This past February Canadian legislature was passed allowing for the legalization of physicians assisted suicide to terminally ill patients. Provinces were given time to draft up laws on how they want physicians assisted suicide to proceed and the protocols that must be administered. Although Canada has already legalized the “death with dignity act” many other countries and states have yet to do so. The reserves these countries and states have on passing laws and bills on this act is rightfully placed, but looking at the issues with an open mind and from an ethical and medical standpoint can help eliminate the fear surrounding euthanasia. There are many deep seeded issues and thoughts surrounding suicide and euthanasia in general that must first be cleared in order to gain a more accurate understanding as to why physicians assisted suicide is ethically permissible.
Christians, Catholics and Judeo-Christians once held the early prevailing views on suicide. They believed it was that is was a morally wrong sin and that all life is sacrosanct (Tomansini 100). This group of religious followers were dead against suicide, for they all believed that is went against the laws of nature, and that only God was able to take life away. They didn’t believe that humans should have a hand in their own fate, and go against the wishes and power of God. Catholics also argued about the fate of a soul who committed suicide; would they be denied salvation (Tomansini 100)? These groups made suicide a terrible, punishable act by as many means possible. From 1917-1983 the Catholic Church’s “Canon Law” stated that “’those who [kill] themselves of a deliberate purpose’ [are] to be deprived of ecclesiastical burial” (Tomansini 100). These religious powerhouses used every scare tactic they could to discourage and demean suicide. It wasn’t until Pope John Paul II made amends to this law that suicide was viewed in a different light. It was stated that is someone suffered from “grave psychological disturbances, anguish, or grave fear of hardships, suffering, or torture” (Tomansini 100) that their responsibility of committing suicide was diminished. This realization sparked many debates among the holy communities, but ultimately led to more questions about the trials and tribulations that sufferers endure. The thoughts regarding suicide shifted from the belief it was a terrible sin to raising concerns over the wellbeing of the victim; a more philosophical and psychiatric argument. Due to the prominence of the Church, many people still feel a stigma and taboo associated with suicide, making it more difficult to gain support for physicians assisted suicide.
Rational suicide, most commonly defined as an autonomous decision, rational in thought, and not due to mental instability or illness, is typically used to give a name to the conscious choice patients make regarding their terminal diagnosis or incomprehensible suffering (Tomansini 99).
Unfortunately the problem with this definition is that it looks more “toward a technical psychiatric definition” (Tomansini 99) and forgets to include the ethics of why philosophically, rational suicide can be justified. Instead of taking into account the unbearable pain sufferers are enduring, it instead leans toward the explanation that if someone has such a desire to die, they must be mentally unstable. In todays culture, the act of suicide is attempted and made by members of society who are mentally ill, or their mental capacity is compromised, and they are not thinking or acting for their long term interests (Tomansini 101). This casts a bad shadow on the term “suicide” and makes it hard to gain support for the “right to die”. If everyone goes by the assumption that only the mentally anguished commit suicide, the terminally ill patients and chronic sufferers will be denied the option to chose their own death to extinguish their pain or hardships, which goes against many ethics codes.
According to one study, suicide is the leading “cause of premature death amongst people with mental illness” (Tomasini 102), and 10% of people diagnosed with mental illness will commit suicide within 10 years of their diagnosis. This statistic to many people is further proof that nobody sound of mind is able to make a competent decision regarding self death, but instead to others it shows an alarming number of people suffering from a mental illness whose suffering may outweigh the benefits to their existence. This is also hard to evaluate because many times it is difficult to tell whether the diagnosis of a mental illness, such as depression, is the side effect to living in massive amounts of pain, or whether it is causing them to be in this anguish (Downar 567). It is true, this distinction rides a fine line, and that is part of the issue many groups have against patients wishes to end their lives (Tomasini 102). With proper evaluation, and tight protocols put in place, the prevention of exploiting the mentally ill population by means of suicide and the easing of suffering patients can exist in harmony.
Another barrier to defining and justifying the act of rational suicide is the argument that suicide is an irrational and unintelligible act. The desire to wish to be dead can be seen as absurd in everyday situations, but understood with more compassion and intelligence when an antecedent cause is present (Tomasini 101). In one argument, it is stated that death annihilates us, and therefore is unable to be experienced or known about, which denies people of having complete knowledge about their options, and cannot be seen as “rational” (Tomasini 101). This argument can be rebuffed by the fact that many citizens of society have strong beliefs in the afterlife and are set in their ways regarding their beliefs on the next step after death. The act of suicide can be rationally chosen, but the problem lies in the identification of those who can competently chose it.
Physicians assisted suicide, performed with euthanasia administered by a team of medical professionals, is legal in five states – New Mexico, Vermont, Montana, Washington and Oregon – The Netherlands, Switzerland and now Canada (Boudreau 3). Individuals can opt for this route of death if their prognosis gives them less than six months left to live, and when they “find their quality of life intolerable” (Lachman 56). The patient must voluntarily and persistently request for the help of a physician in death for 15 consecutive days to ensure that they understand all their options and are confident in their choice (Downar 567). In the Netherlands, each patient’s request to receive lethal barbiturates must also be reviewed by a euthanasia board, consisting of a legal expert, a physician, an ethicist and a lawyer who acts as a secretary (Barbuzzi 18). This is in place so that the legal ramifications of an incident can be minimized, and it will try to eliminate the potential of allowing patients who are not in a rational state to be exploited. The Netherlands also has rules in place stating that the board must deem the patient’s suffering to be “unbearable and have no prospects of improvement” (Barbuzzi 19), which is confirmed by two physicians. A large medical team is usually brought together, consisting of at least two physicians, and numerous nurses and caregivers. The larger the team, the less room for error or wrongful death.
The primary doctor is in place to ensure that every possible alternative treatment is discussed and the patient understands all their options, whereas the secondary physician is there to give expert assessment on their condition and mental state. The nurses and caregivers are there to take care of the patient and help provide them with as much support and care as possible (Lachman 58). If there is potential for recovery, the patient is deemed incompetent, or other options to their treatment exist, the patient is usually denied the option of euthanasia, as it goes against the “Due Care Criteria” put in place to prevent the exploitation and wrongful death of sufferers (Barbuzzi 19). In contrast to that, diseases that have well documented continual degradation of the patient’s health, such as Huntington’s Disease or ALS, and show no promise of a recovery are usually exceptions to this criteria, and patients will typically alter their perspective on their future (Barbuzzi 19). The laws and criteria in place to protect the citizens of the Netherlands from involuntary euthanasia or exploitation has served exceptionally well, and the Netherlands has see a fall in the number of involuntary euthanasia incidents since Physicians Assisted Suicide has been legalized, and is even lower than in some countries that still have Physicians Assisted Suicide outlawed (Downar 19). The Netherlands have made Physicians Assisted Suicide legal since 2002, and have so far demonstrated a solid foundation for a legal model, which is what needs to be put in place before Canada can pass the legislature without massive amounts of backlash from the general public.
One of the many obstacles standing in the way of legalization of physicians assisted suicide is the use of euthanasia, more specifically, active euthanasia. Currently in Canada there are alternatives to physicians assisted suicide, which are completely legal, and recognized as ‘passive euthanasia’. These are classified as either the refusal of life sustaining treatments, or the voluntary stopping of eating or drinking, which collectively is colloquially referred to as ‘letting die’ (Barbuzzi 16). For those terminally ill patients who require life-sustaining interventions, such as chemotherapy or a left ventricular assist device implantations (Lachman 57), they can actively refuse the treatments or insist on the removal of such critical devices to sustain their lives. It is argued that in practicing hospital settings the choice to withhold or withdraw critical treatments is made everyday. Many “courts have stated consistently there is no legal or ethical difference between withholding and withdrawing of life-sustaining interventions” (Lachman 57). If the patient declines to further pursue treatment, they have the legal and ethical right to. Their physician and/or nurses also have the “moral responsibility to honour the refusal” (Lachman 57) of life-sustaining treatments. Unsurprisingly some medical professionals have a hard time honouring their patient’s wishes, and therefore are able to refer their patient to another physician. This method of “death with dignity” is what many groups argue should be the prevailing approach since it allows sufferers to exercise their legal and ethical right to subject their bodies to tiresome uncomfortable medical procedures to temporarily hold off their imminent death.
The other currently legal option for terminally ill patients, usually taking place in a palliative care centre, or a hospice home, is the voluntary stopping of eating or drinking. In this scenario, the patient elects to forgo all nutrition, whether that is artificial or natural, and will terminate hydration, leading to an eventual demise (Lachman 56). This method takes about one to three weeks to end their life of the ill patient. Although this may seem like a viable, more natural option, it can feel dragged out by the patient and they may become more agitated and uncomfortable, unless they receive the right palliative care. Again, care for these patients electing to voluntarily stop the consumption of life sustaining nutrients is up to the moral stance nurses take. This type of end of life treatment requires an immense amount of around the clock support and care due to the patient’s natural instinct to replenish lost nutrients, the discomfort and complication they could face, and the care they need when they eventually slip into an unconscious state (Lachman 58).
The option of palliative care is one that should be presented to all wish-to-die patients as part of the protocol of administering all options. Unfortunately, palliative care, albeit wonderful critical care and end of life support, is very inaccessible for many Canadians, with only approximately 30% of them having access (Downar 567). Wait times, even for urgent referrals, can be exceptionally long, and hinder the availability of end of life care. Due to these factors, the option of this type of care is deemed undesirable for many patients, creating more of a desire to seek out end of life administrations, such as passive or active euthanasia in the form of physicians assisted suicide.
Active euthanasia is the prescription of lethal doses of barbiturates, so that when administered (either by self or by a physician in a clinical setting), the patient would die of an overdose. This has recently been legalized by Canada, but the fear of a ‘slippery slope’ has captured the worries of many citizens. The slippery slope argument works on the basis that every patient has the right to autonomy, and must have his or her choices respected, which could lead down a hazy trail (Barbuzzi 18). It is believed that because it is legalized, and patients have the right to autonomy, the patient “could be somehow coerced to request euthanasia against their true wishes” (Barbuzzi 18) typically done by a greedy family member, or families who feel the burden of care, and deem this a viable alternative. The arguers of the slippery slope also believe that with the allowance of this to the critically disabled or patients suffering extreme pain, eventually less and less serious cases will be permitted until it become too dangerous to the vulnerable population, and far too common (Barbuzzi 18). With proper screening and assessments of patient’s mental and physical health, and the education over the severity and caution these cases present, the slippery slope can be avoided.
If sufferers are adamant about pursuing a dignified death, and it is not legal, physicians who back this ethical stance will be forced to operate in a legal vacuum, such like the ones early physicians had to when dealing with abortions (Downar 567). This can create dangerous medical situations, and dire legal ones, all to help grant suffering patients their wish of comfort and a dignified death. It’s argued that those who suffer from such debilitating diseases like ALS, are too disabled to end their own lives, and are being denied a right that all abled bodied persons have (Barbuzzi 17). Because it is not illegal to commit suicide, those people who are in a position that does not allow them the access to committing suicide are denied a right they may wish to exercise. These patients who have suffered long enough to deteriorated to the point they cannot take their own lives are now being denied the right to their life, liberties and security that every able bodied Canadian is entitled to (Barbuzzi 17). In a report spanning 14 years, released by Oregon’s Public Health Division, it was found that the most common concerns discussed by patients “were [their] loss of autonomy (91.4%), [a] decreasing ability to participate in [the] activities that made life enjoyable (88.9%), and [a] loss of dignity (80.9%)” (Boudreau 6). Dignity is an exceptionally important thing in most cultures, so these patients suffering from these debilitating progressive diseases should be allowed the option of a dignified death when they believe their time is up.
In conclusion, the many myths and taboos surrounding rational suicide and physicians assisted suicide can all be put to rest with an educated viewpoint, and the opinion of what is deemed to be ethical and justified. With a sound review board and tight protocols, the vulnerable populations can be protected from the “slippery slope” while honouring other patient’s wishes to end their terminal suffering. As stated, the administration of euthanasia is not the only way patients can chose to end their lives, as there are other legal, passive treatment options, but may not be viable or desirable for everyone. According to some, the “right to life” also means the right to their death, and that since suicide is legal in Canada, a “cleaner” more peaceful option should be available. There is no question whether or not physicians assisted suicide should be legal, especially now that is has been legalized, it’s the question of what type of protocols will be put in place and how the Canadian and provincial government will govern these laws.
Barbuzzi, Miranda. "Who Owns The Right To Die? An Argument About The Legal Status Of Euthanasia And Assisted Suicide In Canada." Penn Bioethics Journal 10.1 (2014): 16-20. Academic Search Complete. Web. 9 Mar. 2015.
Boudreau, J. Donald, and Margaret A. Somerville. "Euthanasia And Assisted Suicide: A Physician's And Ethicist's Perspectives." Medicolegal & Bioethics 4.(2014): 1-12. Academic Search Complete. Web. 9 Mar. 2015.
Downar, James, et al. "Physician-Assisted Death: Time To Move Beyond Yes Or No." CMAJ: Canadian Medical Association Journal = Journal De L'association Medicale Canadienne 186.8 (2014): 567-568. MEDLINE with Full Text. Web. 9 Mar. 2015.
Lachman, Vicki, D. "Voluntary Stopping Of Eating And Drinking: An Ethical Alternative To Physician-Assisted Suicide." MEDSURG Nursing 24.1 (2015): 56-59. CINAHL with Full Text. Web. 9 Mar. 2015.
Tomasini, Floris. "Stoic Defence Of Physician-Assisted Suicide." Acta Bioéthica 20.1 (2014): 99-108. Academic Search Complete. Web. 9 Mar. 2015.
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