The idea of physician-assisted suicide or euthanasia raises a number and disputes and disagreements in regards to whether a person or their immediate family members should have the right to choose medically aided death. As it stands, current clinical practice, ethical, and legal practices leave decisions regarding medically assisted death to family members and the affected individual. There is a general social agreement that withdrawing or withholding care proves troublesome for the expected paybacks even though denial of treatment is equivalent to the reception of demise. In one instance, the Supreme Court emphasized this accord in Cruzan vs. Director, Missouri Department of health, which upheld a patient’s choice to reject life-supporting treatment.
This paper seeks to discuss some of the current ethical dilemmas and legal considerations faced by families and healthcare providers today. The first section of the analysis will confer the self-determination to the principles of autonomy, non-maleficence, beneficence, and justice. The second part will elaborate on advance care planning, while the subsequent section discusses family autonomy.
Self-Determination
One of the significant concerns in analyzing the ethics of assisted suicide is the issue surrounding the principle of autonomy. The principle of autonomy is evident in its stating that healthcare providers have an ethical obligation to respect the patients’ choices made as per their values, religious convictions, and consciences. In today’s society, economic pressures faced by family members and reaffirmation by healthcare professionals aggravate the need to withhold treatment in scenarios with minimal survivor chance for the patient. Nonetheless, the problem with autonomy is that a majority of patients are in many instances too sick to consent to euthanasia unless they made the decision when they were still healthy.
The federal Patient Self-Determination Act (PSDA) of 1991, therefore seeks to resolve this dilemma by mandating medical practitioners to inform all patients of state-approved healthcare procedures in the event of incapacitation. The PSD allows patients to communicate their preferences should there arise a situation where they cannot exercise authority over the next course of action, after incapacitation (Bennett, 2016). Such information is conveyed to physicians via an enclosed document known as advance directives. Advance directives are a legally binding document that provides people with the opportunity to communicate their medical needs when a psychological or physical injury renders them incompetent (Garrido, Balboni, Maciejewski, Bao, & Prigerson, 2015).
A 2005 case involving Terry Schiavo, demonstrates the ethical dilemma presented by the principle of autonomy. Schiavo, a 41-year-old Florida woman, had entered a permanent vegetative state following a cardiac arrest. Schiavo’s parents engaged in a severe court battle with her husband over whether to disconnect her feeding tubes. Despite lacking an advance directives document, the spouse emerged victorious having based his argument on a sworn testimony by his wife that “I don’t want to be kept alive on a machine” (Burnell & Lund, 2018). His statement negated that of the parents, which is a clear demonstration to prompt individuals to communicate their wishes before an exigent incidence occurs, which could prevent them from conveying their desires. Ever since the conclusion of the infamous case, self-determination or autonomy became a critical aspect of the decision-making process within the United State’s health care structure.
In today’s healthcare system, the advance directives document contains both a living will and medical power of attorney. A living will is a type of directive that inherently guides the healthcare team and the family through the treatment procedure requested by a person during his/her incapacitation. The medical power of attorney refers to a separate person who is appointed to make decisions on behalf of the incapacitated individual. The attorney should be trustworthy enough to convey the end-life-wishes discussed. Typically, most states prohibit the appointment of healthcare providers as the medical power of attorney.
Also, it is possible to have a medical power of attorney or living will at any age, so that every person gets an opportunity to have a say in their medical decisions in the event they are deemed incompetent. Recently, there are emerging controversies in regards to whether a person with a simple condition such as a cold has the right to exercise his/her autonomy rights and refuse medication. Such a situation presents an ethical another ethical dilemma because a physician has to perform their medical obligation even if they do so against the patient’s wishes. Another issue that arises today, especially in the case of disabled persons, pertains to whether an individual is competent enough to qualify for autonomy.
An article by Marett and Mossman (2015) reveals that family members do feud with the medical power of attorney. When a family deals with the problematic situation of a loved one with failing health, the power of attorney verdict could start a gruesome and longstanding court battle that would affect all parties involved in a treatment process. Family members may question the validity of the power of attorney document, and they may go as far as to ask why someone who rarely spends time with the dying patient gets to say whether the person lives or dies. Regardless of the existence of legal documents to validate a power of attorney, these dilemmas cost time as well as money and could end up prolonging or terminate the life of a patient, thereby jeopardizing their dying wish.
In some cases, the living will instruct the physician to engage in the medically advanced treatment, which, according to the medical practitioner’s evaluation proves futile. This occurrence presents another dilemma for providers because, on the one hand, the patient requires advanced treatment based on their stipulations, but on the other hand, medical tests indicate that extending the treatment process is pointless. Such difficulty may yet again prove challenging in situations where family members fail to come to terms with the physician’s counsel against advanced treatment. Regardless, the physician has the duty of explaining to all parties involved regarding withdrawing or withholding of medicine and halt the unnecessary use of hospital resources for the vain treatment while being careful not to cause pain or suffering to the patient (Radbruch et al., 2016).
Other than autonomy, non-maleficence, beneficence, fidelity, and justice also introduce an entirely fresh set of ethical dilemmas. The principle of non-maleficence essentially requires a physician not to inflict intentional harm to the patient. However, this moral requirement directly conflicts with a patient’s autonomous right. Most health providers feel that physician-assisted death is without a doubt, unethical. On the other hand, the principle of beneficence in a way supports euthanasia seeing that the policy requires doctors to do what is best for the patient, even if the just action involves switching off the life support machine to end a person’s suffering.
The principle of justice obligates practitioners to practice truth without discrimination in delivering treatment. Even exercise of justice is paramount in the treatment process, an ethical dilemma may arise when an advance directive requires a physician to exercise justice by prolonging treatment, yet he/she knows that extending treatment is futile. Lastly, fidelity refers to the faithfulness and truth delivered during the treatment process. Providers should, at all time, tell the truth to both the dying patient and his/her family as well. Though a physician can encounter an ethical dilemma in instances where the medical power of attorney relays the wishes of a dying person in the absence of the patient’s immediate family members, the physician may be tempted to contact the family members if he/she feels that there is a slight chance of recovery for the patient. Ethical dilemmas come in different shapes and forms, and as such, healthcare providers should always be prepared to tackle them as they present themselves.
The case of Karen Ann Quinlan vs. Morriss highlighted the need for declaring one’s wishes in the event of a severe injury or medical illness. Having returned from a party, Karen became unconscious, and a lack of oxygen left her in a permanent vegetative state. The hospital then collaborated with the Quinlan family in court battle versus the Morrison County prosecutor. In 1976, the Supreme Court made the landmark ruling that the right to privacy right included the parent’s request to have their daughter taken off life support. This landmark case marked the beginning of changes made to laws about palliative care. For instance, living wills and health care proxy are legally binding in all the 50 states. Lawfully appointed proxies make decisions regarding an incapacitated loved one. Every country had permitted the appointment of healthcare proxies by the year 1997. Proxies appointments are particularly popular in states that do not acknowledge same-sex marriage because they allow gay couples to appoint persons outside the family order
Advance Care Planning
Advance care planning (ACP) is a process that helps the aging population by providing them with the opportunity to decide their future health and individual care in times of future medical emergencies. Since the 1990s, ACP has taken root in advanced countries such as the U.S., New Zealand, Canada, and Australia (Lund, Richardson, & May, 2015). The initiative primarily aims at enhancing the quality of palliative healthcare for the aging population. ACP in the U.S.A. continues to evolve through the adoption of formal directives. For example, La Crosse County in Wisconsin successfully developed an ACP microsystem, systematizing all facilities within the county to provide documents and materials to help patients and their loved ones to establish informed advance care plans (Lund et al., 2015). In the contemporary healthcare setting, the skilled non-medical staff has proven effective in handling planning related activities.
To further ascertain that individual’s end-of-life wishes are respected, physician orders for life-sustaining orders (POLST) became law in 1991 as a similar document for healthcare orders (Hickman, Keevern, & Hammes, 2015). POLST is an ACP tool that outlines the patient’s present objectives for medical decision making about their current health condition. The framework works for people with a limited life expectancy. An assessment of the POLST framework nursing homes in the state of Oregon reveals that comfort levels of care are remarkably high with rare cases of patients’ transfer to hospitals (Hickman et al., 2015). Additionally, study results show that using the tool has diminished the need for CPR or ventilator in advanced care planning. It is therefore vital for elderly individuals to carefully consider an appropriate ACP or end-of-life plan available within their state.
Family Autonomy
Another issue that goes against the “best interest” is the impact of terminal sickness on patients’ family members. First, how people die affects how their family remembers them. From a personal point of view, a majority of people would not wish to be recognized or recall their loved one as incontinent, helpless, sedated, or pain racked. Currently, it is legal to exercise euthanasia in seven U.S. states which means that numerous incapacitated Americans, in unbearable pain, end up dying alone. For example, a leading advocate of Oregon’s Death with Dignity legislation confessed to murdering his wife even though she had committed suicide. Out of guilt, the man unsuccessfully attempted to commit suicide. When conducting the investigation, the judges realized that almost all supporters of assisted suicide avoided prosecution “but experienced a higher degree of guilt.”
Similarly, opponents of assisted suicide end up questioning whether they could have attempted to save their loved ones. Such a burden will be alleviated if all U.S. state enacts legislation authorizing to help end the suffering of terminal patients by directing and supervising health care providers to implement an end-of-life process. Some individuals lack the confidence in their family to oversee a physician-assisted suicide on their behalf in the event they become incapacitated.
Ethical dilemmas are, to a greater extent, significant today as opposed to the past. Traditional medical practices failed to grant society the right to oversee private healthcare in addition to the lack of life support technology. Patients could not question a physician’s approach to treatment. However, advances in healthcare have made it possible for individuals and their families to exercise the right to either prolong or withdrawing treatment. Advanced technology such as life support machines and artificial nutrition apparatus such as feeding tubes have made it possible to extend life. Even so, these innovations and technologies present new ethical problems that call for further advancement in the healthcare sector to navigate the complex healthcare issues in America. The modern patient is now able to come to terms with the death and willing to terminate their life to avoid years of suffering. The presiding medical staff, on the other hand, must make the incapacitated patient as comfortable as possible in final end-of-life moments. Discussing these ethical issues and legal reflections pave the way for the consideration of, which ultimately reduces the chances of wasting resources on inoperable ailments.
Conclusion
The Saint Leo core values of community integrity and excellence have continuously influenced analytical discernment and the enablement to serve people and contribute to the advancement of healthcare. Principally, it is not easy for a person to discuss with the family regarding whether to consider euthanasia, mainly if there exists a difference in opinion regarding the subject. When addressing integrity, healthcare providers should ensure that individual uprightness does not interfere with the patient’s choice, or influences a dishonest diagnosis, regardless of the financial constraints. The U.S. continues to strive for excellence with as witnessed in the ongoing research to find solutions for some of the medical or non-medical circumstances that cause the incapacitation of individuals. Debating death and dying is a personal and community conversation. The idea is to make decisions that serve both individual and community interests. As medical knowledge and technology continue to advance, the legal and ethical implications surrounding euthanasia will only become more complicated.
References
Bennett, M. (2016). Nursing care at the end of life: 25 years after the passage of the patient. Journal of Hospice & Palliative Nursing, 18(6), 550-555.
Burnell, B. M., & Lund, D. A. (2018). Freedom to choose: How to make end-of-life decisions on your terms. London, England: Routledge.
Garrido, M. M., Balboni, T. A., Maciejewski, P. K., Bao, Y., & Prigerson, H. (2015). Quality of life and cost of care at the end of life: The role of advance directives. Journal of Pain and Symptom Management, 49(5), 828-835.
Hickman, S. E., Keevern, E., & Hammes, B. J. (2015). Use of the physician orders for life‐sustaining treatment program in the clinical setting: A systematic review of the literature. Journal of the American Geriatrics Society, 63(2), 341-350.
Lund, S., Richardson, A., & May, C. (2015). Barriers to advance care planning at the end of life: A critical systematic review of implementation studies. Plus One, 10(2), e0116629.
Marett, P. C., & Mossman, D. (2015). Autonomy vs. abuse: Can a patient choose a new power of attorney? Current Psychiatry, 14(3), 37.
Radbruch, L., Leget, C., Bahr, P., Müller-Busch, C., Ellershaw, J., De Conno, F.,… board members of the EAPC. (2016). Euthanasia and physician-assisted suicide: A white paper from the European Association for Palliative Care. Palliative Medicine, 30(2), 104-116.