Arguments regarding proper ethical actions in medicine tend to focus on preserving life and working towards improving the health of a patient. In many cases, the ethical decisions regarding an individual’s health may appear – at least superficially – to be linked with the volume or sophistication of medical care. However, these are inaccurate replacements for the primary focus of truly caring for an individual. The patient’s quality of life is the most ethically significant factor to both the physician and patient, and therefore should always be preserved or improved over the long run. Of course, many medical treatments reduce a patient’s quality of life in the short term while long-term benefits heavily outweigh these negatives. Unfortunately, there are extraordinary cases where the quality of life will likely never improve, only becoming worse with time. When the patient’s forecasted quality of life is not typical, the patient should not be treated or assessed as a typical patient.
Such is the case of Sue Rodriguez, whose quality of life had deteriorated substantially with the progression of amyotrophic lateral sclerosis (ALS). While Sue had made her intentions clear — to continue living as long as she could enjoy life — this presented the issue of requiring physician-assisted suicide if her condition progressed beyond what she could tolerate. This was in violation of Canadian law, where a physician could face up to 14 years in prison from assisting in suicide. While in violation of the Canadian legal code, the Charter of Rights and Freedoms ensured she would not “be subjected to any cruel and unusual treatment or punishment.”
When sanctity of life conflicts with individual autonomy, the decision of the individual must take precedent over the sanctity if the decision was made logically. It is worth noting that anyone in this condition will be unable to act with full rationality, as the extreme degenerative state of the disease compromises an individual’s ability to comply by normal standards. Essentially, the degenerative state is a highly coercive influence over the patient’s wellbeing and should be recognized as having an impact. The patient can, however, act logically considering the realities and possibility of their predicament. The possibilities of improvement, in Sue’s case, were merely hypothetical while the impending deterioration was inevitable by all realistic assumptions. It is reasonable of Sue to assume that her condition would only deteriorate and that assisted suicide would be the only viable option in that case. Such an assumption, even by a person with diminished mental and reasoning capacity, should be treated as a valid decision, as the rational behind the decision is of sound logic and respects the realistic outcomes regarding the future of her quality of life.
As long as the autonomy of the individual is respected, allowing for physician-assisted suicide does not present a threat of progressing into more malicious uses of euthanasia or eugenics, as detractors often propose. The decision ultimately remains with the patient, not the physicians, hospitals, or legislature. There are rigid cultural and social taboos regarding this as well, with numerous organizations existing to prevent physician-assisted suicide from being further adopted legally (Physician Assisted Suicide). However, trends in medicine and law indicate an easing of the laws prohibiting this, allowing for more nuanced ethical and moral discussions to take place regarding end-of-life care and patient autonomy. Also, once adopted by Oregon in the United States, patients can cross state lines if their resident state does not allow for this procedure (Battin). This renders the local bans useless and goes to demonstrate that systems respecting the autonomy of the patient will be popular amongst the target demographic (i.e. deteriorating quality of life patients).
Sources
- Physician Assisted Suicide Violates ADA, accessed 26 Feb 2017. <http://www.adapt.org/newsletter/1997v31n1/22ndy>
- Battin MP, Heide A, Ganzini L. Legal physician assisted dying in Oregon and Netherlands: evidence concerning the impact on patients in “vulnerable” groups. Journal of Medical Ethics. 2007. 33(10) 591-597.
This was a very interesting read, thank you very much for writing on it. I have always found this topic to be very clear and straight forward when regarding patients that are dying or if their quality of life is declining — such as in the case of Sue Rodriguez. If we consider all people to be autonomous beings, then they should have the right to make a choice and decide what they want to do. You phrased it perfectly, ” the decision ultimately remains with the patient, not the physicians, hospitals, or legislature”.
I pose this question to you, What would you say about perfectly healthy people wanting to have assisted suicide? (perhaps just bored of life, or believed the afterlife was waiting for them)
The second question I have for you is, should a persons decision to voluntary amputate an limb be respected? I believe it has been called ” Body Identity Integrity Disorder” (https://www.ncbi.nlm.nih.gov/pubmed/19132621)
These two examples convolute the simple idea of autonomy and right to your own body.
Hello,
Thank you for your post. I agree that there are many interesting cultural taboos surrounding the concept of PAS and society, and think that they are important in ensuring that the public receives a well-rounded view and argument of the issue. As I read your post, I began to think about the rationality associated with someone in a position similar to Sue’s. There must be restrictions or protocol in PAS, if fully legalized, that provides definitive language and action for patients who are, perhaps, marginally competent and desiring PAS. In extreme cases, maybe this situation should be approached similar to that of the Alzheimer’s research trial case we read about earlier in the year, where individual institutions and families have more weight in the decision of those who are incompetent. Autonomy is an important aspect that must be fully considered, but if a patient is declared incompetent and demanding PAS services, how much should their opinion and wish matter?
The role of a family in situations such as these is also important in considering whether or not to legalize PAS. What if the action of someone wanted to die had an outstanding, significant effect on a situation (other than emotional)? How do we protect patients in these situations who may be coerced by family members into requesting PAS for the family members’ benefits (life insurance, etc. — a grim thought, I know, but nothing is impossible)? If legalized, there can be no way to generalize PAS. Everything must be ethically considered on an individual, case-by-case basis.
Sources:
Brody, Howard. “Physician-Assisted Suicide: Family Issues.” Michigan Family Review. Michigan Publishing, University of Michigan Library, 01 Jan. 1995. Web. 27 Feb. 2017. .
Thanks again!
Elisabeth Crusey
Hi!
I think your emphasize on autonomy is very well warranted, and you explain that side well! I too believe that that should be the principle that carries the most weight. If the patient is mentally competent and has given proper consent to a procedure such as PAS, it should be granted . Or at the very least heavily considered.
While reading your section about the sanctity of life, I realized that using that in itself can produce a slipper slope in how we medically determine life and or requirement of a “good” quality of life. I feel that if a patient thinks that the one means they will feel at peace is through death, then keeping a terminally ill patient alive only for it to amount to death is pretty tortuous. Also, I think that it is important for medicine to start to consider more how the patients view their lives after a certain procedure or until their condition takes it. Because personally, I feel that keeping someone alive so strongly against someone’s wishes is in a way harmful. If the situation yields no better outcome for the patient they should have that ability as a fully consenting being to make that call. In a way, much like Sue Rodriguez, keeping person alive while they are in grave conditions is making them a prisoner their own body.
And I for one think it’s somewhat scary to have the government have that much power over our autonomy.
Nice post!
-Arianna E.
Thanks for the post!
It is possible that extreme suffering can be avoidable only through physician assisted suicide. But the ethics surrounding when it’s acceptable to aid in suicide are certainly complicated. I agree that autonomy needs to be focused on and highly valued. I think that when a patient decides that they want PAS ahead of time, it helps to justify it later on–although if the patient then changes their mind that complicates matters and the PAS might actually harm their autonomy.
I think that PAS being justified by quality of life assessment is necessary, but very difficult. It doesn’t seem, to me at least, that it’s appropriate to assist someone with suicide who doesn’t have a major lack of quality of life. However measuring this can be very difficult because medical or technical measurements can be difficult, and self-reported levels of suffering are highly varied between individuals and at different times.
What do you think are good ways of measuring quality of life?
While I agree with you that it is important to measure quality of life, I believe that a “major lack of quality of life” is a subjective term and needs more defining. As seen in the Rodriquez case, Sue’s impending inability to “swallow, speak, walk and move without assistance” clearly showed her diminished quality of life and provided grounds for PAS (Thomas 214). That being said, not all cases are like Sue’s. Does an individual’s mental state provide grounds for PAS? A recent study conducted in the Netherlands provided evidence for PAS in regards to psychiatric suffering. The data suggested that only when individuals are deemed to have unbearable suffering and untreatable mental illness is PAS permissible. Like in the terminal cases, judging the severity of one’s illness proves to be a challenge. Though the evidence isn’t conclusive, individuals who did receive PAS for psychiatric suffering typically had a history of “chronic, sever mental illness with histories of suicide attempt and psychiatric hospitalizations” (Melville). I think this research further emphasizes the need to explore the conditions necessary for PAS in response to mental illness.
Melville, Nancy A. “Euthanasia for ‘Untreatable’ Mental Illness: New Data.” http://Www.medscape.com. N.p., 10 Feb. 2016. Web. 24 Mar. 2017.
Thomas, John E., Wilfrid J. Waluchow, and Elisabeth Gedge. Well and Good: A Case Study Approach to Health Care Ethics. Peterborough, Ontario: Broadview, 2014. Print.