In this presentation we will be discussing the various legal and ethical dilemmas surrounding Physician Assisted Suicide (PAS)
There are currently 10 states debating bills pertaining to PAS Bills in favor of legalization are being introduced in Connecticut, Vermont, New Jersey, Kansas, Hawaii and Massachusetts. Bills related to the issue are being introduced in New Hampshire, New York, Arizona and Montana (Strohm)
We want to take this moment to differentiate between PAS and Euthanasia. Key difference is in the involvement of the physician In PAS – physician prescribes a lethal medication that the patient administers to his/her own self. In Euthanasia – a physician is actively involved in administering the lethal medication.
The chart above mentions some key cases that have led to advancements in end-of-life care
Janet Adkins was not a terminal patient but was still granted PAS by Dr. Kevorkian. Dr Kevorkian provided Thomas Youk with euthanasia (Kevorkian administered the lethal medication) and was convicted of murder.
Montana has not made PAS illegal however, if committed, the physician may go to trial. Cases that have gone to court have been able to effectively use the patient ’s expressed wishes to escape penalty.
In other areas of the world where PAS is legal, such as the Netherlands, “Intolerable and unrelievable suffering” [sic] is a requirement for PAS. In Oregon, this requirement does not exist. The six month time line can become unclear when the patient exercises their right to refuse life prolonging treatment. Under the DWDA physicians are protected from suit so long as they “act in good faith” when determining how much time the patient has left. (Hendin, Foley & White, 1998)
As shown in the above chart, many people who receive the prescription do not take the medication.
Follow these links to find out more on why each organization supports/opposes PAS.
Medicare is a federally funded program so it cannot be used to pay for PAS. In Oregon, PAS is funded through either insurance or state funds for patients who do not have coverage.
PAS viewed from a Deontological theory would be considered “wrong.” In Deontological theory, an action is either always right or always wrong. PAS would be considered murder under Deontological theory and therefore would always be wrong. Utilitarian theory takes into account circumstances surrounding an action and makes an ethical judgment based on the consequences to the individual and society. Under utilitarian theory, PAS could either be viewed as “right” or “wrong” depending on the situation.
The above quotes are excerpts from the classical and modern version of the Hippocratic Oath. The Hippocratic Oath has undergone several changes since its conception. In the earliest versions of the Hippocratic Oath, activities such as surgery, abortion and PAS were outlawed. In more recent years, medicine has changed and surgery has become a recognized treatment. Abortion has also become legal. The most recent Hippocratic Oath does not specifically outlaw any such activities.
Palliative/Terminal sedation does present the question as to whether the illness itself is the cause of death, or the nutritional deprivation. Although, it is noted that many patients that receive palliative/terminal sedation have already made the decision to cease nutritional supplementation beforehand. (Olsen, Swetz & Mueller, 2010) A living will is also a form of Advance Directive that highly resembles the Directive for Physicians and family.
Advance Directives are highly under utilized in the elderly population, which allows for situations like Terri Schaivo ’s to arise. Lack of Advance Directives also puts the terminally ill at risk for being placed on life-sustaining treatments that they may have not wanted. It is important to promote the use of Advance Directives especially among the elderly and the terminally ill.
Legalization of PAS with further defined requirements for patient eligibility or diagnosis is preferred. However, current realistic goals include advocating for all individuals (terminally ill or not) to have advanced directive/living will documents in order to help guide their family, physicians, and nurses in provided care that maintains personal dignity and autonomy.
B. You must have a terminal illness with less than a year to live Explanation: To be eligible for PAS, a person must have less than six months to live.
False. PAS is legal in Washington. There have been cases in Montana where PAS was used as a defense and supported. Furthermore, there are over ten states with current bills about or pertaining to PAS
False: In PAS, the patient administers the medication to his/her self. In euthanasia, the physician administers the medication.
“Physician-assisted Suicide (PAS), n. – orig. U.S. suicide carriedout with the assistance of a physician (whose role is typically toprovide a lethal dose of a drug at the explicit, voluntary requestof a mentally competent patient considered to be incurable)”(Oxford University Press, 2013)
• An Aging Population• Legislation allowing for patients to choose end-of-lifecare preferences has helped lead to this discussion• PAS is Tied to Other Healthcare Debates– Desire for more Autonomy– High End-of-life Care Costs– Difficulty Obtaining Insurance Coverage for the TerminallyIll• Patient Concerns Include– Desire to Reduce Pain & Suffering– Desire to Die with Dignity– History of Inadequate Pain Control
• Physician Prescribes or Providesthe Means• Patient Administers LethalMedication• Legal in 3 U.S. States• Request Process & Wait Period• Physician Administers LethalMedication• Active or Passive• Currently Not Legal in the U.S.• No Determined Process
5thCentury B.C. to 1stCentury B.C. – Ancient Greeks and Romans often complied withvoluntary death requests while still abiding by the Hippocratic Oath1984 - Advance care directives begin to be recognized1984 - The Netherlands Supreme Court approves voluntary euthanasia and physician-assisted suicide under strict conditions.1984 - American Medical Association adopts the formal position that with informedconsent, a physician can withhold or withdraw treatment from a patient who is closeto death, and may also discontinue life support of a patient in a permanent coma.June 4, 1990 - Dr. Jack Kevorkian assists in the death of Janet Adkins, a middle-agedwoman with Alzheimer’s disease. Kevorkian subsequently flaunts the Michiganlegislature’s attempts to stop him from assisting in additional suicides.(ProCon.org, 2012)
1990 - Congress passes the Patient Self-Determination Act, requiring hospitals thatreceive federal funds to tell patients that they have a right to demand or refusetreatment. It takes effect the next year.1997 - Oregon Death With Dignity Act Passed- becoming the first law in Americanhistory permitting physician assisted suicide.1998 - Dr. Kevorkian shares a video on national television of him administering a lethalinjection to Thomas Youk, a man suffering from Lou Gehrig’s disease. He wasconvicted for the murder of Youk and is sentenced to 10-25 years in prison.2008 - Luxembourg legalizes physician assisted suicide and euthanasia.2008 - Washington becomes the second state to legalize physician-assisted suicide.2012 - Massachusetts voters rejected the Death with Dignity ballot by less than60,000 votes.(ProCon.org, 2012)
Year Case / Law Description1976 In re Quinlan Right to remove person in a vegetative state fromventilator1990 Cruzan v. DirectorMissouri Department ofHealthRight for states to grant families the right to removefeeding tubes from a person in a vegetative state1990 Patient Self-Determination ActHealth care facilities must provide information topatients about advance directives1997 Oregon Death with DignityActAllows terminally ill Oregon residents to obtain anduse prescriptions from their physicians for self-administered, lethal medications2008 Washington Death withDignity ActAllows terminally ill Washington residents to obtainand use prescriptions from their physicians for self-administered, lethal medications(Guido, 2009)
• Dr. Jack Kevorkian (1928-2011)– Nicknamed “Dr. Death”– Pathologist in Pontiac, MI• 1980s: Developed PAS Machine• 1990: Janet Adkins– Alzheimers Patient grantedPAS– Charges Dropped• 1998: Thomas Youk– Lou Gehrig’s Patient– Administered by Kevorkian &Aired on “60 minutes”– Found Guilty of murder• 10-25yr sentence• Served 8 yrs.(Hosseini, 2012)
• Believed Pt.’s Right to Avoid Prolonged & Painful Death– Should Die with Dignity– Wanted to be charged and arrested to bring about anational debate• Poll on Kevorkian’s Punishment (Hosseini, 2012)– 39% Felt he should not be punished– 27% Felt he should be charged with a lesser crime– 19% Felt the charges were appropriate• Brief Videos On Dr. Kevorkian– Information on Dr. Kevorkian– 60 Minutes Tape of Thomas Youk (Graphic)(Hosseini, 2012)
• Opposed by the U.S. Supreme Court• Legal in only 3 States• Legal in 4 other Countries– Belgium– Luxembourg– Netherlands– Switzerland(ProCon.org, 2012)
• 1997 in Oregon• First Person Received legal PAS in 1998– Mid-80s with Metastatic Breast Cancer to the Lungs• Requirements– ≥ 18 yrs.– Resident of Oregon– Legally/medically competent– Terminal illness with ≤ 6 mos. to live– Two oral requests & one written (two witnesses)– Confirmed diagnosis by two physicians• Annual Report 2012– PAS only accounted for 23.5 deaths per 10,000 total deaths– 673 patients have died under the DWDA(Hendin, Foley, & White, 1998)(Oregon Public Health Division, 2012)
• Death with Dignity NationalCenter in Oregon• Exit International (Australia)• Euthanasia Research &Guidance Organization(ERGO)• World Federation of Rightto Die Societies• Final Exit Network• American NursesAssociation (ANA)• American MedicalAssociation (AMA)• Care Not Killing• Not Dead Yet• Roman Catholic Church• United States Conference ofCatholic Bishops
• Most Common Reasons Lossof Autonomy– Decreased Ability– Loss of Dignity– Fear of Adequate Pain Control• Other Reasons– Right to end life on own terms– Prolonging the unavoidable– Less medical bills– Don’t want to be a burden tofamily• “Slippery Slope” belief thatPAS will move onto disabledand more vulnerablepopulations• Perceived as murder• Against Religion• Reductions in medicalcoverage for elderly &terminally ill as a result oflegalizing PAS• Forced PAS in the future(Guido, 2009: Hosseini, 2012; ProCon.org,2012)
• By 2020, 2.5 Million Aged ≥ 65 yr. will die eachyear• In 2008 Medicare Spent $55 billion on End-of-life care during the last two months ofpatients’ lives.– Estimated that 20-30% of these expenses had verylittle health impact.– 18-20% of patients spend their final days in an ICUwhich can be painful & expensive(CBS News, 2009)
• Available Options Include– Withdrawal of Treatment• Removing Ventilator & Feeding Tube• Chemo & Medications– Advance Directives• Living Will• DNR• Power of Attorney– Hospice Care– Palliative/Terminal Sedation– PAS (Only where it is legal)
• “Presents a Moral/Ethical Dilemma” Cases can be made for both sides using thefollowing ethical principles• Autonomy– Patient’s right to choose– Should there be limits to a patient’s autonomy?• Beneficence/Non-Maleficence– Do No Harm– Minimize Suffering & Pain– Are we doing this?• Justice– Fair & Equal Treatment– Are we being fair by prolonging the inevitable for terminally ill patients?(Hosseini, 2012)
• Deontological vs. Utilitarian– Deontological• Black & White• Either always wrong or always right• PAS would be considered always wrong– Utilitarian• Consequences weighed for the individual and society• Focused on providing happiness• PAS may be considered right for only some• Doctrine of Double Effect- Principle argued frequently in End-of-life care debates for PAS- Explains that a harmful action is permissible if it promotes a good sideeffect- Ex. Killing a human being to bring about a good end(Webb, 2013; McIntyre, 2004)
• Classical Oath• “I will neither give a deadly drug to anybody who asked for it, nor will Imake a suggestion to this effect. Similarly I will not give to a womanan abortive remedy. In purity and holiness I will guard my life and myart. I will not use the knife, not even on sufferers from stone, but willwithdraw in favor of such men as are engaged in this work.”• Modern Oath– “Most especially must I tread with care in matters of life and death. Ifit is given me to save a life, all thanks. But it may also be within mypower to take a life; this awesome responsibility must be faced withgreat humbleness and awareness of my own frailty. Above all, I mustnot play at God.”(Tyson, 2001)
• Sedation prior to death fromactual illness• Used when other treatmentscannot relieve pain & suffering• Nutrition supplementation istypically withdrawn• Often the last resort in moststates• Shown to be 71-92% Effectivebased on family perceptions ofpatient’s relief• 3 Types for End-of-life• Medical Power of Attorney– Patient designates person to makeend-of-life decisions– Anyone can have this• Out-of-hospital DNR Order– Refusal of life-sustaining treatmentsby first responders– Copy carried at all times• Directive for Physicians and Family– Specifications on withholding orwithdrawing all or certain life-sustaining procedures– Certified by a physician(Olsen, Swetz, & Mueller, 2010) (Texas Hospital Association, n.d.)
Care recipients under age 65 yrs. Were less likely to have any AD thanthose aged 85 and over
• New health care revisions• Clear definitions of PAS andrequirements– Process of application– Location of lethal drugadministration– Diagnosis Inclusion Criteria• Laws that make it legal.•• More emphasis on paincontrol & consideration for thepatient’s perception of theirown dignity• More individuals with livingwills, medical advocates, andother documents prior tofalling ill.• Greater awareness towardswhich procedures are effectiveand which simply prolongsuffering & pain.
We believe that legalizing PAS, after a moreadequate definition of requirements anddiagnosis criteria has been formulated, cangreatly prevent prolonged pain, suffering, andloss of dignity experienced by some terminally illpatients.
Which Statement is not true about the Death withDignity Act of Oregon?A. You must be a resident of OregonB. You must have a terminal illness with less thana year to liveC. You must be legally/medically competentD. Two physicians must have confirmed yourdiagnosis
Which is not one of the legal alternatives to PhysicianAssisted Suicide?A. EuthanasiaB. Withdrawal of TreatmentC. Terminal SedationD. Advanced Directives
True or False: Surgery, Abortion, and Physician AssistedSuicide / Euthanasia are referred to in the OriginalHippocratic Oath. In taking this oath, healthcareprofessionals swore to not perform these practices.The Hippocratic Oath has since been revised and nolonger mentions the three of these things.
True or False: Oregon is the only state in the UnitedStates where PAS is legal.
True or False: In PAS, a physician actively administersthe lethal medication to end the patient’s life.
American Medical Association. (n.d.). American College of Physicians - Care of patients near the end of life. Retrieved from http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/ about-ethics-group/ethics-resource-center/educational-resources/ federation-repository-ethics-documents-online/american-college-physicians/ acp-end-of-life-care.page#organCBS News. (2009, November 22). The cost of dying. Retrieved from http://www.cbsnews.com/ 8301-18560_162-5711689.htmlGuido, G. W. (2009). Legal & ethical issues in nursing (5th ed.). Upper Saddle River, NJ: Pearson.Hendin, H., Foley, K., & White, M. (1998). Physician-assisted suicide: Reflections on Oregon’s first case. Issues in Law & Medicine, 14(3), 243-269.Hosseini, H. M. (2012). Ethics, the illegality of physician assisted suicide in the United States and the role and ordeal of Dr. Jack Kevorkian before his death.Review of European Studies, 4(5). http://dx.doi.org/10.5539/res.v4n5p203Lachman, V. D. (2010). Physician-assisted suicide: Compassionate liberation or murder? MEDSURG Nursing, 19(2).McIntyre, A. (2004). Doctrine of double effect. Retrieved from Stanford Encyclopedia of Philosphy website: http://plato.stanford.edu/entries/double-effect/MedicineNet. (2012, September 20). Definition of physician-assisted suicide. Retrieved from MedicineNet website: http://www.medterms.com/script/main/art.asp?articlekey=32841Olsen, M. L., Swetz, K. M., & Mueller, P. S. (2010). Ethical decision making with end-of-life care: Palliative sedation and withholding or withdrawing life-sustaining treatments. Mayo Clinic Proceedings, 85(10), 949-954. http://dx.doi.org/10.4065/mcp.2010.0201
Oregon Public Health Division. (2012). Oregons death with dignity act -- 2012. Retrieved from http://public.health.oregon.gov/ProviderPartnerResources/Evaluationresearch/deathwithdignityact/ Pages/index.aspxOxford University Press. (2013). Physician, n. In OED online. Retrieved from http://www.oed.com.ezproxy.lib.usf.edu/view/Entry/ 143129?redirectedFrom=physician+assisted+suicide#eid30461454ProCon.org. (2012). History of euthanasia and physician-assisted suicide. Retrieved from http://euthanasia.procon.org/view.resource.php?resourceID=000130Texas Hospital Association. (n.d.). What are my options for advanced directives? Retrieved from http://www.tha.org/generalpublic/advancedirectives/whataremyoptionsfor09c0/Tyson, P. (2001). The hippocratic oath today. Retrieved from http://www.pbs.org/wgbh/nova/body/ hippocratic-oath-today.htmlStrohm, M. (n.d.). Physician-assisted suicide: Is it murder or compassion for a doctor to help kill a patient? ABC Action News. Retrieved from http://www.abcactionnews.com/dpp/marketplace/law_tv/physician-assisted-suicide-is-it-murder-or-compassion-for-a-doctor-to-help-kill-a-patientU.S. Department of Health and Human Services. (2011, January). Use of advanced directives in long-term care populations (Issue Brief No. 54). Retrievedfrom Centers for Disease Control and Prevention website: http://www.cdc.gov/nchs/data/databriefs/db54.pdfUnited States Census Bureau. (2010). Age and sex composition in the United States: 2010 censusbrief. Retrieved from http://www.census.gov/population/age/Webb, M. (Presenter). (2013). Ethics and morality. Lecture presented at Blackboard, University of South Florida, Tampa, FL.