement. New York: Springer, pp. 25–41.

Nuland, S. B. (1995). How we die. New York: Vintage Books.

O’Connell, L. J. (1995). Religious dimensions of dying anddeath. The Western Journal of Medicine, 163(3), 231.

Oregon State Public Health Division, Center for HealthScience. (2006). Attending Physician’s ComplianceForm (ORS 127.800-ORS 127.897). RetrievedMarch 2007, from http://egov.oregon.gov/DHS/ph/pas/index.shtml

Onwuteaka-Philipsen, B. D., van der Heide, A., Koper, D.,Keij-Deerenbergm, I., Rietjens, J. A., Rurup, M. L.,et al. (2007). Euthanasia and other end-of-lifedecisions in the Netherlands in 1990, 1995, and2001. Lancet online. Retrieved March 2007 from,http://image.thelancet.com/extras/03art3297web.pdf

Paris, J. J., & Reardon, F. E. (1992). Physician refusal ofrequests for futile or ineffective interventions.Cambridge Quarterly of Healthcare Ethics, 1, 127–134.

Post, S. G. (1995). Baby K: Medical futility and the freeexercise of religion. Journal of Law and Medical Ethics,23, 20–26.

Redinbaugh, E. M., Sullivan, A. M., Block, S. D., Gadmer,N. M., Lakoma, M., Mitchell, A. M., et al. (2003).Doctors’ emotional reactions to recent death of apatient: Cross sectional study of hospital doctors[Electronic version]. British MedicalJournal,327(185). Retrieved April 21, 2008, fromhttp://www.bmj.com/cgi/content/full/327/7408/185

Rogers, J. R. (1996). Assessing right to die attitudes: Aconceptually guided measurement model. Journal ofSocial Issues, 52, 63–84.

Savage, D. (1997, June 27). High Court refuses to grantconstitutional “right to die.” Los Angeles Times, p. A1.

Sedlitz, L., Duberstein, R., Cox, C., & Conwell, Y. (1995).Attitudes of older people towards suicide and assistedsuicide: Analysis of Gallup poll findings. Journal ofthe American Geriatrics Society, 43, 993–998.

Shalit, R. (1997). When we were philosopher kings. TheNew Republic, 216(17), 24–28.

Singer, P. A., Choudhry, S., Armstrong, J., Meslin, E. M., &Lowy, F. H. (1995). Public opinion regarding end-of-life decisions: Influence of prognosis, practice, andprocess. Social Science and Medicine, 41, 1517–1521.

Steinberg, M. A., Najman, J. M., Cartwright, C. M.,MacDonald, S. M., & Williams, G. M. (1997). Endof life decision making: community and medicalpractitioners’ perspectives. Medical Journal ofAustralia, 166, 131–135.

Suarez-Almazor, M., Belzile, M., & Bruera, E. (1997).Euthanasia and physician-assisted suicide: Acomparative survey of physicians, terminally illcancer patients, and the general population. Journalof Clinical Oncology, 15, 418–427.

Taylor, H. (2005, May 27). Poll: U.S. adults favoreuthanasia and physician-assisted suicide. HarrisInteractive Inc. Retrieved March 2007, fromwww.deathwithdignity.org/fss/opinion/harrispoll04.27.05.asp

Van der Heide, A., Onwuteaka-Phillipsen, B. D., Rurup,M. L., Buiting, H. M., van Delden, J., Hanssen-deWolf, J. E., et al. (2007). End-of-life practices inthe Netherlands under the Euthanasia Act. NewEngland Journal of Medicine, 356(19), 1957–1965.

Van der Maas, P. J., Pijnenborg, L., & van Delden, J. J. M.(1995). Changes in Dutch opinions on activeeuthanasia, 1966 through 1991. Journal of theAmerican Medical Association, 273, 1411–1414.

Vass, A. (2002). What’s a good doctor, and how can wemake one? British Medical Journal, 325, 667–668.

Vorenberg, J., & Wanzer, S. (1997, March–April). Assistingsuicide. Harvard Magazine, p. 30.

Ward, A. (1980). Age and acceptance of euthanasia. Journalof Gerontology, 35, 421–431.

Weir, R. F. (Ed.). (1997). Physician-assisted suicide.Bloomington: Indiana University Press.



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