Palliative Care and Physician-Assisted Death

Barbara A. Supanich

Many events have occurred since 2001 that have stimulated many sectors of the United States society to ponder, reflect, and debate the issues regarding physician-assisted death. Recently, in the United States, the debate has involved the US Supreme Court; (1) the US Congress and US President George W. Bush (in the Teri Schiavo debate), and multiple discussions in state legislatures, local communities, and multiple physician, nurse, patient, and public surveys (2, 3, 4, 5, 6, 7). Recently, the issues have focused on personal choice at the end-of-life, ethical treatment and decision issues at the end of life, and the State’s responsibility for “preserving life.”

Although the US Supreme Court in 1997, made a unanimous decision to uphold the right of states to prohibit physician-assisted death, this decision also allows states to permit it (8, 9). In late 2001, then US Attorney General John Ashcroft made an unsuccessful attempt to halt the practice of physician-assisted death in Oregon; (7) by focusing on prescriber rights to prescribe opiates to terminally ill patients.

The recent heated public discussion and debates regarding the withdrawal of artificial nutrition and hydration from Teri Schiavo highlight the need for better education of health professionals, legislators, patients and their families and the general public on end of life treatment choices for themselves, and their loved ones. For professionals involved in palliative care and hospice care, our current US social milieu provides many unique challenges to our provision of excellent and compassionate palliative care to our patients and their families.

This chapter will review some of the major ethical arguments, look more specifically at the challenges posed for the palliative care professional, and propose ethically sound clinical strategies for responding to the challenges of a patient’s or family member’s request for physician-assisted death.

Definitions

Discussions regarding physician-assisted death are often complicated by the participants not properly understanding the ethical terms regarding end of life care treatment options.

Withdrawing or withholding life-sustaining treatment refers to decisions to stop or not initiate certain medical therapies, with the anticipated outcome that the patient will die from the underlying disease. Common examples include withdrawing of a ventilator from a patient in end-stage emphysema; forgoing the use of anti biotics in a patient with terminal cancer and suspected pneumonia; and refusal of tube feeding by a patient with an end-stage neuromuscular disease.

Voluntary active euthanasia refers to the direct administration of a lethal agent to the patient by another party, with a merciful intent. This chapter considers only voluntary active euthanasia because that is the only form being seriously advocated in the United States today.

Assisted suicide refers to the patient intentionally and willfully ending his or her own life, with the assistance of another party. This assistance may include different levels of involvement—merely providing information about how to commit suicide; providing the means to commit suicide, such as a lethal quantity of pills; or actively participating in the suicide, such as being present at the scene and inserting an intravenous line through which the patient may then administer a lethal dose (9). The widely publicized actions of Dr. Timothy Quill (10). and Dr. Jack Kevorkian (11, 12). provide examples of the second and third levels of involvement, respectively. In the State of Oregon, physician-assisted suicide involves a discussion with the patient regarding the diagnosis, prognosis, capacity for healthcare decision making, and the voluntary nature of the request. After appropriate consultation, the attending or consulting physician can then write a prescription for a lethal dose of medication (8).

For this chapter, assisted death refers jointly to the practices of voluntary euthanasia or assisted suicide. Most of the literature on ethics has focused on the special problems of the physician’s role that is, the practice of physician-assisted death. In the context of hospice, the roles of other health professionals and the family are extremely important, and in some cases, the patient may request assistance in dying from one or more of them as well as (or instead of) from the physician.

It is important to be clear about what is not assisted death. As noted, it is not an assisted death if a competent person decides not to initiate a specific therapy (e.g., further chemotherapy, antibiotics for a pneumonia or another septic process, renal dialysis or artificial nutrition, or hydration). The use of high doses of opioids, when the intent is to relieve pain and not to hasten death, is not physician-assisted death. Although many still believe that high-dose opioids pose a serious risk of fatal respiratory depression, palliative specialists know that this very seldom occurs with proper titration of analgesic doses, even when very large doses of opioids are administered in terminal illness (13). Even if respiratory depression is a foreseen (but unintended) consequence of adequate analgesia, administering the analgesics is not considered to be physician-assisted death.

Withholding and withdrawing life-sustaining treatment is widely accepted today, both in ethics and law, as appropriate
and compassionate care. When the adult competent patient is fully informed and freely chooses these options or has clearly documented these choices in an advance care plan document, all 50 states accept these decisions as legally and ethically binding. As a matter of fact, there have been no successful lawsuits against physicians or others for following a patient’s written choices in an advance directive. Physicians are at more risk of a wrongful life suit for not following the directive than they are of a wrongful death suit. Some, notably Dixon (14), have argued that there is no morally relevant difference between this practice and the practice of assisted death. Dixon argues that fairness requires that if we legalize physician-assisted suicide that we should also make active euthanasia legally available (14). In this chapter, without giving detailed arguments, I have prepared a review of ethical arguments on both sides of the question. I will assume that if assisted death can be justified, it must be justified on its own merits and not merely because it shares some moral features with the relatively uncontroversial practice of withdrawing or withholding life-sustaining treatment (15, 16, 17, 18).

Ethical Arguments

Patient Integrity

Patients who are living with a life-limiting illness want their personal values and goals maintained and respected. For many patients, the most important personal values are autonomy and personal integrity. From the patient’s perspective, this means that one’s belief system, personal values, and life goals will be honored and respected, and that they will play a vital role in treatment plans and palliative care planning. Most patients have the expectation that their suffering will be moderated, their pain will be controlled and they will have the opportunity to have meaningful conversations with their physicians and family concerning the type and extent of their treatments (5, 6, 19, 20, 21). A recent report of the Oregon Health Division (22) confirms that 67% of the 26 persons who experienced a physician-assisted death in 1999 identified loss of autonomy, an inability to participate in activities that would make life meaningful, and loss of bodily functions as reasons for seeking an assisted death.

Proponents of assisted death would argue that they are honoring the personal integrity and the personal autonomy of the person by being willing to discuss and assist the patient with all treatment/care options for the patient, including assisted death. Proponents also claim that physician-assisted death minimizes harm to the patient and others. They argue that the patient would determine what counts as a harm and may legitimately decide that ongoing life with severe suffering is a greater harm than a painless death (22, 23).

Opponents claim that, however important the moral value of patient autonomy is, it is insufficient to justify the practice of assisted death (6, 14, 15, 24, 25, 26). Autonomy may justify withdrawing or withholding treatment because that constitutes a negative right of noninterference, which is strongly grounded in the concept of respecting personal bodily integrity. But it cannot justify a positive right to demand that others take specific actions to promote one’s own idea of one’s welfare—especially when those actions cause death. Some opponents also make the claim that causing a death is one of the greatest harms that a clinician could inflict on a patient. The basic principle of “Do no harm” should be understood as requiring a healing relationship between the physician and the patient and, therefore it is in direct conflict with respect to patient autonomy when assistance in dying is requested.

Compassionate Response to Suffering

For some physicians, a request by a patient for death assistance is viewed as a plea to release the patient from intolerable suffering. From this perspective, such assistance is understood as an act of compassion. Quill and others (10, 27, 28, 29, 30). have argued that a willingness to discuss this option with the patient often may act as a suicide deterrent since once the patient’s concerns and fears have been fully discussed, the physician may be able to propose alternative means of relieving suffering short of death (5, 6, 22, 30, 31, 32). By contrast, if physicians refuse to offer assistance, suffering patients may avoid these searching conversations and instead commit suicide in a manner that actually increases their own and the family’s suffering.

It is a serious mistake to equate suffering narrowly with pain and other unpleasant physical symptoms. Suffering is defined through the experiences of the individual, which includes a personal sense of impaired quality of life, and is understood as a fundamental threat to one’s wholeness as a person. Suffering is ultimately tied to one’s personal belief system. It reflects how those beliefs define the reality of the human person, and how one experiences an illness in the overall context of one’s life journey and personal expectations for the future. Two patients may report similar symptoms but have vastly different experiences of suffering (30, 32, 33, 34, 35).

Proponents of assisted death point to the multifaceted and complex nature of suffering as a defense for the individual’s right to choose a quicker death because no one can really comprehend the severity of anyone’s suffering. Palliative care may be able to relieve unpleasant symptoms very well but it may be much less capable of restoring meaning and function to a life that has irreversibly lost both. Whereas excellent palliative care and hospice care should greatly reduce the number of patients who may request death assistance, it would not negate the need for this option in some cases.

By contrast, opponents claim that proponents have a shortsighted and simplistic approach to the relief of suffering. Precisely because suffering is multifaceted and intimately tied to personal meaning, there are numerous options to offer the suffering individual to assist them in restoring a sense of meaning in her life. To relieve suffering by eliminating the sufferer must always be viewed as an inadequate response. Attending adequately to loneliness, fear of death, depression, unresolved conflicts, and lack of forgiveness, anger, and hopelessness is harder, but ultimately will allow a better personal resolution. This is especially important work for the physician, nurses, and family members since they may tend to project their own suffering onto the patient and, therefore, conclude that a premature death is actually the merciful choice from the patient’s perspective (5, 6, 30, 36).

Safeguards

Both proponents and opponents of physician-assisted death agree that safeguards are needed to protect the patient’s safety and integrity and to protect society from physicians who might abuse the end of life choice (6, 26, 27, 37, 38, 39). Table 64.1 lists some commonly proposed safeguards and guidelines for discussing the choice of assisted death (27, 38).

As previously discussed, proponents believe that patients are the best judge of their own suffering and should have the option of discussing their situation with their personal physicians and developing a mutually agreeable plan for control of their pain and suffering. Proponents also believe that multiple compassionate and appropriately timed conversations between the patient and the primary physician over time will build the trust and rapport necessary for honest and uncoerced
conversations among the patient, the physician, and the family members. Many proponents also believe that consultation with at least one other physician is a vital safeguard. A parallel safeguard is the assurance of accurate and clear documentation that all appropriate guidelines have been followed.

Table 64.1 Safeguards and Guidelines for the Discussion of Assisted Death

The patient must have a condition that is incurable (not necessarily terminal) and is associated with severe suffering without hope of relief.
All reasonable comfort-oriented measures must have been considered or tried.
The patient must express a clear and repeated request to die that is not coerced (e.g., emotionally or financially).
The physician must ensure that the patient’s judgment is not distorted, i.e., the patient is competent to make a rational treatment choice.
Physician-assisted death must be carried out only in the context of a meaningful physician-patient relationship.
Consultation must be obtained from another physician to ensure that the patient’s request is rational and voluntary.

From Quill T, Cassel C, Meier D. Care of the hopelessly ill—proposed clinical criteria for physician-assisted suicide. N Engl J Med (Sounding Board) 1992;327:1380 (27); Miller F, Quill T, Brody H, et al. Regulating physician-assisted death. N Engl J Med 1994;31:119 (38).

Most opponents would agree that suffering is both personal and unique and that all reasonable comfort measures should be discussed with the patient and tried. They would agree that more open and frank discussions between the physician and the patient should occur on topics such as pain and symptom control, and the patient’s perception and experiences of suffering. In their opinion, these types of discussions and the subsequent individualized plan of care for the patient would negate the need for the option of assisted death. Opponents see the potential for coercion as very real and often quite difficult to ascertain, so that the proposed guidelines would be inadequate in practice. Opponents are also concerned about the erosion of the patient-physician relationship occurring when physicians start providing the means of death for their patients. They also would point out flaws in the consultation and documentation guidelines, for example, choosing a like minded consultant, and question the ability of the guidelines to protect patient safety (6).

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