Is Physician Aid-in-Dying suicide? What are the ethical issues involved? How as a medical professional would you handle this situation?
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Doctor’s assistance in dying goes under numerous labels. Perhaps the best known is “suicide by the physician.” Alternative words include: dignified death, prescribed death for doctors, the right to die and physician-assisted dying. We employ death aid (AID) to make it easy, but we realize that there will be some who object, regardless of the term.
Some AID proponents prefer not to use the term suicide; they argue that AID is not an act of suicide for a deprived or despondent person. Conversely, the opposition maintains that suicide always takes place early and purposefully, irrespective of motive. Some insist that the dissociation of “aided suicide” from other suicide types reduces those who die from suicide on other grounds, as if only doctor – assisted suicides are legitimate.
People on both sides of the problem are concerned whether ‘death aid’ or ‘assisted dying’ may be mistaken with palliative, hospice or any other care for dying patients.
ethical issues involved
The ethical difficulties presented by the concept of medical suicide include patient autonomy, quality of life and what it means to act in the best interests of the patient. The level of participation of the health professional in suicide may vary.
To ensure the autonomy of a patient, nurses and other medical practitioners must ensure that the choice of the patient is informed (i.e. that the patient understands the ramifications of his or her decision) and not the product of pressure or coercion. It may not always be evident, unfortunately, if the decision of a patient is genuinely fully informed and freely taken. For example, some patients may want treatment withdrawal or assisted suicide because they feel that their caregivers are financially or emotionally burdened and hence feel an obligation to die. Furthermore, a patient who is ill or in pain is likely to be sad or otherwise mentally disordered. Although the patient is theoretically qualified for his own judgments, it is vital to assess the extent to which such decisions are affected by treated mood disorders or other mental conditions. Thus, “autonomy” can be affected by various circumstances, which cannot all be quickly identified or properly assessed by a medical practitioner.
“Quality of life” is another significant aspect. At what point does life no longer have “quality” and who should decide the quality of life of a certain patient? One relevant and effective concern is whether the patient is always capable of assessing the “quality” of his or her life and who should make that judgment if the patient is unable to do so? Quality of life considerations are intimately tied to determining what is in the best interests of a patient.
The challenge is to define the best interests of a patient and, again, determine who should be authorized to assess the best interests and whether a treatment is rejected or administered. Some proponents of suicide with physician aid claim that individuals who oppose it place their own abstract ethical concerns above a practical examination of the best interests of the patient. These advocates claim that when his life is almost over it, it is not in the best interests of a pain-wracked patient who suffers unnecessarily. In this respect, the failure to terminate that suffering, although the end of the patient’s life, is an abdication of the obligation of the healthcare professional to provide the best for the well-being of the patient. For such a sufferer, death is better than an awful, acute torment. However, the argument is that medical practitioners trained to identify what is best for the health of the patient can determine the best for the patient in general. This attitude, however well-meant, threatens to run out of paternalism, where the physician so trusts in his knowledge of the best that he or she overlooks the right of the patient to self-determination. There is thus an inherent contradiction between the autonomy of a patient and the best interests of that patient.
how to handle it
The Code of Ethics for Nurses offers direction to nurses facing end-of-life concerns and suicide demands. Both nurses and doctors have an obligation to reduce the pain and to offer the terminally sick “supportive care.” The nurses treat more than the physical problems of the patient, but they also attempt to provide the patient and her family with psychological comfort and support.
Furthermore, “the concept underlying all nursing practices is respect for each individual’s inherent dignity, dignity and human rights.” The nurses therefore have the need to respect patient autonomy, while taking into account the “lifestyle, value system and religious convictions” of the patient. Caregivers should actively assist terminally ill patients in preparing for death and “minimize unwanted or unexpected treatment and patient suffering” by counseling with decisions such as DNR orders, experimental treatments and pain management. However, under the ethical prerogative of the nurse the administration of palliative care which may incidentally lead to death is prohibited under the Code of Ethics from “acting with the sole purpose of putting an end to the life of the patient even if such an action can be driven by compassion, respect for patient autonomy, and quality of life.”