ABOUT THE AUTHOR: Nahel Kapadia graduated in May 2013, majoring in Biological Sciences.
Kate Cheney was diagnosed with terminal stomach cancer at eighty-five years old. She requested assisted suicide, but her doctor refused to prescribe the lethal medication and instead referred her to a psychiatrist. Again, Kate was denied the procedure on the basis that she lacked the decision-making capacity to make a fully informed and conscious choice about her end-of-life treatment. Kate ultimately came to terms with the psychiatrist’s judgment, but her daughter, Erika, demanded a second opinion. They visited a clinical psychologist; although the psychologist felt that Kate’s “choices may be influenced by her family’s wishes and her daughter may be somewhat coercive,” he agreed to prescribe lethal barbiturates. Shortly after consuming the drugs, Kate died in the presence of her family on July 23, 1999 (Steinbock 238). Stories of terminally ill patients like Kate illustrate the need for better, more effective safeguards that protect patients in places where physician-assisted suicide is legalized. In “shopping” for a consenting doctor, Kate and her daughter were eventually able to find a healthcare professional whose opinion matched their own, successfully averting the barriers designed to deter patients from impulsive and ill-advised decision-making (Wisconsin Right to Life). In addition, familial pressure from Erika may have persuaded Kate to stand by her initial requests for assisted suicide and to finally ingest the medications. Such circumstances bring into question the objectivity and validity of laws that permit physician-assisted suicide. How can we preserve a patient’s right-to-die with legislation so that it is not prone to misinterpretation, while considering alternatives to physician-assisted suicide that can protect both patient life and integrity?
Physician-assisted suicide is a form of active voluntary euthanasia in which a doctor provides a terminally ill patient with the necessary information and lethal medication to end his or her life. The intention is to free the patient from any unremitting pain and suffering so that he or she can experience a more dignified death. The controversy around physician-assisted suicide illustrates the current conflict between patient autonomy and physician beneficence in medical ethics. Using Oregon as our model, we will examine how the legalization of physician-assisted suicide comes at the expense of the medicalization of death. The introduction of assisted suicide in Oregon has coincided with an increase in the number of assisted suicide requests over the past decade, from thirty-nine in 2000 to ninety-five in 2009 (Oregon.gov). These numbers speak to the gravity and significance of the issue. The focus should not be on the fight for the legalization or ban of physician-assisted suicide, but on the installation of safeguards that protect patients and physicians from misusing assisted dying, and more importantly, on the improvement of palliative care and patient-doctor communication. An increase in the quality of end-of-life treatment would create both a greater awareness for patient-centered care and reduce the need for physician-assisted suicide.
The advancement of technology is responsible for bringing the issue of physician-assisted suicide to the forefront of medical discussion. There are two principal reasons for why the rise of modern medical technology has popularized the topic of assisted suicide. First, while medical progress has lowered the death rate among HIV patients through effective antiviral drugs and extended the lifetime of cancer patients through chemotherapy and developments in gene therapy, it has also created a lower quality of life characterized by a prolonged and costly death (Martin 54). Life-sustaining interventions such as dialysis and feeding tubes allow patients to live longer on machines, limiting their mobility while under constant medical care. For many, physician-assisted suicide is viewed as a more humane alternative to living a debilitated, and often painful, life. Secondly, the widespread availability of lethal medications in the form of barbiturates, like sleeping pills, enables terminally ill patients to experience a relatively peaceful and painless death. The ease with which patients can commit medically authorized suicide increases the chances that they will request such drugs (56). Thus, in improving patient medical treatment, technology has also inadvertently created the need for more progressive and compassionate end-of-life care so that assisted suicide is not perceived as the sole solution.
In November of 1994, Oregon became the first state to legalize physician-assisted suicide with its Death with Dignity Act, which passed with a fifty-one percent majority vote. The law allows terminally ill patients in Oregon to end their lives by obtaining lethal medication from their physicians. Under the guidelines of the act, a patient receiving a prescription for any lethal medication must 1) have the mental competency to make a health care decision, 2) be diagnosed with around six months left to live, and 3) provide a written and oral request for the procedure (Oregon.gov). But regardless of the detailed requirements mandated by the state of Oregon, several issues must be addressed before physician-assisted suicide is permitted in other states. For example, it is difficult to characterize terminal illness by a legal definition; each medical case is different and deserves a personalized evaluation. Similarly, a patient’s ability to make clear choices can be compromised by his or her pain and suffering, making it hard to assess whether they are mentally competent to make decisions(University of Washington School of Medicine). This ambiguity complicates the dialogue surrounding physician-assisted suicide .
The recent legalization of physician-assisted suicide has correlated with an increase in the number of requests, a phenomenon consistent with the “slippery slope” argument: if states allow assisted suicide, the practice will become more generally accepted among the public and medical community (Kant 42). In the Netherlands, where physician-assisted suicide has been permitted by the courts since the 1970s, the number of suicide requests has increased from 1600 in 1979, to 4000 in 1985, and to 5000 in 2001 (Marquet et al. 201). Moreover, while 30 percent of physician-assisted suicide requests were granted in 1990, 39.6 percent of requests were carried out in 1995. These numbers may correspond to a growing acceptance and tolerance of assisted suicide over time. Similarly, in Oregon, where the procedure became legalized in the 1990s, the ratio of assisted suicide deaths to total deaths grew from 5 in 10,000 to 14.7 of 10,000 over the course of eight years (1998-2006) (Hendin and Foley 1636). Thus, the Netherlands can be seen as a precedent for the consequences that Oregon will face for legalization of physician-assisted legalization.
In the Netherlands, there has also been a shift in the reasons for requesting assisted suicide. Pain has become a less important reason, while fear of deteriorating health has become more important (Marquet 201). This fear is related to the loss of control and autonomy common for terminally ill patients. For example, a study conducted in the Netherlands “found that sixty percent of the elderly were afraid that their lives could be ended against their will” (Kant 42). Although the arguments in favor of physician-assisted suicide are centered around the importance of respecting patient will and autonomy, they often ignore the long-term implications of voluntary euthanasia. Social scientists Sharon Fraser and James Walter believe that the legalization of assisted suicide is consistent with the principles of liberty and justice in our society, arguing that the presence of divergent opinions and beliefs justifies a patient’s right to choose between life and death (125). Decisions about death are extremely personal and no one medical case is the same. For terminally ill patients who must cope with a loss of independence, health, and emotional well-being, physician-assisted suicide serves to alleviate suffering and humanize death. However, in the long run, the legalization of assisted suicide does not change the fact that without advancements in end-of-life care, we can never properly respond to the concerns of patients. As stated by physician Dr. Robert Twycross, presenting physician-assisted suicide as an option “serves simply to weaken the resilience and resolve of those who are ill” and turns a blind eye to the real problem which is the shortage in compassionate and palliative treatment (92).
In the United States, this shortage in palliative care is characterized by a need to better manage pain and the possibility of death, as well as an obligation to understand the physical, psychological, and spiritual desires of terminally ill patients (Ferris et al. 3055). In a recent study conducted by the American Hospital Association, only forty-two percent of hospitals in the U.S. offer a pain management plan and just fourteen percent provide a formal palliative care program (Last Acts 21). Accordingly, fifty-five to seventy-five percent of cancer patients experienced “moderate to severe pain, discomfort, anxiety, sleep disturbance or unsatisfied hunger or thirst,” suggesting inadequacies in comfort care (27). Even though most healthcare professionals agree that severe pain can be effectively controlled and treated, more than half of patients residing in hospitals and nursing homes complain of unrelieved pain (34). These statistics are shocking because they are in stark contrast with what we consider progressive, advanced medical care in America. Despite the developments made in palliative care and medicine as a whole, it remains an unfortunate fact that these practices are underused, perhaps due to our “death-denying culture” or our lack of awareness regarding the existence of other treatment options (1).
The underlying misconceptions about palliative care emphasize the need to better integrate the ideas for improving the quality of life into modern medicine. The World Health Organization describes palliative care as the “active total care of patients whose disease is not responsive to curative treatment” (Foley and Gelband 3). This definition wrongly differentiates between medicine that is intended to cure and medicine that is intended to heal and provide comfort. Instead, palliative care must be comprehensive, combining medical technology with symptom control and emotional support. Likewise, institutional and economic obstacles foster misinformation about the efficacy of end-of-life care, deny healthcare professionals training and education in the area, and prevent further investments into palliative treatment options (2). For example, the National Cancer Institute spends less than one percent of its budget on “any aspect of symptom control, palliative care, or end-of-life research or training” (3). In order to improve the implementation of palliative care, we must focus on three general approaches: the education of healthcare professionals so that they can properly address the needs of end-of-life patients, the delineation of standards of palliative care, and the greater investment of funds and research to increase the availability palliative care.
Educating physicians about the relevance of palliative care in end-of-life treatment is critical for improving the quality of medicine. In 2007, only nine percent of forth-year medical students in the United States received training in some aspect of end-of-life care (Hammel et al. 1356). While medical schools must provide extensive clinical experience, the overarching goal of medical education should be to emphasize compassionate care so that physicians can learn to properly treat and comfort patient who are facing end-of-life decisions. As described by Dr. Danis Marion, “the goals of care should guide the use of technology,” not vice-versa (2005). For example, in the intensive care unit (ICU), doctors attend to critically ill patients and often encounter difficult situations that necessitate the withholding of life-supporting technologies, or even assisted suicide (2005). A lack of education in palliative care can lead to miscommunication and cultural misunderstandings between patients and doctors, fostering conflict and distrust (Center for Bioethics: University of Minnesota). The development of guidelines that stress effective communication and cultural competence would help to preserve doctor-patient relations and allow doctors to respect patient concerns.
Another important approach to improving end-of-life treatment is the establishment of palliative care standards. The purpose of these standards is twofold: they hold healthcare professionals accountable for providing proper palliative treatment and also function as guidelines for improvement (Foley and Gelband 16). Although palliative care is a broad area of healthcare, some standards may be widely applicable. Quality indicators include the extent of pain management, the degree of patient satisfaction and decision-making, and the level of coordination between physicians and patients to ensure excellent care (17). These provisions can offer insight into areas where adequate end-of-life care is lacking, allowing public policymakers to target specific medical issues. For instance, the National Comprehensive Cancer Network is currently modifying guidelines for addressing symptoms such as depression, anxiety, and fatigue to apply to dying patients. The guidelines identify the status of the treatment for a particular symptom and diagnose areas for further development (14). These advancements in palliative care will allow doctors to better outline both the medical and emotional needs of terminally ill patients.
In the long term, increasing the level of public investment in end-of-life research is critical to the progress of patient-centered care. Palliative care specialists Kathleen Foley and Hellen Gelband describe the current state of end-of-life treatment as “poorly organized, poorly conceptualized, underfunded, and dependent on an insufficient number of well-trained researchers” (24). Nevertheless, pain management is one field of palliative care research that has gained headway in recent years. How pain can be minimized, how a patient’s cultural background affects how patients perceive and respond to pain, and what neurobiology is behind pain are just some issues that healthcare professionals are targeting (25). The National Palliative Care Research Center has built research networks and coordinated with palliative care experts across the United States in an attempt to “establish the knowledge base of the field” and offer “an evidence-based approach to palliative care practice.” Further research in palliative care will attend to the needs of a growing population, of which twenty percent is projected to be over the age of sixty-five in 2030 (National Palliative Care Research Center).
While the legalization of physician-assisted suicide reflects a growing respect for patient rights and autonomy, it overlooks the underlying need to deliver holistic, compassionate care. As noted by Dr. Robert Twycross, it is crucial to humanize the experience of the dying so that their emotional, physical, and spiritual needs are met (87). Moreover, end-of-life care that focuses on providing familial and emotional support to relieve suffering does not have to apply to just terminally ill patients. Patients facing chronic non-malignant conditions and progressive illnesses would benefit from extended palliative care as much as those with Stage IV cancer. While there is much room for improvement, the establishment of several hospices and care units has significantly improved the standard of care received by terminally ill patients. By adopting a multidisciplinary approach that incorporates both regular analgesic use and non-drug measures like creating a positive, comfortable environment, these care facilities have revolutionized the practice of medicine (89). In the future, perhaps the investment in palliative care will prove worthwhile as these patients will be less likely to wait out life on a machine or request physician-assisted suicide as the only way out (Murray 1056).
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