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A study of death and euthanasia in the medical field

This article has been cited by other articles in PMC. Abstract Assisting or hastening death is a dilemma with many ethical as well as practical issues facing healthcare practitioners in most countries worldwide now.

Various arguments for and against assisted dying have been made over time but the call from the public for the legalisation of euthanasia and assisted suicide has never been stronger. While some studies have documented the reluctance of medical and other healthcare professionals to be involved in the practice of assisted dying or euthanasia, there is still much open debate in the public domain.

Those who have the most experience of palliative care are strongest in their opposition to hastening death. This paper explores salient practical and ethical considerations for healthcare practitioners associated with assisting death, including a focus on examining the concepts of autonomy for patients and healthcare practitioners. The role of the healthcare practitioner has clearly and undoubtedly changed over time with advances in healthcare practices but the duty of care has not changed. Introduction Public debate over legalizing assisted or hastened death is occurring in many countries including the UK, Australia, New Zealand, Canada and the United States where there is understandably much academic and healthcare professional interest as well.

Many arguments for and against assisted suicide and euthanasia have been made over the years. Most of these have not considered what it would be like for the healthcare practitioner to be involved in the decision to take a life and also involved in the practice of actually taking a life.

The focus in this paper is on the practical as well as personal ethical or moral considerations of assisted suicide and euthanasia for healthcare practitioners. To this end, a history of this debate is outlined. Throughout this paper, major dilemmas are identified, with these included to aid in the discussion of whether assisted or directly hastened death is something that healthcare professionals most often physicians should be responsible a study of death and euthanasia in the medical field.

This paper starts with a historical background to the current discussions concerning assisted dying and euthanasia. Literature from general medical, bioethical, legal, and palliative care journals is included to illustrate contemporary considerations of the views of healthcare practitioners. Practical and ethical considerations in this area are also explored. It is also clear from ancient scholars that a self-administered death was not explicitly prohibited, and furthermore, that some physicians were instrumental in helping terminally-ill or fatally injured individuals to die Gillon, 1969 ; Stolberg, 2007.

Regardless, healthcare practitioner opinion on the permissibility of assisted suicide and euthanasia remained divided at the beginning of the 20th century. However, there is little doubt that throughout human history those charged with providing healthcare services have assisted very-ill individuals to die more rapidly than nature would have allowed.

Much less information is available on the historic views of other healthcare professionals, such as nurses and pharmacists. However, never has the call to formally debate these issues been as vocal and organised as it is today.

What are euthanasia and assisted suicide?

Much of this current and historic debate has been focused on suffering at the end of life. Current Considerations Thankfully, the tremendous advances in health care over the past five decades have benefited society in numerous diverse ways; perhaps the most significant of these is the ability to sustain and prolong life where once individuals would simply have died.

These advances have also meant that it is increasingly possible for people to have long terminal illnesses and long dying processes. Death thus remains a reality for all people, with the specialty of palliative care having proliferated globally since the 1970s as a way to prevent and address end-of-life suffering. Palliative care is an active form of care that focuses on improving quality of life and it aims to neither hasten nor postpone death, and this focus is made clear to recipients of such care.

Regardless, some terminally-ill and some dying people request assisted suicide or euthanasia as they would trade quantity of life for quality of life, or at least a certainty to the end of life. Among the physicians surveyed, palliative specialists were particularly opposed. Other studies have found additional select factors were associated with physician willingness or unwillingness to participate in hastening death such as their specialty, gender, and ethnic group Cohen et al.

Another major issue, beyond the question of a study of death and euthanasia in the medical field death hastening can or should be legally performed, is who will be responsible for the decisions about which persons can or cannot be assisted to die. Clearly, palliative care physicians are the least likely to want to be involved in these decisions and yet arguably these are the most relevant physicians to be involved.

A related concern is based on the person or persons who will be involved in the actual practice of hastening death. It would seem reasonable that healthcare practitioners would be instrumental in ensuring that assisted suicide and euthanasia are conducted properly when it has been authorized. However, despite public opinion generally favoring PAS, physicians are rarely supportive of the view that they be the instrument through which death hastening should occur.

Other healthcare professions have also expressed a similar sentiment. Switzerland is the only country in the world where the act of assisted dying can be conducted by someone who is not a physician. Furthermore, non-Swiss persons are permitted to take advantage of the Swiss law, with individuals travelling to Switzerland to die by assisted means.

Oregon is another interesting jurisdiction, as in this US state since 1997, a terminally-ill person who has been diagnosed as having less than six months left of life may request and receive a prescription from a physician or nurse practitioner and they are then at liberty to take or not take the medication to end their life.

  • In any case, unbearable suffering should never be equivalent to unbearable pain and physicians should be particularly acquainted with this difference;
  • Despite these legal developments, requests for assisted suicide and euthanasia raise a number of challenging practical and ethical considerations for healthcare practitioners;
  • Furthermore, it is not evident which tool s for recording personal requests for assisted suicide or euthanasia are the most appropriate, as these need to be completed before incompetence occurs with advancing ill health;
  • However, nearly a quarter of the physicians regretted their actions.

In these Oregonian cases, the ill person may be assisted by a family member or home care nurse or anyone else to commit suicide. Within the US, several other states also allow assisted suicide. Several other states are currently considering their own DWD laws i. Similarly, in Canada, a Supreme Court judge ruled in mid-2012 that persons who cannot commit suicide themselves are disadvantaged by the current law that prevents assisted death practices from occurring openly Wilson et al.

Quebec, a Canadian province, has also studied the matter of assisted death and completed a report in late 2011 that recommends both assisted suicide and euthanasia should be practiced in the province for those who wish it, and also that palliative care should be more accessible and available to those who need it Wilson et al.

Despite these legal developments, requests for assisted suicide and euthanasia raise a number of challenging practical and ethical considerations for healthcare practitioners. It is to these we now turn. Practical Considerations Assessing capacity to decide on any intervention is a key component of this discussion, however, surprisingly little commentary is made on this issue in the literature.

1. Introduction

Screening methods for cognitive impairment are needed for detecting those with or without mental capacity, to ensure that requests for assisted suicide or euthanasia are made by competent persons. Furthermore, it is not evident which tool s for recording personal requests for assisted suicide or euthanasia are a study of death and euthanasia in the medical field most appropriate, as these need to be completed before incompetence occurs with advancing ill health.

Advance directives are one tool in which the wishes of persons may be clearly recorded. Depression is another major consideration, as patients having both cancer and depression experience more physical symptoms, have poorer quality of life, and are more likely to have suicidal thoughts or a desire for hastened death than cancer patients who are not depressed Breitbart et al.

Kissane and colleagues differentiate this syndrome from depression and assert that demoralization is associated with chronic medical illness, disability, bodily disfigurement, fear of a study of death and euthanasia in the medical field of dignity, and social isolation. Because of the sense of impotence or helplessness with impending death and terminal illnesses, those with the syndrome may progress to express a desire to die or to commit suicide.

Similarly, those persons who are depressed and feel hopeless have been found to have an increased desire for death Breitbart et al. Another issue is the direct personal impact emotionally, professionally, spirituality and psychologically on the doctors and other healthcare practitioners who have a socially and professionally-endorsed mandate to prevent premature death and actively address suffering but who may be asked to assist patients to die.

The impact of this request can be profound and long-lasting. In countries where assisted suicide is illegal, doctors who do assist their patients to die may be entirely unable to access help for any personal issues that may arise for them as a consequence of their actions. Patients who request help to die from their doctor are also vulnerable as this help must occur in secret, and yet practitioners are extremely vulnerable to being discovered and reported if someone witnesses the death or becomes aware of it and discloses it to the authorities.

Macleod 2012 also suggests another pressure that doctors may become weighed down by the psychological issues associated with their patients who are dying. No doubt, physicians and other healthcare professionals may find themselves in the position of being begged at times by patients or their family members to end a life.

This burden to assist or hasten dying comes with a cost. Some Flemish GPs in Belgium have also found the practice of performing euthanasia to be difficult Sercu et al.

However, some argue that there are no negative repercussions in having both palliative care and PAS available for dying patients. Another dilemma is the use of sedation near the end of life — at times used as a strategy of last resort to minimise distressing refractory symptoms that are difficult to manage - not hasten death, but with this practice resulting in confusion about PAS.

There is now good evidence to support the view that the dose of morphine or other analgesics used in sedation near the end of life and the rate of dose increase has no effect on the time of death. Recent studies have concluded that palliative sedation therapy does not hasten death when used to manage refractory symptoms Maltoni et al.

However, clear communication to explain the purpose of such sedation is needed, as an increase in the use of strong opioids near the end of life can cause confusion about death hastening in the minds of healthcare staff and families.

Trust in the healthcare team is one of the most important aspects for quality end-of-life care Heyland et al. Similarly, effective and empathetic communication is essential to avert differences in understanding about the goal of all end-of-life medications and treatments Steinhauser et al.

Together, these factors highlight the importance or relevance of providing effective palliative care Ganzini et al. Effective interventions for pain and psychological distress could produce a change in view among persons who are seeking an early end to a difficult life.

Ethical Considerations While laws that permit or prohibit assistance to hasten death are evident in most jurisdictions around the world, the ethical dimensions associated with them remain deeply contentious.

The Nathaniel Centre

This is not surprising, given that the death of any individual is neither trivial nor inconsequential for those involved. Assisting an individual to die, with or without consent and regardless of the circumstances, is unethical for some because of the inherent value and sanctity of all human life Kass, 1991.

This stance would imply that denying terminally-ill individuals an assisted death who wish it is perhaps cruel and unfair. In these cases, they could argue that an assisted death may be more humane than allowing nature to take its course Rachels, 1974.

Patients and Healthcare Practitioners The past several decades have seen the principle of respect for patient autonomy assume a central place in health care. The dilemma now is that fear of losing autonomy or dignity during the dying process could lead a study of death and euthanasia in the medical field patients to request a hastened death.

In addition, French researchers who were investigating requests to hasten death in palliative care settings also found loss of autonomy was a factor for patient decision-making Ferrand et al. Salem claimed that PAS ultimately extends the power of physicians in regulating death. Prichard and others thus claim that our right to do with our bodies what we will is relevantly different to a right to demand hastened-death assistance from others.

Some feminist scholars have raised other considerations of relevance claiming that autonomy - an individualistic notion that focuses on separateness - fails to adequately account for the complex web of social relationships that underpin families, friendships, and relationships with colleagues Donchin, 2000 ; Heath, 2012 ; Parks, 2000.

Clearly, autonomy arguments must also consider the healthcare practitioner as an autonomous agent. Some have argued that respecting healthcare professional autonomy necessitates that they cannot be required — against their will - to assist patients to die, an argument that obliges some practitioners to refer patients to someone else who will help them achieve a hastened death. To this end, laws in some countries have been crafted so that the autonomy of practitioners is not compromised in jurisdictions that allow assisted suicide and euthanasia, even when they are also crafted to protect the death-hastening decisions of patients.

The Netherlands and Belgium illustrate this situation. Duty of Care and the Role of the Healthcare Practitioner There is little doubt that the roles of healthcare practitioners have changed as health care has advanced.

As technologies, treatments, and care have improved over time, so too has the efficacy of healthcare practitioners. This advancement can be clearly illustrated in the way that palliative care has developed in many parts of the world. With improvements in the medications used to manage refractory end-of-life symptoms, and a greater awareness of how individuals and their families cope with the dying process, palliative care has evolved to shift the focus of care away from cure when cure it no longer an option.

Palliative care has also become most successful in addressing the spiritual, emotional, physical, and social needs of patients and their families at the end of life. Thus the role of healthcare providers near the end of life has shifted over time from that of healer and decision-maker to one that may be better articulated as a chaperone or companion through a highly normal but often difficult life process.

Drawing closer to the patient and family who is near the end of life is a central aspect of the palliative care approach, as it underpins a crucial aspect of the duty of care for palliative care providers.

We already have clear guidance for doctors that they must always act within the law and assisting or encouraging suicide remains a criminal offence.

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This guidance will not in any way change the legal position for doctors. Others would appear to agree with this view Kass, 1989; Paris, 2009 ; Pellegrino, 1992. For instance, Rosenblum and Forsythe 1990 claimed that were doctors to engage in assisted suicide or euthanasia: This stance stems from the view that doctors have a duty in law to protect life and further the health of their patients.

Similarly, others argue that doctors are educated to preserve life, not take it; their intent must be to provide care and not death Foley, 1997. They also stated that this assistance must be a practice of last resort.