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Physician-assisted suicide (PAS) is a type of euthanasia, which, in turn, is divided into several categories. Euthanasia can be classified as active or passive, as well as voluntary or involuntary, which determines ethical or legal dilemmas regarding different types (Jordan, 2017). Thus, PAS refers to voluntary active euthanasia, when a physician intentionally helping a competent person to terminate his or her life by providing drugs for self-administration, at that persons voluntary request (Sprung et al., 2018, p. 2). In this context, the physicians role in action is especially emphasized, implying certain tasks and responsibilities (Radbruch et al., 2015, p. 6). Such an active position of medical workers at the end of a patients life, therefore, is the reason for the debate.
Legislative Issues
The legalization of PAS is a subject of controversy for many medical organizations in different countries. The procedure is currently legal in the Netherlands, Belgium, Luxembourg, Colombia, and Canada,&six American states (Oregon, Washington, Montana, Vermont, California, and Colorado) (Dierickx, 2018, p. 115). Professional international medical organizations have expressed their opinion on the legalization of PAS as part of palliative medicine. For example, the American Psychiatric Association opposes any intervention or willful action to cause the death of a patient (Sprung et al., 2018). However, in 2016, the World Medical Association considered the possibility of approving PAS, and the American Medical Association discussed the possibility of changing its position on the issue to neutral (Sprung et al., 2018). Thus, there is currently no unequivocal opinion regarding the legalization of assisted suicide.
The main reasons for legislative dilemmas are the existence of palliative medicine and the clinicians role in the fate of the patient. PAS can be considered a violation of the medical mission, according to which the physician provides the patient with the help and necessary care (Sprung et al., 2018). However, in the context of PAS at the legislative level, it is challenging to define precisely what may be the basis for assisted suicide. The lack of sufficient research on the impact of the practice on palliative medicine and terminally ill patients care presents a challenge to consider the advantages or disadvantages of PAS. However, Gerson et al. (2020) report a unique situation in Belgium, where legalized assisted suicide is used effectively alongside palliative medicine. However, in other countries, such as Canada and the United States, there is no clear evidence of support or refusal of the practice, as, for the most part, moral beliefs prevail (Gerson et al., 2020). Thus, the legalization of PAS requires first the solution of ethical issues, and then the development of specific legislative guidelines.
Ethical Issues
In addition to legislative issues, PAS is primarily the subject of ethical and moral controversy in the global community. First of all, the problem arises of transforming the health care system into a business that provides services to patients for money (Radbruch et al., 2015). Thus, a criticism of PAS implies the assumption that physicians should not perform the procedure, focusing on palliative care, and providing medical help to all the patients. At another point, there is a controversy that the spread of the practice may lead to its abuse by even those patients who are not terminally ill (Sprung et al., 2018). It is especially true for PAS because the patient himself decides to perform the procedure; however, the approval remains with the physician. Thus, he is responsible for resolving the issue of the patients life and death, which is morally controversial.
The ethical dilemmas related to PAS can also be considered in terms of philosophical, ethical theories. For example, Jordan (2017) suggests considering the procedure in the context of three different approaches: rule and act-utilitarianism, Kantian deontology, and virtue ethics. From the point of view of rule and act utilitarianism, the physician must consider and assess all factors, not making a decision based solely on the patients desire. This approach will allow him to choose the option that will bring the most benefit to the patient. However, in making a choice, the physician violates the common morality of not killing, assuming that the result will be more beneficial than following the rule (Jordan, 2017). Therefore, it is difficult to determine which will be best for the patient in each situation: assisted suicide or palliative medical care.
Kantian deontology presupposes respect not only for the interests of the individual but also for all the people around him. Thus, on the one hand, the satisfaction of the patients desire for assisted suicide should be satisfied, which, on the other hand, may cause a moral dilemma on the part of the physician. However, Kant denies the possibility and legitimacy of any kind of killing, including suicide (Jordan, 2017). Thus, it is ethically difficult to meet the needs of all parties, which is controversial.
Virtue theory appeals to physicians virtuous qualities such as compassion for the patients pain as crucial aspects of decision-making. Thus, the physician should pay attention to the experience gained, rather than to the principles of common morality, thinking about what is best for the patient. However, it is difficult to assess the motivation and whether the decision was based on virtuous qualities or other motives (Jordan, 2017). Thus, the theory involves the use of complex concepts which cannot be considered unambiguously.
PAS addresses difficult ethical dilemmas challenging the international medical community and society at large. However, at the moment, it is not possible to solve them since the desire for assisted suicide presupposes psychological, existential, and social motives (Sprung et al., 2018, p. 3). Thus, it is impossible to determine whether a patients request is due to unbearable physical pain or a symptom of depression. Many patients with terminal diseases cannot find a reason to continue living, which underlines the importance of palliative care.
Palliative Care in Relation to Physician-Assisted Suicide
Multiple ethical controversies about PAS are attracting more attention to the role of palliative medical care in the lives of terminally ill patients. Palliative care involves symptom control, psychological and spiritual well-being, and care of the family, fit the goal of helping patients to live with dignity until their death (De Lima et al., 2017, p. 10). Health care specialists are supposed to provide patients with various medication support to relieve pain symptoms of the disease. It is also noted that the main reasons for requesting assisted suicide are depression, hopelessness, being tired of life, loss of control and loss of dignity (Emanuel, 2017, p. 1). Thus, the development of palliative medicine and the improvement of its quality can improve the patients psychological condition and prevent his desire to end life.
PAS can have a negative impact on patients attitudes towards palliative care and relationships with physicians. It is mentioned that patients may hesitate to accept palliative care for fear that a doctor might hasten their deaths with medication (De Lima et al., 2017). The practice of palliative medicine is the communitys responsibility towards people in need of aid, while PAS can be a sign of physicians impatience and reluctance to care for terminally ill patients. Therefore, assisted suicide is recognized by many people as a violation of the civil rights of individuals and should be considered separately from the health care system (De Lima et al., 2017). Thus, PAS should not be a part of palliative care, nor should its specialists be involved in such activities.
Physician-Assisted Suicide in Cancer Patients
The problems of palliative care and PAS are especially relevant for patients with end-stage cancer. It is noted that 80% of all requests for assisted suicide are from cancer patients, although only 25% globally of all deaths are caused by the disease (Emanuel, 2017, p. 1). As noted, oncologists deal with extreme distress, to advise against harmful choices, to mobilize needed resources, to overcome barriers, and to provide dependable care with continuing support for patients and caregivers (ORourke et al., 2017, p. 685). Thus, terminal cancer patients often refuse adequate medical care in hope of PAS, which undermines the professionalism of the clinicians working with them. Therefore, the problem of providing adequate long-term medical care in the context of the existence of assisted suicide methods is especially relevant for such patients.
Conclusion
Physician-assisted suicide is legalized or partially legalized in several countries worldwide, but there is still no consensus regarding this practice. On the one hand, it is considered a violation of medical ethics since a physician ought to provide medical assistance even to terminally ill patients. On the other hand, alleviating suffering is also a priority for healthcare professionals, which palliative medicine does not always do. Most of the request for PAS is related to psychological causes rather than physical pain, which complicates the decision. The legal framework requires objective indicators for choosing one or another medical care tool since compassion or personal desire cannot be a valid reason. Therefore, in order to determine the legal basis for assisted suicide, complex ethical dilemmas affecting the foundations of public morality must first be resolved.
References
De Lima, L., Woodruff, R., Pettus, K., Downing, J., Buitrago, R., Munyoro, E., Venkateswaran, C., Bhatnagar, S., & Radbruch, L. (2017). International Association for Hospice and Palliative Care position statement: euthanasia and physician-assisted suicide. Journal of Palliative Medicine, 20(1), 8-16.
Dierickx, S., Deliens, L., Cohen, J., & Chambaere, K. (2018). Involvement of palliative care in euthanasia practice in a context of legalized euthanasia: A population-based mortality follow-back study. Palliative Medicine, 32(1), 114-122.
Emanuel, E. (2017). Euthanasia and physician-assisted suicide: focus on the data. The Medical Journal of Australia, 206(8), 1-3.
Gerson, S. M., Koksvik, G. H.,Richards, N., Materstvedt, L. J., & Clark, D. (2020). The relationship of palliative care with assisted dying where assisted dying is lawful: A systematic scoping review of the literature. Journal of Pain and Symptom Management, 59(6), 1287-1303.
Jordan, M. (2017). The ethical considerations of physician-assisted suicide. Dialog & Nexus, 4(12), 1-7.
ORourke, M. A., ORourke, C., & Hudson, M. F. (2017). Reasons to reject physician-assisted suicide/physician aid in dying. Journal of Oncology Practice, 13(10), 683-687.
Radbruch, L., Leget, C., Bahr, P., Müller-Busch, C., Ellershaw, J., de Conno, F., & Vanden Berghe, P. (2015). Euthanasia and physician-assisted suicide: A white paper from the European Association for Palliative Care. Palliative Medicine, 30(2), 104-116.
Sprung, C. L., Somerville, M., Radbruch, l., Collet, N. S., Duttge, G., Piva, J. P., Antonelli, M., Sulmasy, D. P., Lemmens, W., & Ely, W. (2018). Physician-assisted suicide and euthanasia: emerging issues from a global perspective. Journal of Palliative Care, 33(3), 1-7.
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