Do No Harm; A Physician’s Take

By: Randi D.

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          When it comes to physician-assisted suicide (or PAS, for short), there are plenty of opinions on both sides of the spectrum. The family members, patients themselves, and government officials responsible for making PAS laws cannot seem to find common ground. Today, I will be exploring a point of view that is not often considered: the physician’s.


Currently, there are six states in the United States that have passed legislation permitting assisted suicide. While each state’s verbiage varies, generally speaking, the requirements are similar. In order for PAS to be an option to a patient, the patient must be diagnosed as being terminally ill with less than six months to live. The patient must be deemed mentally competent, not suffering from any mental illness that would impair judgment. In some states, the request must be made in writing twice, 15 days apart, as well as requested verbally to multiple physicians. The idea is to prevent the patient making a decision based on pressure from outside opinions. The catch is, no physician may directly cause the patient’s death (ex: administering the life-ending drugs intravenously, which is considered euthanasia, not PAS). The physician may only prescribe the drugs. It is entirely up to the patient to decide if or when to fill the prescription and take them.

It is also important to take into account the terminology used. PAS can be broken down into two categories, active and passive. Active meaning something (such as drugs) are actively given to induce death. An example of passive PAS would be removing a tube for tube feeding when it is required for the patient to receive nutrients, which passively and directly causes death. Terminal sedation (TS, also referred to as ‘Palliative Sedation’) is often mistakenly associated with PAS[1]. Terminal sedation is administered when pain cannot be controlled by medications alone. The patient can be conscious, but sometimes that is not enough. In this situation, they may need to be completely unconscious. Sometimes, the patient remains in this state until death. This is not considered PAS, as death cannot be proven to be a direct result of sedation. TS must be initiated either by the patient themselves, or by other means such as a medical power of attorney or as requested by the patient’s advanced directives.  Another term incorrectly interchanged with PAS is euthanasia. Voluntary euthanasia is done at the request of the patient, to be done directly by a physician. It is important to note, while voluntary euthanasia is legal in a few countries, involuntary euthanasia is not legal anywhere in the world.


          Now that we have defined exactly what PAS is and is not, we will look at the physician’s point of view.


In a study done by the American Journal of Hospice and Palliative Medicine[2], as many as one in three physicians support PAS. But, we also find that even though one in three agree with the option of PAS, far fewer are willing to participate in PAS themselves.  Digging deeper into this study, it is revealed that 31% had “no objection” to PAS but when it comes to withdrawal of life support, the number of “no objections” jumps to 95%. Why is it that physicians tend to be okay with withdrawal of life support but not PAS, if the outcome is the same? Dr. Gerrit Kimsma, a general practitioner and lecturer in medical ethics at the Free University of Amsterdam gives his opinion; he says it is a conflict between two of his goals as a doctor: the goal of saving a life, and the goal of helping people who are suffering. It is suggested that some physicians may not agree with PAS for religious reasons, some believing life is sacred and should be saved at all costs. According to a study done by the AIM[3], another suspected reason is some physicians believe having PAS as an option decreases the quality of palliative care in general. The study revealed a correlation between the physician’s education on end of life care and support of PAS. The physicians that felt they had adequate education and training on the various methods of palliative care were less inclined to support PAS, suggesting adequate knowledge of other options makes PAS a less appropriate solution. In addition, another study[4] showed differences in PAS approval rates when the method used to assist death changed.  When the method was a lethal prescription, 36% of physicians would prescribe the medication “if it was legal”. When it came to a physician administering a lethal injection “if it was legal”, the number fell to 7%.

Responses vary by physician demographic, physician specialty, and many other factors. This makes research on the topic very difficult to accurately portray how physicians feel about it. An oncology specialist would presumably receive far more requests for PAS than a pediatric specialist, potentially skewing results.

One of the most important things to remember, is that even where it is legal, physicians are never required to participate in PAS. It is always their decision. If is against a physician’s personal beliefs, or the physician believes there is a better alternative for the patient, they are within every right to refuse the patient’s request and furthermore, they are not required to refer the patient to another physician who would be willing to grant the patient’s wishes.

With all of this in mind, whether physician assisted suicide is truly considered “doing no harm” or the opposite, it appears that physicians, much like the patients and family members, will just have to agree to disagree. Before making any permanent decisions, physicians should consider all options and view each patient for the individual that they are. PAS is not a one-size-fits-all solution.

 

-RD


 

[1] (Angela Morrow, 2017)

[2] (To Die, to Sleep: US Physicians’ Religious and Other Objections to Physician-Assisted Suicide, Terminal Sedation, and Withdrawal of Life Support, 2008)

[3] (Attitudes and Practices of U.S. Oncologists regarding Euthanasia and Physician-Assisted Suicide, 2000)

[4] (A National Survey of Physician-Assisted Suicide and Euthanasia in the United States, 1998)

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