Resolving Ethical Dilemmas – Physician-Assisted Suicide

Introduction

My ethical dilemma comes from a New York Times article written by Catherine Potter on May 25, 2017. According to the article, Mr. Shield, a 73-year-old man had been diagnosed with a hereditary form of amyloidosis. A rare, incurable disease caused by a build-up of an abnormal protein called amyloid in body tissues and organs. The doctor had informed Mr. Shield that the disease would most likely cause him to lose sensation in his arms and legs and eventually shut down his heart. After the diagnosis, Mr. Shield was stricken with grief; he had witnessed how torturous death from a crippling disease could be and did not wish to suffer the same fate. At this point, Mr. Shield began taking an interest in end of life treatment.

One day, his wife attended a panel discussion about medical deaths near their home and solicited the services of Dr. Green, a specialist on medically assisted suicide. The onset and progression of the neuropathy was a particularly difficult time for Mr. Shield and his family. His skin was perpetually itchy; he could no longer swallow dry food, and his feet were numb and covered in sores. In February, Mr. Shield’s pain grew exceptionally worse, and the family realized they could not care for him at home. During his stay at the hospice, his pain became worse and failed to respond to medication. On March 23rd, the family held a farewell party for Mr. Shield at his hospice room, and the next day, Dr. Green administered the lethal injection.

What is the key ethical question?

Physician-assisted suicide has been a contentious issue within the healthcare community for a considerable period of time (Sulmasy & Mueller, 2017). Like Mr. Shield, patients who often request end of life treatments often have terminal, debilitating conditions with death as the only foreseeable outcome. A variety of critical ethical questions arose when considering physician-assisted suicide from a professional perspective. One must examine issues of autonomy, dignity, maleficence and beneficence, and sanctity of life.

There has been widespread consensus that despite the capacity of clinical interventions to improve therapeutic outcomes for patients, people reserve the right to decide what should be done with their bodies. It, therefore, stands to reason that in the presence of the prerequisite mental capacity, patients should be allowed to make life-limiting decisions in his/her won treatment.

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According to Kantian ethics, autonomy is governed by rational choice. Kant emphasizes that nature in itself is not moral, and human beings must strive to find morality outside the realms of nature by recognizing themselves as phenomenal and noumenal beings (Kain, 2009). Phenomenal beings can be influenced by inclinations which will lead to them to act via natural mechanisms. Noumenal beings can step outside of the realms of nature to a place of moral conscience that is independent of how the world functions (Kain, 2009). At this point, human beings can exercise determinism.

Determinism gives them the capacity to be rational, imaginative, and transcend the influence of their inclinations and desires and adjust their behavior according to the moral law. Thus, a patient must ignore his/her desires and engage the physician in a decision making process that involves pure practical reasoning (Davis et al., 2001). Furthermore, Kantian ethics argue that it was morally impermissible to kill oneself if continued living held the promise of greater life satisfaction. Conversely, John Stuart Mill’s understanding of autonomy is founded on the individual right to self-determination. According to Mill, the individual’s preferences and desires should take precedence over rationality as long as those preferences do not cause harm to others.

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Terminally ill patients are often under a great deal of psychological and physical distress. In the case of Mr. Shield, the promise of future life satisfaction was indeed daunting. His days were often filled with insurmountable pain that was persisted despite numerous clinical interventions. Mr. Shield’s eventual death was inevitable, waiting any longer would only cause him more distress and diminish his life satisfaction. Concerning autonomy, the ethical question presents itself is; Given Mr. Shield’s poor prognosis, should his desire to seek end of life treatment be respected and fulfilled or should the physician prolong his life in anticipation of improved life satisfaction?

Like Mr. Shield, many terminally ill patients express the desire to die with dignity without having to suffer severe physical pain, subject family, and friends to psychological turmoil and become dependent on others for self-care. Aspirational dignity dictates that individuals must uphold their standards and norms irrespective of existing societal expectations (Killmister, 2010). Thus, what these individuals perceive as a dignified death should be respected even if it necessitates end of life treatment. On the other hand, the intrinsic worth of dignity cannot be diminished even in the presence of severe hardship (Schroder, 2008). Human dignity is an irrevocable inherent right for every individual. Unbearable pain and psychological trauma are irrelevant in determining the extent to which an individual’s life is dignified.

Mr. Shield considers dignity as a critical aspect in the quality of his life. Central to his wellbeing is sparing his wife and daughter undue anxiety and torment due to his illness. The eventual outcome of his disease would be complete paralysis. He would have to be confined to a hospital bed, rely on machines for nutrition. According to Mr. Shield, all of these outcomes would be demeaning and below the standards of how he wishes to live his life. Concerning dignity, the ethical question raised is whether allowing Mr. Shield’s disease progression respects his right to dignity and self-determinism.

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Non-maleficence refers to the professional obligation not to cause harm to others. While beneficence is the obligation to help others. The Hippocratic Oath specifies that medical professionals are obligated to help sick and suffering people but refrain from doing them harm. The physician’s substantial training, experience, and knowledge allows him/her to determine the patient’s best interests (Miles, 2005). The patients may be ill-informed and make irresponsible choices. Thus, the physician must override these preferences if the action he/she seeks to undertake will benefit or limit potential harm to the patient.

However, exercising a paternalistic approach to medicine may negate the individual’s assessment of harm and benefit. According to Gillon (1992), when considering when to override a patient’s concerns it is essential to consider what exactly the patient views as harm and what he/she perceives as a benefit. Mr. Shield’s assessment of his conditions revealed that ending his life before his disease progressed to a debilitating state would provide the most utility for himself and his family. In deciding whether to fulfill his desire for end of life treatment, the physician examining the issues pertinent to his condition and determine whether a prolonged painful existence would provide the most utility as opposed to an end of life treatment that takes away Mr. Shield’s suffering and gives his family the opportunity to heal.

The final ethical question that should be considered is one that recognizes the sanctity of life. Life is regarded as a divine gift. Numerous religious laws exist to protect and prolong life and prevent human beings from exercising arbitrary prerogatives over their lives. These laws also promote medical interventions designed to increase longevity because life is always better than death. However, life in itself does not have a pre-specified prudential value. Human beings attach value to their lives based on prevailing circumstances and the promise of a future with better outcomes. A few months after his diagnosis. Mr. Shield’s amyloidosis was already progressing at an exponential rate. His condition is incurable, and his distress is likely to get worse with time. In this case, is it still accurate to posit that life is more valuable than death?

What is the most important information you would need to answer the ethical question?

Central to resolving an ethical dilemma is gathering appropriate information. In my opinion, it is vital to examine existing legislation regarding physician-assisted suicide to determine whether any decision made will bring about legal issues. In June 1997, the United States Supreme Court made a ruling that established that individuals do not have a constitutional right to die (Lachman, 2010). However, this ruling does not prohibit individual states from passing laws to establish such a right under their jurisdictions (Salladay, 2004).

Consequently, states like Oregon, Washington, Montana have since removed obstacles for terminally ill patients who wish to seek physician-assisted suicide. However, none of the laws in the United States permit mercy killing, active euthanasia, or lethal injections. Physicians are only allowed to issue prescriptions to mentally competent individuals with terminal illnesses (O‘Reilly, 2010).

Next, it is vital to examine the patient’s motivation to seeking end of life treatment. Suicide often occurs as a manifestation of psychological disorders. Maladaptive attitudes, depression, or destabilization by trauma. Mr. Shield does not demonstrate any visible signs of psychological disturbance. The rationale behind his choice reflects a thorough decision-making process that examined all the facts pertinent to his condition and settled on his preferred alternative. According to Hockely (1993), many terminally ill patients requesting end of life treatments do not typically display depressive symptoms but rather despair at the pointlessness of continual suffering.

Finally, it is crucial to examine Mr. Shield’s quality of life to determine if death is the most rational intervention. Although novel clinical interventions promise to prolong the lives of amyloidosis patient’s a cure for the condition is yet to be discovered (Comenzo, 2009). Despite promises of increased longevity, treatments may not be able to stop the progression of the disease or prevent eventual paralysis and clinical confinement. Thus, Mr. Shield’s last days will most likely be spent confined to a hospital bed. According to him, prolonged debilitation will be demeaning and likely to cause his family great distress.

What are the key ethical concepts and principles to consider?

Thus Kantian ethics dictate the application of a vigorous and rational decision making process which remains unencumbered by personal preferences and desires. Kantianism provides a deontological approach to morality that highlights the idea of an unconditional categorical imperative (Kain, 2009). This imperative delineates a sense of duty that should guide every moral decision. According to Kant, human beings respond to what is unconditionally good. An action is deemed right or wrong not because it leads to a good or bad outcome but because it is done out of a sense of duty and responds to what one ought to do. According to Kant, human beings are obliged to follow the categorical imperative as a result of the rationality that exists within them. Thus the deontologist would argue that killing is unacceptable regardless of the prevailing circumstances.

            On the other hand, utilitarian ethics describe an action as right or wrong based on its resultant consequences. From a utilitarian perspective, individuals should choose actions that bring about the most significant balance for everyone involved. In the case of Mr. Shield, the utilitarian would consider allowing an exception to the universal rule of “do not kill’ (Mandal & Parija, 2016). In his mind, death provides the most utility for everyone involved. It offers Mr. Shield the opportunity to escape a prolonged and painful death, allows redirection of time and resources to patients with better prognosis and prevents his family from witnessing his suffering (Mandal & Parija, 2016). The aim of physician-assisted suicide is to reducing suffering for the patient. Consequently, the deontologist might also argue that pertinent non-maleficence and beneficence the physician must avoid harm and minimize pain. 

Finally, it is crucial to consider virtue ethics, especially when examining the physician’s role in end of life treatment. Virtue ethics is concerned with becoming a good person rather than following specific rules or providing the most utility (Huxtable, 2002).  According to virtue ethics, the physician must display characteristics that are morally valuable by cultivating honesty and loyalty through education and role models (Huxtable, 2002). From a virtue ethics perspective, a physician must possess the virtues of compassion and the ability to demonstrate genuine empathy. These virtues allow an understanding of the kind of pain the patient is in and facilitate incorporation of the patient’s wellbeing into the decision making process. From this perspective, ending Mr. Shield’s life is, therefore, a respectful and compassionate response to his suffering. Virtue ethics does not follow a set of principles but rather conforms to the physician’s character and the standards he/she sets for himself/herself (Huxtable, 2002).

What assumptions will you use to resolve the ethical question?

Several assumptions will guide my resolution of the ethical dilemma presented by Mr. Shield’s case.  I am assuming that no research has provided promise in treating amyloidosis. That Mr. Shield is mentally competent and legally able to make the end of life decision for himself, and his decision is not a manifestation of an underlying psychological disorder.  That he is not under coercion and has undergone the prerequisite psychological counseling before his plans to end his life were consolidated.

What viewpoints with respect to the facts would a reasonable person consider in thinking through this dilemma?

To resolve this ethical dilemma, we must consider viewpoints from proponents and opponents of physician-assisted suicide. Arguments supporting the need to legalize physician-assisted suicide claim that healthcare professionals have a duty to respect patient autonomy. The physical and psychological suffering induced by terminal illness can be unbearable for patients. Furthermore, terminal illness imposes significant interpersonal suffering due to dependency on family members and friends. The inevitability of death also indices existential suffering, feelings of hopelessness and despair (Marko et al., 2006). Proponents of physician-assisted suicide have argued that it is essential for healthcare practitioners to recognize the limits of pharmacological and surgical interventions in addressing human finitude and mortality and existential suffering during terminal illness (Maynard et al., 1992).

Furthermore, it is essential to respect the patient’s assessment of his/her clinical situation and his/her perspective on the benefit and burden imposed by life-sustaining interventions. Human beings reserve the right to determine the prudential value of their own lives. Thus, the decision to end one’s own life should be private and personal. From this perspective, physician-assisted suicide fulfills a professional obligation of non-abandonment, respects the patient’s autonomy and upholds their dignity (Quill et al., 1995).

Opponents of physician-assisted suicide have argued that the medical profession ought to acknowledge that eliminating all human suffering is an impossible task. Instead, healthcare professionals should use their expertise to alleviate the medical conditions that cause suffering at the end of life (Byock, 1997). Physician efforts should be centered toward providing palliative care to alleviate somatic and psychological symptoms. Feelings of hopelessness from the failure of pharmacological and surgical interventions do not provide sufficient rationale to justify physician-assisted suicide. By remaining with the patient, the physician exercises compassion and fulfills the professional obligation of non-abandonment. 

At the height of physical or psychological suffering, clinical efforts should be geared towards alleviating this suffering with pharmacological and surgical interventions. However, it is beyond the scope of medical care to palliate interpersonal and existential conflict. Furthermore, healthcare practitioners must remain faithful to ethical traditions that emphasize the role of the physician as one healing and comfort. Any contrary position would undermine trust within the patient-physician relationship and the integrity of the profession as a whole (Gaylin et al., 1988). While it is essential to respect the patient’s autonomy, the duty to do so should not be considered absolute. The physician’s responsibility to safeguard the value of human life should trump all other considerations.

What are your main inferences/conclusions in thinking through this ethical question?

In my opinion, Mr. Shield’s decision to end his life should be respected and acted upon. Providing end of life treatments for individuals who do not wish to endure persistent suffering at the end of life is conforms to utilitarian, deontological, and virtue ethics. From a utilitarian perspective, physician-assisted suicide provided utility for the patient, the healthcare system, and his family (Jordan, 2017). The physician’s ability to recognize and understand suffering in his/her patients demonstrates the virtue of compassion (Jordan, 2017).  Finally, this decision fulfills the physician’s categorical imperative to minimize harm and reduce suffering (Jordan, 2017).

What are some important implications/consequences for yourself and others to your conclusions?

Opponents of physician-assisted suicide have argued that if the practice is legalized, it will eventually lead to the acceptance of non-voluntary and involuntary euthanasia (Synder & Sulmasy, 2001).  In its initial stages, the practice may be considered a last resort but may eventually become more prevalent and preferred. Thus, legislators need to ensure that a stringent regulatory framework is in place before allowing physicians to administer end of life treatments. The determination of the value of life should be the patient’s voluntary and autonomous prerogative. Moreover, physicians should scrutinize the patient’s rationale to ensure no coercion has occurred and sufficient justification is present to necessitate death.

What are the implications for Social work of your ethical dilemma?

Social workers are expected to conform to the ethical guidelines stipulated in the National Association of Social Workers code of ethics. The social worker’s ethical responsibilities are to promote the patient’s self-determination except when the patient’s action pose an imminent risk to themselves and others (National Association of Social Workers, 2008). Thus social workers are expected to be familiar with the complex bioethical and legal considerations involved in end of life care. Furthermore, social workers need additional training in mental health, ethics, and suicide to prepare them to work with clients making end of life decisions (Mannetta & Wells, 2001). This kind of training will enable them to provide more effective support for patients and families making end of life decision.

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