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Assisted Suicide and EuthanasiaMichael Wassenaar, PhDFebruary 16, 2012

Goals

Identify arguments on both sides of ethical debate

Understand significant ethical distinctions

Practice respectful conversation

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Withholding/withdrawing life support

No ethically relevant distinction between withholding and withdrawing.

Both are question of harms and benefits.

W/w life support is not assisted suicide or euthanasia.

Intention matters: intention is not to kill, but to prevent harm and allow disease/condition to run its course

Killing vs. letting die

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“[W]hen a patient refuses life-sustaining medical treatment, he dies from an underlying fatal disease or pathology; but if a patient ingests lethal medication prescribed by a physician, he is killed by that medication.”

US Supreme Court, Vacco v. Quill, 1997

The principle of double effect

Is it ever morally acceptable to administer a drug that may hasten the patient’s death?

Does this count as assisted suicide?

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Principle of double effect

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ACT

EFFECT 1(intended)

EFFECT 2(unintended)

Principle of double effect: there is a morally significant difference between A-E1 and A-E2.

Principle of double effect

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Administration of IV morphine

Relieve symptoms

Hasten death

Continuous deep sedation

Evidence suggests CDS hastens death

Does the principle of double effect apply?

It depends: Is unconsciousness, or death, the means to symptom relief?

If death is intended as the means, then it counts as killing (ie, double effect does not exonerate).

Palliative vs. terminal sedation

Terminology

Suicide: Intentionally ending one’s own life

Assisted suicide: Clinician assists patient to perform an act that is intended to end his/her life

Euthanasia: Clinician acts intentionally to end a patient’s life

■ From the Greek: eu (good) + thanatos (death)

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Historical context

■ Ancient Greece and Rome tended to be tolerant

■ Hippocrates represented the minority view:

■ “I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect” (Hippocratic Oath)

■ Historically, Christianity opposed suicide and endorsed Hippocratic view

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Contemporary context

■ Legal in 6 countries: Albania, Switzerland, Belgium, Netherlands, Luxembourg, Columbia

■ Legal in 3 US states: Oregon (1994), Washington (2008), Montana (2009)

■ Between 1994 and 2010, there were 75+ legislative bills to legalize assisted suicide in at least 21 states

■ AMA, ACP, ASIM do not support legalization

■ MedScape.com survey, 2010 “Should physician-assisted suicide be allowed in some

situations?”Yes: 45.8% No: 40.7% It depends: 13.5%

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Motivations

Loss of autonomy

Loss of dignity

Inadequate pain/symptom control

Depression

Abandonment

Burden on family

Self-image

Prospect of long-term care

Finances

In Oregon

Oregon Death with Dignity Act passed in 1994, implemented in 1997.

Safeguards: Terminally ill (6 month prognosis) Mentally competent Confirmed by a second opinion Waiting period of two weeks

Lower rates than rest of nation (?)

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Main arguments: Pro

Killing is not always murder (e.g. self-defense, warfare, capital punishment).

Respects the patient’s autonomy.

Relieves the patient’s suffering.

Safeguards can mitigate abuse.

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Main arguments: Con

It is not our right

Corrupts traditional role of health provider

Erodes trust

Risks abuse

Slippery slope

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Ethical vs. Legal

If one believes assisted suicide may be justified in some cases, it does not necessarily mean it should be legal.

Recall utilitarianism: What would the consequences be if something became a general rule?

How to respond?

Clarify the Request

Determine the Root Causes

Affirm Your Commitment to Care for the Patient

Address the Root Causes of the Request

Educate the Patient About Legal Alternatives for Control and Comfort

Consult With Colleagues

17Source: Endlink Resources for End of Life Care Education. http://endoflife.northwestern.edu/eolc_physician_assisted_suicide_debate.cfm