Addressing Non-Maleficence at End of Life

Healthcare professionals in the United States and across the globe play important roles in safeguarding human health. To ensure that the conduct of these professionals enhance patient wellbeing, a code of ethics has been developed. Essentially, this code identifies the values that the professionals should uphold at all times in their engagements with patients. Non-maleficence is among these values. Basically, non-maleficence concerns the avoidance of harm (Edwards, 2009). This value challenges practitioners to take all necessary steps to ensure that patients do not suffer harm. For example, a practitioner may provide the patient with effective treatment to prevent such issues as the emergence of complications. Most medical practitioners uphold the principle of non-maleficence in their practice. However, there are some practitioners who routinely violate this principle. For example, recently, it has emerged that some practitioners and medical institutions are engaging in patient dumping. In addition to exposing patients to harm, dumping also tarnishes the image of the medical community. While such practices as patient-dumping are obviously a violation of the principle of non-maleficence, there are other practices which fall in a grey are. Physician-assisted suicide (PAS) is among these. Given the benefit that it delivers to patients, PAS should be exempted from the non-maleficence principle.

Background

PAS is a contentious issue in the United States. There are many Americans who feel that human life is sacred and that all measures should be taken to preserve it. On the other hand, there are millions of Americans who feel that there are certain situations which compel medical practitioners to take deliberate action to end human life. In fact, support for physician-assisted suicide in the US is growing. In a poll that it conducted in 2017, Gallup established that a whopping 73% of Americans are in support of euthanasia (Wood & McCarthy, 2017). The overwhelming support for ending the life of patients who are terminally ill is indeed encouraging. However, this support does not answer the ethical conundrum that medical professionals encounter. As pointed out in the introduction above, medical ethics require practitioners to avoid exposing patients to harm. Many would argue that ending the life of a patient is detrimental to them. Given this argument, it appears that PAS amounts to a violation of the principle of non-maleficence. While this is true, one needs to remember that the ethical and moral status of PAS is complex and multi-faceted. In the discussion below, an examination of why PAS should be exempted from the non-maleficence promise is offered. The purpose of the discussion is to shield medical practitioners who are involved in PAS against blame or legal action.

Exempting Physician-Assisted Suicide (PAS)

Before exploring the reasons for exempting PAS from the non-maleficence principle, a background examination of this practice is needed. This examination will allow for a better understanding of the role that PAS plays in shaping medical care today, to be gained. Basically, PAS involves physicians working with patients to end their (patients’) lives (Battin, Rhodes & Silvers, 2015). In most cases, PAS is carried out on patients who are terminally ill and have no hope of recovery. As part of PAS, physicians often offer counseling. Furthermore, the physicians either prescribe the drugs needed to end the patient’s life or administer the drugs themselves. How PAS is carried out seems rather cruel and inhumane. However, one needs to remember that this procedure involves patients who are expected to die soon anyway.

It has been mentioned repeatedly above that non-maleficence is one of the ethical principles which govern medical practice. A note has also been made that protecting patients from harm is the essence of non-maleficence. One of the ways that practitioners protect patients from harm is respecting the wishes and desires of the patients. A patient would suffer emotional harm when their physician disregards their wishes. It is therefore not surprising that among the ethical principles that practitioners are expected to uphold is respecting patient autonomy and right to choose. Research shows that most terminally-ill patients are fully in support of PAS. Keith Wilson et al. (2000) conducted a study to determine the perspectives of terminally-ill patients as regards PAS. They established that a majority of the patients welcomed PAS. They felt that PAS would redeem them from the unbearable pain that they were enduring (Wilson et al., 2000). This finding is significant as it sheds light on how PAS does not violate the non-maleficence premise. Physicians who carry out PAS are simply satisfying the wishes of patients. If they deny the patients this procedure, the physicians would be violating the rights and dignity of the patients. Therefore, since it enables physicians to honor the wishes of patients, PAS is a fulfilment of the non-maleficence promise.

That PAS allows physicians to honor the wishes of patients helps to show that this procedure does not violate the non-maleficence promise. However, to build an even stronger argument, it is important to consider other implications of PAS. As pointed out above, PAS is almost always carried out on terminally-ill patients. One of the challenges that these patients grapple with is unbearable and extreme pain. This is an observation that Weiss et al. (2001) made after carrying out a study on the experiences of terminally-ill patients. They noted that “half of terminally ill patients experienced moderate to severe pain” (Weiss et al., 2001, p. 9265). Given the level of pain that they endure, one would expect that the patients would ask for pain relief medication. As Weiss and his colleagues found out, this is not necessarily the case. Surprisingly, they observed that only 30% of the patients who took part in the study asked for medication to relieve their pain (Weiss et al., 2001). The implication of this observation cannot be overstated. Now that the terminally ill patients do not want pain relief medication, one is prompted to wonder what their true desires are. Maytal Guy and Theodore Stern provide an answer. In their article, they state that terminally ill patients desire death (Guy & Stern, 2006). While this is disturbing and depressing, it shows that the patients find the pain to be so unbearable that they find death to be an escape from their agony. PAS brings an end to the pain that the terminally ill patients suffer. For this reason, it is a tool that practitioners can use to demonstrate their respect for the non-maleficence promise. Through PAS, the entire medical community reminds patients that its primary focus is shielding the patients against all forms of harm.

Extreme pain is one of the features that define terminal illness. However, it is not the only one. Indignity is another trait which makes terminal illness so undesirable and frightening. For example, many terminally ill patients are in vegetative states that render them unable to perform basic tasks. They need help with such issues as relieving themselves. The experiences of the terminally ill violate their dignity. There is agreement among many scholars and ethicists that PAS restores the dignity of terminally ill patients. For example, Julian Prokopetz and Lisa Lehmann (2012) hold that PAS places patients back in control of their lives. It allows the patients to make such important decisions as how and when they die (Prokopetz & Lehmann, 2012). It is evident that PAS helps terminally ill patients to regain their dignity and humanity. Once they have undergone this procedure, a patient no longer needs to rely on the help and support of others. Most importantly, PAS relieves the patients of the indignity of being pitied. Therefore, since it restores the dignity of terminally ill patients, PAS is a fulfilment of the non-maleficence promise that practitioners make to patients.

It is the desire of nearly all individuals to lead lives that bring satisfaction and meaning. Terminally ill patients share this desire. They wish to participate in activities and pursuits which make their lives meaningful. However, their terminal illness means that they are unable to engage in these pursuits. For example, the case of a 60 year old man who loves surfing may be considered. Surfing is the main source of meaning for this individual. Since he is terminally ill and confined to a hospital bed, this man is unable to surf. It should therefore not surprise anyone when this man requests PAS. In their article, Prokopetz and Lehmann (2012) identified the lack of meaning in one’s life as among the factors that push terminally ill patients to PAS. They note that since the lives of these patients are meaningless, the patients feel that their lives serve no purpose. Essentially, the patients find a dignified exit from the world and on their own terms to be far more favorable that continuing with a meaningless and depressing life. In an earlier discussion, it was noted that a majority of Americans endorse PAS. It is very surprising that many practitioners are uncomfortable with being involved in PAS despite the overwhelming public support. These practitioners need to understand that as they conduct PAS, they are ending lives that bring their owners nothing but sorrow and depression. This means that PAS does not violate the non-maleficence principle. If anything, it is a tool for ending the agony of terminally ill patients.

The cost of medical care in the United States is prohibitively high. Millions of Americans are unable to afford treatment. The situation is worse for patients who are ailing from terminal illnesses (Scitovsky, 2005). Even after their death, the families of the terminally ill patients are left with huge bills. It is estimated that in some cases, costs of up to $10,000 are incurred when treating patients in the intensive care unit (“The Cost of Dying”, 2009). Since huge amounts are spent in the care of terminally ill patients, one would be forgiven for assuming that the treatment that these patients receive has an impact on their wellbeing. Unfortunately, this is not the case. As Scitovsky (2005) points out, a significant portion of the treatment offered does not have any real impact on the state of the patient. Writing for National Public Radio (NPR), Alison Kodjak (2016) observed that those who die in hospitals are subjected to more procedures and incur higher costs. She notes that “people who die in the hospital undergo more intense tests and procedures than those who die anywhere else” (Kodjak, 2016). The extra treatment that these patients are offered does not translate to improvement in outcomes. Essentially, it is as though the treatment that is offered to terminally ill patients is a costly and futile undertaking. Instead of aiding the recovery of these patients, the treatment only leaves families in financial ruin. PAS offers an escape from financial difficulties for the families of terminally ill patients. It eliminates the need of offering ineffective and costly treatment. Therefore, by engaging in PAS, physicians demonstrate to patients that they honor their obligations and the non-maleficence promise in particular.

Weiss and his colleagues (2001) are among the scholars who have explored the complexities of PAS. In their article, they give special focus to the factors that necessitate PAS. They note that the US has failed to make adequate investments in end of life care: “Unresolved pain has been cited as evidence that end-of-life care is of poor quality” (Weiss et al., 2001, p. 1311). This observation helps to strengthen the argument that PAS is in line, and not in conflict, with the non-maleficence promise. It is true that a lot of progress has been made to the US healthcare system since Weiss and his team authored their article. However, some gaps still remain. For example, Mark Betancourt (2016) argued that Americans without insurance endure challenges in their last few days. The experiences of these Americans show that the US healthcare system has yet to mature to the level where it is able to address the needs of patients who are staring at death. PAS enables medical practitioners to assure terminally ill patients that while the country may have failed to improve healthcare, the practitioners still care. While hastening the death of these patients is not ideal, it provides an exit from pain and anguish. Once dead, these patients no longer have to endure the poor end-of-life services. Essentially, PAS can be used to express the medical community’s dedication to promoting patient wellbeing. For this reason, PAS should be exempted from the non-maleficence promise. It is important to understand that the exemption is not absolutely necessary. From the discussion this far, it is evident that through PAS, practitioners are able to end patient suffering. This is why there is no absolute need to exempt PAS from the non-maleficence promise. Even without this exemption, PAS remains a benevolent procedure conducted to safeguard the wellbeing and dignity of terminally ill patients.

To better understand how PAS enables practitioners to honor the non-maleficence promise, it is helpful to consider the experiences of certain patient populations. Patients ailing from Alzheimer’s disease are among those who would experience the greatest benefit. One of the symptoms of this condition is a deterioration of such cognitive functions as memory. As Kayla Asbury (2015) charges in her article, PAS enables patients with Alzheimer’s to exercise their freedom to choose before the condition consumes all their cognitive faculties. In a previous section, it was pointed out that one of the obligations that medical practitioners have is respecting the wishes of patients. Through PAS, the practitioners manage to ensure that the voices of such vulnerable patients as those with Alzheimer’s disease are heard. Therefore, PAS should be exempted from the non-maleficence promise since it does not harm patients in any way.

This far, the discussion has focused on the numerous benefits that PAS delivers to patients. This procedure ends needless pain and suffering while sparing patients of the huge costs of continued treatment. However, these benefits become irrelevant if the death that the patients experience is painful and undignified. It is therefore important to examine the manner in which PAS is carried out. Sarnia Hurst and Alex Mauron partnered to pen an enlightening article on the experience of death for patients who undergo PAS. In the article, they make it clear that “physicians are believed to know how to ensure a painless death” (Hurst & Mauron, 2003, p. 271). Since it is largely a painless procedure, PAS serves the interests of patients and is in line with the non-maleficence promise. For the sake of balance and objectivity, it is helpful to consider the views of those who feel that PAS exposes patients to harm. Ezekiel Emmanuel (2017) is among these individuals. In his discussion, he challenges the belief that PAS is a painless and flawless procedure. To support this challenge, he provides data which raises questions about the safety and effectiveness of PAS. For example, Emmanuel records that “5.5% of all cases of Euthanasia and PAS (in the Netherlands) had a technical problem and 3.7% had a complication” (Emmanuel, 2017, p. 339). He proceeds to add that “an additional 6.9% of cases had problems with completing euthanasia or PAS”. The revelations that Emmanuel shares are indeed troubling. However, these revelations do not imply that PAS is inherently dangerous. Some of the technical issues that were encountered during this procedure are rather minor. For example, some physicians had difficulties finding the patient’s vein. These technical difficulties and the risks associated with PAS pale in comparison to the many benefits that this procedure delivers. While it is not perfect, PAS is mostly a safe and effective procedure. It allows patients who are facing certain death to end their life by choice instead of enduring the ravages of incurable illness.

The primary obligation that practitioners have is to the patient. However, this obligation can be extended to the family of the patient. While protecting the patient against harm, the practitioners also need to ensure that the family does not suffer needlessly. PAS offers the practitioners an opportunity to promote the wellbeing of the patient’s family. Watching as a member endures pain and suffering causes the family to share in the suffering and agony. Through PAS, practitioners can end the suffering of the family. The practitioners may also enlist the help of family members in ending the patient’s life. Robert Pearlman et al. (2005) authored an article in which they examine the role that family members play in PAS. They observed that some members administered the medication that ended the life of the terminally ill patient (Pearlman et al., 2005). The key takeaway from this observation is that families are so eager to end their own and the suffering of terminally ill patients that they agree to administer lethal medication. Therefore, because it shields the families of dying patients, PAS should be exempt from the non-maleficence promise.

For the most part, the principle of non-maleficence is concerned with protecting patients against direct harm. For instance, this principle forbids practitioners against denying patients treatment. However, the non-maleficence principle can be extended to cover indirect forms of harm. In their study, Pearlman and his team noted that one patient shot himself using a shotgun (Pearlman et al., 2005). This patient found the pain he was suffering to be too unbearable. The case of this patient shows that when they are denied PAS, patients can resort to desperate measures. When physicians turn away patients who request PAS, they are essentially encouraging the patient to adopt dangerous and desperate measures. One may argue that since PAS and suicide in the conventional sense achieve the same end, PAS is unnecessary. This individual would need to be reminded that PAS provides numerous benefits that are lacking in the kind of suicide that the patient in the study by Pearlman and his colleagues, committed. For example, it is fair to assume that the family of this patient was shocked and traumatized when they found his body. On the other hand, PAS involves the family and ensures that the family is prepared for the death of a patient. Therefore, since it ensures that the patient does not resort to extreme self-destructive measures, PAS should be exempted from the non-maleficence promise.

Providing patients with the information that they need to make wise and informed decisions is one of the fundamental duties of medical practitioners. Initially, many practitioners were apprehensive of PAS and viewed this procedure with dread. As more and more states in the US legalize PAS, physicians are beginning to openly talk about the procedure with their patients (Karlamangla, 2017). This is one of the surprising benefits of PAS. Thanks to the acceptance of this procedure, physicians are able to establish that a patient is terminally ill and that they are mentally competent to consent to PAS (Karlamangla, 2017). Since PAS has inspired practitioners to be more transparent and open with their patients, it is essentially enhancing the wellbeing of the patients. To understand why open discussions among practitioners and patients are important, it is helpful to contrast it with the situation in past years. Physicians were in the habit of lying to patients by giving them false hopes. Now, the practitioners no longer need to lie and mislead patients. They are able to engage in candid and honest discussions. This way, the physicians demonstrate respect for the right to information that patients have. Therefore, PAS should not be included in the non-maleficence promise.

Response to Objections

The discussion above has presented compelling arguments which support the position that since it presents many benefits to patients, PAS should be exempted from the non-maleficence promise. Despite the strength of these arguments, there are those who are likely to insist that PAS goes against the non-maleficence promise. One of the arguments that they may raise is that PAS amounts to a violation of the principle of benevolence. Benevolence is among the basic values that govern the conduct of medical professionals (Buetow, 2013). The basic premise of this principle is that practitioners should do what is best for the patient. As regards PAS, the benevolence principle is moot and irrelevant. It is moot because the patient is expected to die soon. What is best for the patient would be to restore their health. However, since the patient is terminally ill and is simply awaiting death, the benevolence principle is suspended. Therefore, PAS needs to be exempted from the non-maleficence promise.

It has been pointed out in the discussion above that opponents of PAS may contend that this practice violates the principle of benevolence. On its face, this argument sounds valid. However, a critical scrutiny of the motivations that drive physicians who perform PAS reveals that the argument that opponents of the procedure raise are baseless and invalid. In his article, Marcel Boisvert (2012) suggests that a desire to demonstrate sympathy and mercy are the main forces that drive physicians involved in PAS. What these physicians wish to do is simply to end the suffering and anguish of terminally ill patients. This is the essence of benevolence. The implication of the motivations of physicians is that instead of seeking to harm patients, these physicians simply wish to demonstrate benevolence. Therefore, PAS is a benevolent procedure which deserves exemption from the non-maleficence promise. To dispel any and all doubt, it is necessary to reiterate that PAS is not a maleficent act which would collapse without being exempted from the non-maleficence act. The exemption is merely needed to build confidence in PAS and assure practitioners that when they administer PAS, they are not violating the non-maleficence principle.

That PAS is a contentious and controversial issue is evident. While a majority of the American people endorses this procedure, full consensus has not been achieved since there is a significant number of Americans who vehemently oppose PAS. The opposition to this procedure is not entirely baseless. There are some valid arguments which raise serious questions about the impact of PAS. One of these arguments is that PAS is open to abuse (Benatar, 2011). Critics of PAS argue that families of terminally ill patients may pressure these patients to end their lives. For example, the family of a terminally ill patient who is wealthy may force the patient to undergo PAS. This family would be being motivated by greed and the expectation of taking over the possession of the patient. It is indeed possible that this scenario could arise. If the scenario actually occurs, physicians would essentially be colluding with families to defraud and harm patients. However, one should understand that there are safeguards in place to insulate PAS against abuse (Benatar, 2011). For example, before PAS is carried out, at least two physicians must agree that the patient will die within six months. Moreover, the physicians need to establish that the patient is sufficiently competent to make the decision to undergo PAS. The safeguards that have been put in place show that physicians who perform PAS are driven by the desire to demonstrate benevolence. The medical community has taken all necessary steps to ensure that no harm comes to the patient undergoing PAS. Therefore, the argument that PAS is maleficent and amounts to a violation of the benevolence principle is invalid, inconsistent with the situation on the ground and based on a shaky premise.

PAS is a permanent procedure. One conducted, there is nothing that physicians can do to bring the dead patient back to life. It is for this reason that there are stringent procedures and guidelines that accompany PAS. These procedures and guidelines are intended to protect PAS from abuse and to avoid setting society on a slippery slope where PAS becomes a cheap procedure available to all those who wish to die. For the most, part the slippery slope prediction has not been realized. However, as Ira Byock (2015) reveals in his discussion, there are numerous instances where PAS has been abused. For example, in the Netherlands, where PAS is legal, a number of patients have undergone the procedure for conditions and illnesses that are not terminal or intolerable. For example, Byock alleges that a patient underwent PAS for depression (Byock, 2015). While depression can significantly lower an individual’s quality of life, there are effective treatment interventions. Byock offers another example of a patient who underwent PAS because she found some ringing in her ear to be too much to bear (Byock, 2015). The examples of these Dutch patients demonstrate that PAS is indeed open to abuse. These examples also suggest that physicians may be violating the non-maleficence principle when they perform PAS. However, it should be remembered that the cases of abuse of PAS in Netherlands are few and isolated. Overall, this procedure has allowed many patients to end their suffering. For this reason, the “do-no-harm” promise that physicians make to patients should not be applied to PAS.

Conclusions and the Way Forward

Today, thousands of medical practitioners in the United States work tirelessly to deliver much-needed care to patients. As they deliver care, the physicians demonstrate their dedication to the ethical principles which make up the foundation of medical practice. Non-maleficence and benevolence are the main principles that the practitioners uphold. They endeavor to protect patients from harm through noble, generous and kind acts. PAS has raised questions regarding whether the medical community is truly committed to ethics-based practice. PAS causes the death of a patient. However, to fully understand PAS, one must consider the many and wide-ranging benefits that PAS delivers. PAS protects patients from needless and intolerable suffering. This procedure also allows patients to communicate their wishes and to have these wishes honored by medical practitioners. Moreover, PAS allows patients to die with dignity while minimizing the cost of treatment. That PAS is a procedure that is in line with the benevolence and non-maleficence principles is not in question. The concerns that this procedure violates these principles are simply red herrings that are intended to distract from the important issues. The truth remains that PAS has brought peace and closure to families who watched helplessly as their loved one wasted away and endured unimaginable suffering. Since it delivers many benefits, PAS should not be regarded as an exception from the “do-no-harm” promise that underlies medical practice.

The discussion on PAS and its ethical implications would not be complete without charting the way forward. From the discussion, it is evident that PAS remains contentious. Even medical practitioners are divided on the ethical and moral status of this procedure. If the practitioners are to enhance healthcare delivery, they need to speak with one voice. It is advised that the practitioners should engage in extensive, deep and candid discussions on PAS. The discussions should give particular focus to the role that practitioners play in PAS. Moreover, as they discuss this procedure, the practitioners should also address the concerns that have been raised about the potential for abuse of PAS. The practitioners also need to identify measures that can be implemented to seal any and all loopholes which expose PAS to the threat of abuse in the first place. As they do this, the practitioners will be silencing critics. More importantly, the practitioners will be assuring terminally ill patients and their families that PAS is a safe, painless and fair procedure for ending suffering. For physicians who perform PAS, they should rest assured that this procedure is completely in line with medical ethics and relevant legal guidelines.

References

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