FREE ESSAY ON PHYSICIAN ASSITED SUICIDE: A POLICY AND ANALYSIS

PHYSICIAN ASSITED SUICIDE: A POLICY AND ANALYSIS

Policy on Physician Assisted Suicide
________________________________________
St. Wildes Medical Center, Georgetown University
Washington, D. C.
Submitted By Elinor Bazar & G. Konrad Brown
April 11, 2000
Introduction
The mission of this hospital is rooted in our emphasis on the individual, and directed
toward providing the highest level of autonomy, beneficance, comfort, healing, privacy
and respect for the dignity of the patient. With these as our guiding principles, we
evaluated Physician Assisted Suicide (PAS) as a possible treatment option at this
institution. We have concluded that PAS can be a viable treatment option after making the
following considerations: 1. Defing the elements of justified PAS, 2. Consideration of
moral justifications, 3. Why personal autonomy is important, 4. Informed consent, and 5.
The benefits of the approach of causitry to issues of biomedical ethics. The elements of
PAS are an agreement between a physician and the patient on the treatment option after
consideration of all other options, (informed consent) conditions consistant with the
Oregon state law and the asurance of the agent choosing this course of action in an
autonymous nature. Moral arguements question the validity of PAS as an option. We make
the determination that PAS can indeed be considered equivelent to other medical decisions
regarding whether or not continue treatment in cases where the prognosis is immenent
death, or prolonged intense suffering followed by death. If for example, a patient with a
terminal illness such as lung cancer has a choice between hospice care, and being made
comfortable, or PAS, we can not say that the two approaches are inconsistant with
eachother. A patient who refuses treatment and accepts death as a consequence has the
right self determination by law. If this action is acceptable under law, it is not unfair
to consider PAS as an equivelent means to the same end. Therefore, there will be cases
where PAS is most certainly a valid option for the patient. To reach our decision, it is
important to understand our view of personal autonomy. We will elaborate on it's
relevance and worth in addressing PAS. Finally, criteria for PAS candidates is intricate,
and established. Though we justify PAS as a viable treatment option, we do not take issue
with the legal criertia established by the state of Oregon. 
Personal Autonomy
Personal autonomy can be characterized as self-determination or the the extent to which
an individual actively participates in in how his or her life is lived. Autonomy,
therefore, requires some elements of control and choice. Defining autonomy in a being
that is both rational and passionate can prove complex and problematic. A differentiation
of first and second order volitions will help us conclude the what the exact nature of
what defines autonomy. First-order desires are those passions to which the agent is
subject to as a living being. The desire to live, procreate, feel secure and content are
some examples of these desires. While they are certainly expressions of human passions,
they do not account for man's rational capacity, a fundemental facet of human nature.
Second-order desires are wants about wants, or the desire to have certain desires. We
will focus, however, on second order volitions, which differ from second order desires.
Second order volitions involve the wish of an individual that certain first-order desires
will motivate him to action. It is the rational choice of the agent which characterizes
this, and therefore we will conclude that second-order volitions represent contemplation
of a choice by the agent, which leads to a choice that by virtue of this process, is an
indication of his true-self. Therefore, it is through these second-order volitions that
we exercise autonymous action.1 The expression of rational choice in relation to a
first-order desire is what we will define as the main component of an autonymous action.
There are those who would oppose this view in lieu of other moral considerations. If the
agent has a lack information, or choices, the action in relation to the first-order
desire is then no longer autonymous. Therefore, we will require that another dimension to
autonomy is the range of options availible to the agent. In order to promote autonomy, it
is absolutely essential that informed consent is a focal point of treatment. It is the
concept of autonomy which is our guiding force in our formulation of a policy on PAS.
PAS as a treatment option has no universal application. In Oregon, where it is legal, two
patients with the same doctor, the same illness and the same prognosis can make opposite
decisions regarding treatment. If one patient simply chooses to wait for death to occur
after stopping treatment, and the other chooses PAS, both of these autonymous actions are
therefore equal. They have the same end, and individual considerations of quality of
life, and an array of potential first-order desires explain the difference in choices.
Therefore, it is the execution of the choice by the informed agent which constitutes the
autonymous decision. With personal autonomy as the primary consideration, the patient
then has the right to PAS as a treatment option, and denial is deprivation of
self-determination. (Indeed this constitutes deprivation of freedom, which is
intrinsically wrong, and contrary to the patients natural right to self determination.
PAS in a Clinical Setting
In relation to PAS, the agent must act 1) intentionally, 2) with understanding, and 3)
without controlling influences that determine their action.2 As an institution concerned
with autonomy as a central right of the patient, we are supporters of requested withdraw
of treatment (as well as PAS,) as there is no difference in the matter of allowing to die
and killing. Killing is any form of deprivation or destruction of life, and allowing to
die is intentional avoidance of causal intervention so that a natural death is caused by
a disease of injury,3 which in itself is deprivation. Therefore, there is no distinction
between allowing to die and directly intervening to bring about a patient's death. 
Moral Jusifications
Compassion is a focal virtue in our practice. Compassion is defined as a feeling of
profound sympathy and sorrow for another who is affected by misfortune, accompanied by a
strong desire to ease the suffering. Sometimes in healing the terminally ill suffering
from profound pain, assisting the patient in suicide is the only means of alleviating
his/her suffering. Those who oppose PAS are not subject to judgement or coercion. PAS is
a matter of choice and is not an alternative to be suggested by the physician. It is a
procedure which is only regarded among request and acute investigation thereafter.
Patients are protected from non-voluntary euthanasia because, again, physicians will only
address the option of PAS upon the request of the patient and the physician cannot
physically be the cause of the death (euthanasia). No actions will act out of accordance
with such, especially in situations of life and death. 
It is clear that opposition to PAS is rooted in the execution of normative judgements,
which object to the action unequivically and universally. This view neglects the secular
and universal standard of self-determination and autonomy in patient care. This is not a
criticism of religous institutions which find PAS intrinsically wrong. The standard which
we adhere to leaves these considerations in the hands of the agent and physician.
Central to the hypocratic oath is the principle of beneficance, which holds that the
physician is obligated to act in the agents best interest. As technology has increased
and advances have been made, what constitutes beneficance in any given action is becoming
trivial; quality of life issues and painful but successful treatments have clouded what
constitutes beneficance to the point that the 1960s saw the emergence of Biomedical
Ethics as a field. Indeed it is difficult to simply decide whether or not PAS should be
considered universally a medical treatment or universally suicide. Rather than make this
judgement, we hold that it is not a black and white issue, and that right action through
policy requires consideration of all applications and scenarios. We further offer that
causistry, or the evaluation of correct choice on a case by case basis, is essential to
any approach hoping to yield just results. 
Requests to Withdrawl Treatment
[Any] person who is above [18 years old] and of sound mind has the right to exercise
control over his/her body.4(p.279). This implies a right to refuse medical treatment even
if the deprivation of treatment results in death. The right to refuse treatment is
fundamental to principles of autonomy such as privacy. Therefore, this rule is not
conditional, and all requests for treatment withdrawal are honored upon completion of an
informed consent. This particular type of informed consent acts independent of any
previous informed consent (particularly ones such as advanced directives which will be
spoken about in the next section) and only pertains to the task at hand. The document
affirms that the physician and the patient had a discussion about the consequences and
benefits of withdrawing from treatment as well as those with proceeding of treatment. It
will also affirm that the physician told the patient all possible alternatives to the
situation and all the patient's questions were answered and understood. Most importantly,
the patient has a sufficiently clear understanding of the situation in its entirety. 
Upon association with our hospital, all competent persons are encouraged to fill out an
advanced directive indicating treatment directives (documents such as a living will
stating the person's treatment preferences in the event of future incompetence), proxy
appointments (documents such as a durable power of attorney appointing a proxy decision
maker), or both.5 This hospital makes a continuing effort to educate patients about
directives and, most importantly, to educate physicians in their obligation to honor
them. Because there is room for interpretation and the advanced directives are not always
case sensitive, a decision regarding treatment withdrawal will be one that proceeds from
a collaboration of the proxy's views and the patient's preferences stated on the advanced
directive. In cases of incompetence where no advanced directives exist, the legal right
of the patient to consent to any procedures is handed over to the next of kin. If there
is no next of kin, the attending physician will use his sound judgement to assess the
situation.
Continuing Treatment When There is No Hope For Recovery
It is the belief of this institution that mere quantity of life does not eventuate in
quality of life. The desire to continue treatment when there is no hope for recovery is
indicative of fear in the patient. Healing is key to the mission of our hospital.
Therefore, diminishing fears in our patients, particularly fears involving such natural
processes as life and death, is of surmounting importance. In such cases, we will do
everything possible through palliative care to assess the spiritual, emotional, and
mental needs of the patient while we continue to respect the autonomous decision of the
patient to continue treatment when there is no hope for recovery. In cases where the
individual is deemed incompetent, the advanced directive of the patient should be honored
if one exists. Otherwise, the decision will be handed over to the next of kin. This will
be treated similarly to the previous competent-patient-decision process in that if the
decision is fear-based then palliative care will be appropriated to ensure the most
accurately desired procedure. A beating heart or a pair of working lungs does not assert
an individual among the living, rather consciousness is what distinguishes an individual
as alive. Lawrence O. Gostin assesses the Cruzan case stating that, when asked, very few
people would choose to be kept physically alive when all conscious life is over.
Particularly in cases of perpetual vegetative state (PVS), where all consciousness is
gone, our hospital does not agree with life prolonging procedures and therefore will
perpetuate palliative care among decision makers, whether it is the next of kin, or the
attending physician. Although each case is different and should be assessed individually,
the general view of the hospital stands. 
REQUESTS FOR PHYSICIAN ASSISTED SUICIDE (PAS): 
In accordance with The Oregon Death and Dignity Act, terminally ill adult Oregon
residents are permitted to request drugs from their physician with the intent to end
his/her life. This act ensures the removal of any criminal penalties for qualifying
physician-assisted suicides. All of the following strict guidelines are pertinent to a
qualifying PAS:
1) physicians predict patient's death within 6 months;
2) the patient makes 3 requests for PAS, 2 oral, and 1 written;
3) 15-day waiting period after requests;
4) second physician's opinion; and,
5) counseling if either physician believes that the patient has a 
mental disorder or impaired judgement from depression. 
It is our view that meeting this criteria, PAS has a stong case for legitimacy as a
medical procedure and treatment option.
Conclusion 
Implementation of PAS as a legal medical treatment in Oregon aroused the passions of so
many. As the public debate continues, and as other initiatives work their way through
state legislatures, it is clear that their is no answer that will apease both sides of
this very difficult issue. As caregivers, it is essential to take a much longer
consideration. In order to find what we believe to be the right approach to PAS by an
institution, it was inevitable that we had to make a clear decision regarding what
principles were to guide us. Compassion and beneficance are required. They are also
desired; every caregiver wants to help his patient, deliver treatment with excellence,
compassion, and with the intent of beneficance. These principles in and of themselves
require us to consider their purpose: the benefit of the agent. With this, we hold that
autonomy is the expression of the human self. It is the manifestation of human
rationality, and therefore, should be held in the highest regard. The right to self
determination is the key to this. As we hold this as our central virtue, it follows that
beneficance in any action is contingent upon upholding personal autonomy. Violation of
this constitutes deprivation of freedom, and is in turn, intrinsically wrong.