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Is Physician-Assisted Dying Moral?

The road to uncover the hidden moral realms behind the often untalked about realities of death and dying was lengthy. The first realization I had was simply that I had been using a rudimentary title. Doctor-assisted suicide as I was calling it, is more frequently called physician-assisted dying or PAD. I have discovered that what people call “it”, differs based on their own moral standing. There is an implicit bias in declaring this topic. My sources varied from calling it assisted suicide, to assisted dying. One, obviously bearing more negative connotations than the other. In this essay, I have decided to alter which term I use, based on the source I’m drawing information from, to attempt to present an unbiased source. In 2011, a Gallup poll concluded, doctor-assisted suicide is the most polarizing cultural topic in America with 45% viewing it as morally acceptable, and 48% viewing it as morally unacceptable, followed by abortion as the second most culturally polarizing issue. Democrats also seemed to be more in favor of doctor-assisted suicide, at 51% finding it morally acceptable, than Republicans at 32%. This led me to make a comparison to abortion, specifically on the stress of the importance of choice versus the importance of life. This comparison echoed in many of the conversations I had about the issue.

First I would like to clarify between euthanasia and physician-assisted suicide. The Hasting Center differentiates between euthanasia and physician-assisted suicide by declaring euthanasia as the “painlessly killing or permitting the death of individuals who are ill or injured beyond hope of recovery” and physician-assisted suicide “the practice where a physician provides a potentially lethal medication to a terminally ill, suffering patient at his request that he can take(or not) at a time of his own choosing to end his life”. The main difference is that physician-assisted suicide means that the patient administers the medication to themselves and euthanasia involves the physician directly administering the medication - actively participating in the process.

To tackle this broad and weighty issue, I decided to approach the topics from four perspectives: legally, medically philosophically, and religiously. The first step in my research process was a google search. This led to the expansive legal battles surrounding the issue. Assisted suicide is legal in several Western European countries like Switzerland, Belgium, Luxembourg, and the Netherlands, where some countries are currently debating it: the United States and New Zealand. A survey by Ipsos MORI asked people in fifteen countries whether doctors should be able to help patients die7. 11 out of 15 countries were in favor, Poland and Russia were notably against. Within the United States, physician-assisted suicide is legal in seven states and the District of Columbia, by state law in Colorado, District of Columbia, Hawaii, Oregon, Vermont, Washington and by a court ruling in Montana and possibly California. Each state has varying rules and requirements.

The history of the legal battle on physician-assisted suicide is relatively young in the United States. It begins in 1997, on the Supreme Court of the United States, when in the case Washington v. Glucksberg, the court ruled that state laws banning PAD did not violate the Constitution. It sustained the idea that the right to PAD was not a fundamental liberty protected by due process and it should be determined by state law . Four months later, Oregon passed the Death with Dignity Act. The Death with Dignity Act lets doctors prescribe a lethal medication to terminally ill patients, who were predicted to die within six months. It required a second doctor to agree with the addition of cooling off period of 15 days to decide whether the patient still wanted to go forward. The last requirement was that the final lethal dose was self-administered by the patient. The Act passed with a close 51% majority but was deferred for three years, because of an injunction that asserted that it was unconstitutional.

Then came the November of 1998. Even the general, straightforward bullet point facts of CNN could not conceal the eerie story of the doctor who went by Dr. Death, a name so riddled with connotations. Dr. Death, otherwise known as Jack Kevorkian, was an American pathologist and an assisted suicide advocate. He videotaped injecting Thomas Youk, a man with Lou Gehrig’s disease, with a lethal drug, then submitted the video to 60 Minutes. He was found to have assisted in the deaths of 150 people. He spent eight years in prison after being found guilty for second-degree murder and illegal delivery of controlled substance in 1999. The country viewed him both as a hero and a criminal, a startling polarity. He stated in court, ““The patient’s autonomy always, always should be respected, even if it is absolutely contrary—the decision is contrary—to the best medical advice and what the physician wants.”.

In 2008, Washington passes the Death with Dignity Act. In 2009, the Supreme Court of Montana ruled in the case of Baxter v. Montana, that the Rights of the Terminally Ill Act, protected a doctor who prescribed a lethal medication from liability. In 2013, Vermont signs a Patient Choice and Control at End of Life Act into law. In 2014, New Mexico ruled in favor of a patient’s autonomy in their own death in the case Morris v. Brandenberg. Colorado legalized physician-assisted suicide in 2015, the District of Columbia followed in 2016 and Hawaii by 2018. California’s history with physician-assisted suicide has more back and forth. California governor, Jerry Brown, signed the End of Life Options Act into law in 2015, but in May of 2018, a country superior court judge by the name of Daniel Ottolia in California overturned the state law, declaring it unconstitutional. In June, the judgment was appealed and the litigation is still pending5.

Next, I decided to approach the topic based on statistics from states who have legalized physician-assisted suicide. There have been several conflicting studies on the effect of assisted suicide. In the Netherlands, one study noted a steep increase of people killing themselves, because of psychiatric distress, which could be seen as helping mentally ill people commit suicide. Another study concluded that the people partaking in physician-assisted suicide for psychiatric disorders were mainly women who had complicated, chronic histories of psychiatric, medical and psychosocial issues. Another study found a 6% increase in total suicides in the states that have passed physician-assisted suicide laws, with a 15% increase for people over the age of 65. After it was legalized in Oregon, the data collected by the Oregon Health Department revealed that it had increased from 1 in 1000 deaths to 1 in 300 deaths.

In places where physician-assisted suicide is illegal, people frequently find ways around the law. Many believe the decision to end one’s life is extremely personal should not be dictated by law. Companies like Compassion and Choices, a nonprofit organization that advocates for and provide end-of-life options, agrees. In the film, The Suicide Plan, a Frontline documentary, they have constructed a maze of options that let you slip beneath the law. In the documentary, we follow one person who is informed of all the various options. They have pamphlets with extremely specific instructions. You’re able to order the necessary medication online. For this person in particular, she has to take sixty pills in fifteen minutes, they advise her to take an anti-anxiety medication if she’s afraid at the time. They even remind her not to tell other people like the hospice or physicians, so no one will be implicated. They reassure her no one will find out, because they won’t conduct an autopsy: she was already terminal. The president of the organization, Barbara Coombs Lee, said, ““It’s our position that people who are terminally ill who are looking at death’s approach, not some distant time in the future, here it is, I’m approaching it now. Those people can’t and should not have to wait for absolute clarity in the law before they too are empowered with the means to control their suffering.”

Other alternatives include voluntarily stopping to eat and drink, and then sedating the patients to unconsciousness or more controversially refusing to receive life saving medication. I was struck by the clinical way they approached death, although my view on PAD at this point is considerably liberal, the documentary left me stunned, aching for a natural death, one not conspired about and ordered from the internet. Due to the fact that physician-assisted suicide already occurs despite its varying legality, legalizing it would just mean transparency, standardization and monitoring.

From a medical perspective, many in the medical profession have conflicting views on the issue. The Hastings Center cited a study that only 30% of physicians would directly assist. Ira Byock, an American physician wrote, “You will not find a “right to die” in the Magna Carta, Declaration of Independence or Constitution. Instead, society exists in service of life, liberty and the pursuit of happiness.” Some people would argue that physician-assisted suicide contradicts with the main tenet of the Hippocratic Oath: do no harm. But others would argue that this 2400 year old text is outdated, the phrase, “do not harm”, that we recognize, actually is not located within the text, in addition is the doctor causing more harm by letting the patient live in prolonged pain? The oath has already been modified plenty in time. I interviewed my uncle, Dr. Jordan Shlain, for his perspective. He is a practicing primary care physician as well as the chairman and founder of Private Medical and Healthloop. I spoke to him on his perspective. I began by asking him to define physician-assisted suicide or what alternative term he would choose to use. “So I guess what I would say is everyone is going to die. No matter what. And so if you are confronted with a terminal condition and you are going to suffer and die a slow, painful death, I don’t know that I would use the word suicide, because that is a term loaded with moral and societal, and religious implications. I would say physician-assisted compassionate ending... a physician-assisted dignified ending. Anytime you use the word suicide, the other words are genocide, homicide, none of these things are good. You use the word ‘cide’ and you’ve just loaded it up.” He explained to me several of the various cases in which patients have approached him with a physician-assisted dignified ending in mind. “For example, I have a patient who told me when he was 79, super healthy guy, with kids, grandkids and he said, I want you to give me a big dose of morphine when I’m eighty because I really don’t want to live past eighty. Like I’m done. I’ve had a full life, a big life, just stop it at eighty and I said you know...I don’t know about that. That’s not a ‘he’s dying of something’, he just wanted to end it and so that’s actually killing somebody, so that’s homicide, physician-assisted homicide. So I think you need to take into account the situation at hand and if you’re 112 years old, you have pneumonia and the odds of you surviving that pneumonia are really small, even though you could make it, like if someone said, ‘Hey man, you know, float me that morphine and let me just go comfortably into the night. I don’t want to battle for three weeks in the intensive care unit.’ Okay, note to self, that’s a tricky one. If someone’s got Lou Gehrig's disease or ALS or some terminal cancer and they’re like please stop the misery. That’s another separate question to ask. Nuance and circumstance are everything and I do not think there is a single answer.” He elaborated on the views of medical community, “This is a hot topic when it comes to these things [physician assisted dignified ending]. Every patient should be offered every reasonable option and the patient should have a significant opportunity to weigh in on what they want. Medicine typically views the world of patients as what’s the matter with you. They don’t typically ask the question what matters to you. A physician that’s worth their weight will ask both questions: what’s the matter with you and what matters to you and will present a range of options that are tailored to that person’s preferences, cultural background, religious sensibilities, political affiliation whatever. Like it’s not up to the doctor to judge whether someone has a preference, you just have to know what that preference is and you have to try to accommodate it in the frameworks of the law and one’s own ethics, there’s not a single answer.”

Economically, people contend that physician-assisted suicide may be a slippery slope for palliative care. Will physician-assisted suicide just become a cheap alternative for expensive palliative care or will it downgrade care? I asked my uncle what he thinks. “Well, I think it is palliative care, what does palliative care mean and relieving somebody’s suffering with some degree of dignity and a plan and I would say that this is the same thing, it’s only quicker. I don’t think they are different. And by the way, as soon as you introduce the word cheap alternative, you’ve attached a financial connotation like that opens up a whole other can of worms. The palliative care industry is sadly, a lot of its nonprofit, but a lot of its for profit. So capitalismcapitialism should not be playing in this space. If you took money off the table, and you only left compassion and dignity on the table, what do you do? That’s on a the situation, what the patient really wants and the family can weigh in and have some meaningful input, but ultimately it’s the patient that gets to call their shots.”

My sources online backed up his words. Many supporters argue that physician-assisted suicide is a last resort: before considering it as an option, it must be ensured that the patient is receiving optimal palliative care. Palliative care is defined as “excellent pain and symptom management, psychosocial support for patients and families, and assistance with difficult decision-making”3. In addition, the studies out of Oregon, and other places which have legalized it show no such slippery slope. However, countries like Holland and Belgium, which allow for assisted dying, also have arguably the best palliative care in Europe. Some think that assisted dying will mean vulnerable patients, bullied by their doctors, relatives, and insurers, are the ones receiving the treatment, but again, the precedent in Oregon proves otherwise. Patients are motivated by pain, not guilt. In addition, even when assisted dying is illegal, it is done despite the law and rarely results in a charge if investigated.7

There are many issues with our palliative care system. The Institute of Medicine’s Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life found numerous challenges to ensuring high-quality end-of-life care due to the growing elderly population. Challenges included access to care, communication barriers, time pressures, and care coordination. In 1997, a report by the Institute of Medicine was published called Approaching Death: Improving Care at the End of Life. It illustrated the state of end-of-life care in the United States. It found that inappropriate palliative care was “harmful and draining-physically, emotionally, and financially for patients and their families” This was illustrated for me in the book, Being Mortal, by Atul Gawande. He wrote, “You don’t have to spend much time with the elderly or those with terminal illness to see how often medicine fails the people it is supposed to help. The waning days of our lives are given over to treatments that addle our brains and sap our bodies for a sliver’s chance of benefit. They are spent in institutions-nursing homes and intensive care units-where regimented, anonymous routines cut us off from all the things that matter to us in life” (Gawande 9). Gawande notes that this is relatively new. For a minority of people who survived to old age, they were usually cradled within their family in “multigenerational systems”. Now, care for the elderly is relegated to physicians.

In terms of the physician/patient perspective, my uncle, Dr. Shlain, explained how he faces elderly patients. “One of the ways I look at this is: I ask two questions to patients. One is: what are the elements of life that must exist for you to want to be alive, meaning if I can’t laugh, if I can’t talk, if I can’t walk...what are the things that, in life, if they were taken away you’d say, ‘I’m done’. This is not a life worth living for me because the quality of life is all below some line. So what are the things if taken away and on the other hand and what are the things that you must have to exist... they’re functionally different. And then you go through that exercise with people and you start to get clarity on hey this is not a life worth living or you know this is a life worth living. You’ve got all these elements that you say you must have to live, you have them, why do you want to call it a day? So it helps people clarify a little bit better their understanding of what this step means.”

However, disabled rights activists take offense at the idea that death may be a better alternative to a chronic condition. Some would say that it insinuates that disabled people’s lives are worthless. Or the laws are lacking enough safeguards to stop disabled people suffering depression to end their lives. A legislative advocate for Disability Rights California, Deborah Doctor, wrote that the law, debated being passed in the California Senate, would make disabled people vulnerable to being coerced by family members, placing pressure to take the medication, in addition to physicians misestimated how long a patient has to live. “Our responsibility is to think of people who are the most vulnerable to coercion, abuse, and pressure.” A recently disabled person in the depths of depression could have reasonable cause to petition for a physician-assisted suicide, but it is likely the underlying mental illness that is causing their despair: one that will end, although it doesn’t seem like it at the time. Ben Mattlin, an author born with spinal muscular atrophy, wrote, “To be clear: My opposition to physician-assisted death doesn’t stem from any religious belief. It comes from my experience as a profoundly disabled person living on the cusp between life and death...Why should it be easier or more acceptable for certain groups to end their lives than it is for others? What does that say about the value we place on those lives?”

Following, I attempted to find a philosophical solution to my moral dilemma. I found an article in the Inquiries Journal, detailing Kant and Mill’s supposed views on physician-assisted suicide. This author stipulates that John Stuart Mill’s concept of utilitarianism proved assisted suicide immoral because it inflicted more pain on the people around them, which outweighed their own pleasures. This is a teleological view of morality, maximizing happiness as the ultimate goal. Maximizing happiness, in addition to minimizing the amount of pain for the greatest amount of people. Utilitarianism ranks all people’s happiness equally. So the decision of the patient might make the doctor uncomfortable, the possibility that he could be seen as a criminal with the possible accompanying loss of a medical license. As well as the pain of the patient’s relatives and friends that would follow their death. However, I disagreed with the writer’s interpretation. I think that utilitarianism would find physician-assisted suicide morally acceptable, because the prolonged pain of a long, drawn-out death, filled with ups and downs, would equate less happiness for everyone involved than if the patient was to receive assisted suicide.

The writer also approached physician-assisted suicide from Immanuel Kant’s perspective, a deontological system of morality. In Kant’s book, a Groundwork of the Metaphysics of Morals, Kant illustrated his deontological moral theory, that the morality of an action depends entirely on its intent and the fulfillment of duty. To Kant, what happens after an action is taken is of no consequence, he believed that thinking before taking an action was key. The action must be capable of being universalized, what he called a universal maxim. The writer characterized the patient in a study in the New England Journal of Medicine’s maxim as “If I suffer in indignity, I should end my own life.” This maxim is quite obviously not able to be universalized, because it would mean that anyone suffering any injustice would commit suicide. But again, I believe that the writer misconstrued the sentiment of physician-assisted suicide. The maxim should be, “If I suffer from a loss of my facilities and a terminal illness, I should be able to end my life.” This maxim , I would argue, is capable of being universalized and thus moral by Kant’s view.

The writer does address the faults in these two moral theories. First, utilitarianism is lacking, because we cannot know. We cannot know how an action will affect the people around us. Kant’s view completely overlooks the personal and emotional stance of an individual on a situation. He believed that the satisfaction from accomplishing a moral action would drown out any hurt sentiments. Human beings are rarely able to see an action like death so clear-cut.

The true debate concerning the morality of physician-assisted suicide is whether the right to autonomy outweighs the right to life. The realm of medical ethics establishes a respect for a patient’s autonomy. Some would argue that the combination of duties that a physician has to their patient, beneficence, proceeding in the best interest of the patient, nonmaleficence, minimizing harm, respecting the patient’s autonomy and being fair would guide a doctor to believe physician-assisted suicide moral.

When the Supreme Court of Canada faced a case revolving around suicide in Carter v. Canada, they agreed that a balanced needed to be reached between, “the autonomy and dignity of a competent adult to seeks death as a response to a grievous and irremediable medical condition... and the sanctity of life and the need to protect the vulnerable”. But an article in the blog, Philosopher’s Stake, Gordon Hawkes wrote, “If personal autonomy were truly a primary justification for allowing assisted suicide, then why is the choice limited to adults suffering a “grievous and irremediable medical condition”? Why can’t a healthy young woman walk into an Oregon clinic and get the same suicide pills as cancer patient Brittany Maynard?... Why can’t all people who want to kill themselves be allowed to get medical help in order to do so? Why this discrimination of the law based on one’s health?” This is an intriguing and bewildering perspective. I´m not sure what I think about his perspective. My uncle thinks, “the law needs to get out of the way.” And I would be compelled to agree. He articulated this further by saying: “Should a woman have the right to choose? Should a patient have the right to choose? The answer is yes on both fronts. So what the hell does the government do getting in the way of that? I mean obviously you have to prevent capricious activity like you don’t want a prison or a hospital to say you know we’re going to speed up these people’s death, because they’re costing us a lot of money. When you have religion, capitalism and liberty all mixed together when it comes to procreation or death. It gets messy.”

There are cases where physician-assisted suicide is arguably misused when the patient is not terminal. In the case of David Goodall, an Australian scientist, who at 104, decided to end his own life. He wrote, “I no longer want to continue living, and I’m happy to have a chance tomorrow to end it.” He died to the final notes of Beethoven's ¨Ode to Joy¨: exactly he wished to. Dr. Goodall was not terminally ill, but had lost the use of many of his facilities and was unable to teach. Or in the case of Aurelia Brouwers. Brouwers was a 29-year-old, Dutch woman suffering severe depression. She argued in court, in an eight-year legal battle, that her depression caused her life to be unbearable. Brouwers won her case and drank her prescribed medication on January 26th, 2018, and died surrounded by friends. Brouwers was young and suffering no physical illness. Many think that the line should be drawn before this.

The big question is whether the idea of freedom outweigh the idea of life, as a moral and existential good? To answer, I looked to the three main religions: Christianity, Islam, and Judaism. Pope Francis is unilaterally opposed to physician-assisted suicide and has spoken out about it many times. In addressing managers of Medical Orders of Spain and Latin America at the Apostolic Palace on June 9th, 2018. He said, “You are well aware of the meaning of the triumph of selfishness, of this “throwaway culture” that rejects and dismisses those who do not comply with certain canons of health, beauty, and utility...True compassion does not marginalize anyone, nor does it humiliate and exclude-much less considers the disappearance of a person as a good thing.”

All three religions stress the sanctity of life above all else. According to BBC, Muslims are against euthanasia, due to the idea that ¨all human life is sacred¨ because it is given by Allah. Allah also determined how long a person should live. It is not a human´s job to interfere with Allah´s will. In the Qur´an 17:33, it says, ¨Do not take life, which Allah has made sacred, other than in the course of justice.¨ The Islamic Code of Medical Ethics prescribes that ¨it is futile to diligently keep the patient in a vegetative state by heroic means... It is the process of life that the doctor aims to maintain and not the process of dying¨, condoning turning off life support, but not physician-assisted suicide or euthanasia.

In Judaism, Jewish Law or Halakhah one of the cardinal commandments in the preservation of life. Suicide is prohibited. Maimonides supported this idea by writing that bodies are divine property. To deliberately destroy the property of G-d is forbidden. This was also a view associated with Socrates in Plato´s book, Phaedo. However, Jewish law admits the importance of patient choice in certain situations, such as the prevention of the desecration of G-d. Rabbi Ephraim Oschry permitted suicide to avoid the agony of witnessing the destruction of one’s family and community during the Holocaust. In the Mishnah, it is written, ¨It was for this reason that Adam was first created as one person, to teach us that anyone who destroys a life is considered by Scripture to have destroyed an entire world; and anyone who saves a life is as if he saved an entire world.¨ Maimonides rules that a murderer is fit for capital punishment, “whether they killed a healthy individual or a sick person on the verge of death, or even a dying person.” While Orthodox and Conservative Judaism have must stricter rules around physician-assisted suicide, Reform Judaism is more lenient. The Reform Central Conference of American Rabbis prohibited euthanasia, but several Reform rabbis have defended assisted suicide or at least conceded that there is some wiggle room as ¨Jewish law may permit praying for a suffering terminal patient to die, while at the same time obligating us to do everything possible, including violating the laws of Shabbat, to prolong his or her life”. Rabbi Phil Cohen wrote, “In these dire circumstances, it is not right to force a human being to suffer against his/her will. We should instead honor one of the hallmarks of Reform Jewish thinking—individual autonomy—and grant a patient the right to end his or her own life.”

Stephen Hawking wrote that ¨Keeping someone alive against his wishes is the ultimate indignity.¨ But does this apply to children? In 2016, a teen in Belgium became the first minor to be legally euthanized with parental consent. Mr. Distelmans, the head of Belgium’s Federal Control and Evaluation Committee on Euthanasia, said, “Fortunately there are very few children who are considered (for euthanasia) but that does not mean we should refuse them the right to a dignified death.” The child must be terminally ill, in unbearable physical pain and request to die multiple times in addition to a psychological evaluation. Belgium passed lifted age restrictions for euthanasia in July of 2018.

After concluding this compilation of research in the rings of religion, medicine, law, and philosophy, I fear my original opinion has not changed. I found that I sifted through my research through the lens of my own biases. When it disagreed, as it did with almost every philosophical inquiry, I ended up picking holes in their interpretation of Kant and Mills. It demonstrated the thickness of the rose tinted glasses I wear (a play on Kant’s idea of causality). I attempted to be unbiased, but I believe I failed. My mind was unfortunately resolutely made up before I began this project. I fell into the sly trap of confirmation bias and I’m afraid my research might reflect this. But I feel I was able to capture the sphere of knowledge surrounding physician-assisted suicide.

I believe, as I believe with women’s rights, a person should have the ability to choose. I believe that why not every case may be morally permissible, the key factor is that each of these persons chose to be assisted in their deaths. They took the ultimate route in their personal liberty. I am at once in awe and trepidation. I feel a greater compassion for those terminally ill and the doctors who treat them. I sought out desperate to understand whether I could make a similar choice in similar circumstances, but I think the answer is no clearer to me. Death is far from imminent, but never too soon to consider.

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