By Anna Chong
Brief Summary of Reading:
Physician-assisted death is when a physician provides a patient with the means and information necessary to end his or her life. Only six countries and ten U.S. states have legalized the procedure. In the Hippocratic Oath, doctors explicitly promise to not administer a poison to anyone. As a healer, physicians want to promote the patient’s good (beneficence principle), and also avoid harming the patient (nonmaleficence principle).
The concept of medical futility refers to cases in which there is no reasonable way for the patient to be helped. Quantitative futility and qualitative futility are tools that set standards for when interventions become futile, when likelihood and quality of benefit fall below a minimal threshold. Futile interventions can give patients false hope and cause the physician moral distress. The justice principle is about allocating resources and treatments to patients who can benefit instead of wasting resources on patients who will not.
Physician-assisted dying relates to physicians, morality, and dignity. The “significant responsibility argument” and “significant relationship argument” assert that physicians bear some responsibility for the situation of their dying patients and have built up a relationship of trust, so physicians be the ones to carry out the assisted dying procedure. The “dignified lives argument” is that protecting dignity for terminally ill patients may involve giving them the ability to control when and how they die. The concept of action vs. omission is whether taking action to end a life is different from omitting life sustaining treatment.
Discussion Questions:
- Is there a difference between withholding/withdrawing life-sustaining treatment (omission) and prescribing a lethal dose (action)? (consider moral and conceptual perspectives, outcomes, and intentions)
- What circumstances can euthanasia be justifiable under, if at all?
- Should doctors be required to give euthanasia to patients who demand the procedure (autonomy principle)?
- Should doctors be able to suggest euthanasia as a recommended medical procedure?
- Should doctors be required to notify family members if a patient requests euthanasia? And if a family member or friend of the patient objects, should doctors carry out the wishes of the patient or the family?
Class Discussion:
Our class agreed that withholding/withdrawing LST and prescribing a lethal dose were conceptually different, but looking at the situation from a moral standpoint is more complex. Some patients want to die with dignity. In Canada, euthanasia is allowed for some psychiatric patients (MAiD).
Then, we started to talk about how a physician’s intentions matter. One argument is that withdrawing or withholding life-sustaining treatment (LST) allows the patient to live their lives and leaves room for a miracle, whereas prescribing a lethal dose is giving patients exactly what they need to kill themselves. However, a counterargument is that omission itself is an action. When LST is withdrawn, the physician knows that the patient will die. The intention and knowledge – knowing that the patient will die – is the same. Whether a physician withdraws LST or prescribes a lethal dose, both options mean that a physician is admitting the patient is going to die.
Our class agreed that if someone wants euthanasia, there should be multiple steps completed before the euthanasia is administered. The patient should have to sign paperwork, get their request approved by a council, and also have a conversation with the doctor and someone that the patient loves and trusts. A patient might not be in the best state of mind, so someone that the patient trusts should be there before the patient makes a rash decision. The physician should let the patient know euthanasia is an option and lay all cards on the table in a medically futile case.
Although patient autonomy is important, physician autonomy should also be taken into consideration. If a physician feels that administering euthanasia conflicts with their moral values or ethics, then the physician should not be forced to do the treatment. The physician should refer the patient to another physician who will do the treatment.
At the same time, physician autonomy is a slippery slope. Can a physician deny a patient of any treatment just because the physician does not believe in it? What if a physician denies a patient based on a patient’s identity, or because the physician does not believe in the procedure?
Doctors are there to serve. If doctors are not treating their patients to the extent they need help, then perhaps doctors are not doing their jobs.
Some terminally ill patients cannot do much with their lives; treatment can extend life, but cause quality of life to suffer. A patient could be on so many pills that their body lives but the person inside deteriorates so much that they are unrecognizable. One perspective is that euthanasia ends suffering. Perhaps we should be asking ourselves, from the physical, mental, and spiritual perspectives, what is death, and what is life?
For example, if a physician unplugs someone from life support, the physician is withdrawing treatment but also killing the patient. If you take away the very thing that keeps someone alive, you are still killing them.
When we discussed how much a patient’s family should know, we agreed that although physicians should notify family members, but patient autonomy rules – the patient should still be allowed to get euthanasia even if the family members object. Also, there is the possibility that physicians cannot legally tell anyone that their patient is considering euthanasia. HIPPA protects patients and their health information from being disclosed, and requires the patient to give permission before a physician can share health information with someone else.
Reflection:
Physician-assisted death is a complicated topic with no objective correct answer. Medically futile patients have to ask themselves: at what point is life not worth living anymore? And what does it mean to live a fulfilling life? Patients who have to face these difficult existential questions are conflicted with a roller coaster of emotions, and the physician should be there to help guide them through this emotional thought process.
Death can be defined in multiple ways. We should all ponder the meaning of death. Death can be defined from the physical perspective and the physical body giving up. Death can also be defined as the death of personhood and soul, where one’s mind deteriorates until they are a ghost of who they used to be, such as patients who are in a permanent vegetative state.
During the end of the discussion, we explored the idea that the omission vs. action debate is not really a debate at all: not doing anything is an action. When one chooses to not do anything, they are choosing to stick with the status quo. If we view omission as an action, then perhaps pulling the plug for life support is not really that different from euthanasia.
Finally, we need to take into account the responsibility of physicians. Physicians brought upon the treatment, and so medicine should bear some responsibility for the pain that patients experience.
We can strive for a particular ideal of ethics in the realm of medicine, but the boundaries and ends of medicine are evolving. We as humans need to ponder and meditate on these difficult and personal questions on what it means to live, to die, and medical ethics.