Physician Aid in Dying
Physician aid in dying includes any act that helps a patient die
in response to an informed patient's request.[124]
This includes physician-assisted suicide (in which the physician makes a medication
available to the patient, but the patient must perform the act of ingestion) and
physician-administered euthanasia (in which the physician administers the medication
directly). Some believe that there is an ethical distinction between making the
medication available and administering it, and they think that requiring the patient
to perform the final act is an important safeguard. Others, however, do not believe
the distinction is ethically significant, because both require effort and contribution
from the physician. For purposes of this discussion and unless otherwise specified,
voluntary euthanasia and physician-assisted
suicide are considered together, and
TABLE 89-5 -- Arguments for and against legalizing physician aid in dying
|
Issue |
Arguments Against |
Arguments For |
|
Autonomy |
Requests for physician aid in dying (PAD) are false expressions
of autonomy: |
Because the definition of a good death is personal, people should
be allowed to control the circumstances. |
|
Inadequate patient and physician knowledge
about pain and comfort control leads to a poorly informed choice. |
If the burdens of being alive outweigh the benefits, physicians
are obligated to permit PAD. |
|
Patients may be depressed or feel obligated
not to be a burden on the family. |
|
|
Beneficence |
Medicine can do a better job of maintaining patients' comfort
and dignity. |
Physicians are obligated to help patients have a good death (as
defined by the patient). |
|
Permitting PAD will harm the image of physicians. |
Supporting patients in their desires to have a good death will
enhance the image of physicians. |
|
Legalization |
There will be concern about the caregivers' impetus for offering
euthanasia (e.g., race, gender, socioeconomic status). |
Legal safeguards and public oversight will prevent abuses. |
|
Permitting PAD will discourage physicians from solving the problems
surrounding end-of-life care. |
|
|
Permitting PAD will devalue the sanctity of life, further nudging
society down the slippery slope toward accepting nonvoluntary euthanasia. |
|
the term physician aid in dying (PAD) is used to
denote both. Arguments surrounding PAD center on the interpretations of the principles
of respect for autonomy and beneficence and the possible ramifications of legalization
( Table 89-5
).
Society's experiences with PAD are primarily from the Dutch.
Although the Dutch had been practicing PAD for several decades, in 1993 the Dutch
parliament granted physicians immunity from prosecution if the competent patient
repeatedly requested euthanasia, had suffering that could not be relieved, and the
physician reported the true cause of death to the coroner. Two nationwide investigations
have been conducted into the Dutch practice of PAD.[125]
[126]
The 1990 Remmelink study found that of the
130,000 deaths in the study period, 2700 resulted from PAD. Nearly all patients
who received PAD were expected to die within 1 month, and physicians rejected more
than two thirds of patients' requests for PAD. In addition to those 2700 cases of
PAD, however, the Remmelink study found that an additional 1000 patients had their
lives ended by a physician without the explicit request of the patient. Primary
reasons given by patients requesting PAD were loss of dignity, pain, discomfort,
fear of pain and discomfort, dependency and "tiredness of life." The second study,
in 1995, showed similar results. Nearly all the patients who received PAD appeared
to have had a short life expectancy. An analysis of the two studies looking at 114
cases of assisted suicide and 535 cases of euthanasia found that complications and
incomplete aid in dying occurred more frequently with assisted suicide than euthanasia.
[127]
In 18% of assisted-suicide cases, physicians
chose to help the patient die. It is worth noting that this covered many years and
that complications are a matter of expectations and technique. The Royal Dutch Medical
Association has recommended that physicians be in attendance when lethal measures
are used to minimize suffering.[128]
In the United States, Washington v Glucksberg
[129]
and Vacco v Quill
[130]
provided guidelines for physician-assisted
suicide. In these cases, the courts held that there was no constitutional right
to physician-assisted suicide. The courts followed common ethical opinion in drawing
a distinction between the positive right to demand an action, such as physician-assisted
suicide, and the more powerful negative right to be free of bodily invasion. Although
there was no constitutional right to assisted suicide, individual states may choose
to legalize or prohibit it.[131]
In 1997, Oregon
legalized the Oregon Death with Dignity Act, which permitted terminally ill patients
to receive prescriptions in lethal quantities for the purpose of self-administration.
It does not permit any other forms of PAD, such as another person administering
the medication. Over the Act's first 5 years, 198 prescriptions have been written,
increasing each year from the 24 prescriptions written in 1998 to 58 prescriptions
written in 2002.[132]
During this time, 129 patients
died after ingesting the legally prescribed lethal medication, with a similar yearly
increase ranging from 16 in 1998 to 38 in 2002. Patients with cancer and amyotrophic
lateral sclerosis had a significantly higher rate of use of PAD than patients with
other diagnoses. The most common medications prescribed were secobarbital and pentobarbital,
and 97% had no seizures or vomiting after ingestion. The time from initial request
to death was a median of 43 days, and the range was 15 to 466 days.[132]
Primary concerns of the patient were loss of autonomy and loss of control of bodily
functions. The financial status of the patient did not seem to play a role in requests
for PAD.
 |
