Physician-assisted suicide (PAS) occurs when a doctor facilitates patient death through the provision of the necessary information or means to enable their client to act in a manner that ends their life. Physician participation in PAS may be characterized by actions, including knowingly providing information on lethal dosage and availing of the medication that a patient uses to commit suicide. In most cases, patients with debilitating, terminal and painful illness are the ones that may prefer death to life, a factor that necessitates the exploration of PAS options (Battin, Rhodes & Silver, 2015). Nonetheless, the role that doctors play in PAS is irreconcilable with their healing responsibilities, making it a contended subject matter on which individuals have contrasting views.
Background on PAS
According to Sulmasy and Mueller (2015), the number of people advocating for the legalization of PAS has increased, resulting in the subsequent rise in the public interest rate on the subject. People are concerned about the nature of their death, and some autonomously advocate for the legalization of PAS as a form of end-life care. However, institutions such as the American College of Physicians (ACP) express their inclination to opposing the legalization of PAS on policy, clinical practice and ethical basis. Sulmasy (2019), in his exploration of PAS, explains that law-based safeguards against the practice are viewed as barriers. For instance, Oregon State Bill 579 enables patients to bypass the PAS waiting period and take the lethal treatment within two days. Moreover, in the Netherlands and Belgium, statistics indicate that about 5% of all deaths are by euthanasia, the patients of which are regular organ donors. Hence, regardless of the lack of evidence depicting whether the US will follow the stated trends or not, the country must have an ethical debate on the subject and come up with a conclusion because empirical research will not mitigate PAS occurrences.
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Ethical Issues associated with PAS
The most crucial ethical principle governing healthcare matters, including those associated with PAS is autonomy. It is considered to be a central decision-making factor. Arguments made in favor of the legalization of PAS express that respecting a patient is characterized by the consideration of the autonomy and capacity they have to make decisions concerning their death or life. Regardless, in cases involving PAS, decision-making freedom may conflict with the ethical principles of non-maleficence and beneficence ( Paterson, 2017) . However, it must be realized that the best interest of a patient is not limited to the perception of their physician. As such, it must be assessed by factoring in the details of a specific case. Banović, Turanjanin and Miloradović (2017) explain that restricted respect for patient autonomy is crucial because there are cases that involve clients that may opt to shorten theirs despite the possibility of healing. However, in instances that a patient is aware of the terminal nature of their illness and chooses to continue treatment, the authors named above establish that patient autonomy should dominate the decision-making process thereof. Thus, finding the right balance of ethical requirements involved in PAS proves difficult among healthcare practitioners.
Human Subject Protections Related to PAS
In two Supreme Court cases ruled in 1997, it was established that PAS is not a constitutionally protected liberty. However, the rulings delivered in Washington v. Glucksberg and Vacco v. Quill allow states in the US grounds to sanction PAS. Considering the history of PAS laws in the US, the court rulings thereof established that there were no liberty interests in the right to assisted suicide, which is covered by the due process clause. Nonetheless, the ban on PAS, as ascribed by the Washington law, was related to government interests including those that focus on the preservation of life, suicide prevention, protection of medical practitioners’ integrity and mitigation of the abuse of euthanasia and other drugs. As of 1997, the Supreme Court imposed no ban on PAS (US Legal, 2019) . Thus, strengthening of human subject protections in the US should involve the undertaking of extensive research to determine the cases for which PAS should be made an option. American policymakers must come up with specific laws governing PAS practice instead of allowing states the autonomy to do so, for standardization purposes and the protection of the right to life within American society.
Informed Consent in PAS
The definition of informed consent provided by the American Medical Association (AMA) establishes that the stated concept defines the communication between a physician and a patient, which results in the client’s authorization or agreement to undergo a specified medical intervention. In cases involving PAS, informed consent oversees medical practice by regulating communication between a patient and their doctor. It requires that the physician offer the client adequate information about their condition and the nature of the proposed treatment, including its risks, as well as the available alternatives and their potential dangers (Basanta). The latter is expected to allow patients access to enough data that would adequately inform the decisions they make about their treatment.
Informed consent in PAS is not adequate in the US. Peled, Bickel and Puchalski (2017) explain that despite the legalization of PAS in some states, there are no palliative care requirements or PAS educational process that have been implemented. The patients that may be interested in PAS are those dealing with severe illnesses and advanced chronic diseases, who tend to experience spiritual, psychological and physical distress. In its current state, palliative care focuses on improving patients’ quality of life and relieving stress but fails to encompass the provision of information on PAS. As such, Peled et al. (2017) establish that the inclusion of PAS data in palliative care procedural safeguards would enhance the integrity of informed consent, shared decision making and boost patients’ understanding of the available options. Hence, the adequacy of informed consent in PAS can only be realized through patient education on the subject matter as part of palliative care.
Obtaining informed consent through advance directives would require evidence depicting that the care of a specific patient was planned. The latter would indicate the designation of the decision-making power to the surrogate to act on behalf of the client that is incapable of choosing the type of medical care they would want to receive. However, the nature of the therapeutic choices that a surrogate can make are limited by state statutes such as the California Civil Code Sec. 2500, which establishes that a patient agent assigned durable attorney power for medical care may make decisions that the client themselves would if they had the capacity. In California, state law provisions do not require the grantor of the power of attorney to provide specific instructions on the type of care they wish to receive, whereas in Nevada the stated specifications are mandatory (Tang et al., 2014). Thus, the acquisition of informed consent through advanced directive within the US depends on the applicable legal provisions.
Recommendations to facilitate Ethical PAS Choices
First, policymakers in the US should create laws that govern the administration of physician-assisted suicide services, which provide specific instructions on the process thereof. The administrators of the service will have a standard reference point that will guide their practice. Secondly, patients receiving palliative care should be offered information concerning PAS to increase the scope of data available to them and enhance their decision-making capacity. Thirdly, physicians must be sensitized and held accountable for abiding by the codes of the practice to ensure that they do not abuse their professional power and wrongfully exploit legal provisions on PAS. Fourth, the healthcare system in the US should be restructured to ensure that it emphasizes on the necessity of advance care planning to reduce treatment uncertainties when patients are at the end of their lives. Lastly, the legalization of PAS in the US should follow extensive research on the subject matter to ensure that the provisions implemented guarantee the enhanced well-being of Americans.
Conclusion
The subject of physician-assisted suicide is highly debatable among both practitioners and researchers. The latter has resulted in the legalization of the practice in only some parts of the US, primarily because of its breach of doctor’s healing role. Consequently, patients receiving palliative care do not get adequate information about PAS to inform their care decisions fully. Thus, to maximize patient care and well-being, policymakers in the US must conduct extensive research to inform the decision to legalize PAS. Similarly, care practitioners must focus on abiding by professional codes to mitigate the violation of legal provisions governing the practice.
References
Banović, B., Turanjanin, V., & Miloradović, A. (2017). An ethical review of euthanasia and physician-assisted suicide. Iranian journal of public health , 46 (2), 173.
Basanta, W. E. Communicating with dying Patients: Informed Consent, Physician First Amendment Rights, And State Regulation in the United States.
Battin, M. P., Rhodes, R., & Silvers, A. (2015). Physician-assisted suicide: expanding the debate . Routledge.
Paterson, C. (2017). Assisted suicide and euthanasia: a natural law ethics approach . Routledge.
Peled, H., Bickel, K. E., & Puchalski, C. (2017). Enhancing informed consent for physician aid in dying: Potential role of handout on possible benefits of palliative care. Journal of oncology practice , 13 (10), e838-e843.
Sulmasy, D. P. (2019). Physician-Assisted Suicide and the Perils of Empirical Ethical Research. JAMA Network Open , 2 (8), e198628-e198628.
Sulmasy, L. S., & Mueller, P. S. (2017). Ethics and the legalization of physician-assisted suicide: an American College of Physicians position paper. Annals of internal medicine , 167 (8), 576-578.
Tang, S. T., Liu, T. W., Liu, L. N., Chiu, C. F., Hsieh, R. K., & Tsai, C. M. (2014). Physician-patient end-of-life care discussions: Correlates and associations with end-of-life care preferences of cancer patients—a cross-sectional survey study. Palliative medicine , 28 (10), 1222-1230.
US Legal. (2019). Supreme Court Rulings – Right to Die. Retrieved 21 December 2019, from https://righttodie.uslegal.com/physician-assisted-suicide/supreme-court-rulings/
