What comes to your mind when you think of death? While death is an uncomfortable subject to ponder, it is one of our few unavoidable certainties. Due to modern technological advances, there has been an overall increase in the life expectancy of the general population. However, the incidence of terminal diseases such as cancer also increases with age. Patients and their loved ones, in turn, must face difficult but necessary conversations deciding how to cope with death. This process is often unpredictable, scary, and painful. Physician assisted suicide (PAS), also referred to as physician-assisted dying or euthanasia, has been fiercely debated in the U.S. over the past few decades as a way to control our deaths. PAS must have strict legal safeguards for the practice to be truly effective at putting patients’ well-being in life first.
Before examining the implications of PAS policy on human life and death, it is important to define its definition and history. According to professors at the University of Pennsylvania’s Department of Medical Ethics and Health Policy, PAS is defined as when physicians intentionally administer “medications or other interventions to cause the patient's death with the patient's informed consent” [1]. Medical professionals are in wide consensus that involuntary and nonvoluntary PAS are unethical as they end the life of the patient without their informed consent — a doctrine that protects patients’ right to their own body [2]. As such, they should not be the subject of this debate. Voluntary PAS on the other hand has been slowly gaining support from different countries around the world, from Switzerland’s legalization of the practice in 1942 to most recent approval in Canada, New Zealand, and Australia. In the United States, PAS is authorized in 10 states and 1 district, including but not limited to Oregon, Maine, and Washington D.C. Therefore, the growing legalization of PAS warrants serious discussion on how it should be applied in medical settings.
Legalizing PAS helps some patients to regain autonomy and dignity in death. In deciding exactly how and when they will die, it creates a space for mourning that would not otherwise be there if the patient was either unconscious in critical life support, or suffered a sudden death. In one example, Avivah Wittenberg-Cox recalled that her mother used Canada’s Medical Assistance in Dying (MAID) program to end her life [3]. She believed this decision empowered her mother to live as an “essentially whole person, brave, realistic, [and] facing the truth of life and inevitable death.” Using MAID, her mother was able to pass away with family by her side in her own home instead of the hospital. For the mentally capable, terminally ill patients in particular, choosing PAS may relieve their suffering by owning autonomy and coming to terms with death. PAS holds the key to a meaningful death for some patients.
We must not, however, forget that the implication of PAS is death. Strict legal safeguards must be enforced to prevent the unethical use of this practice. Patients experiencing immense physical and mental suffering should not choose PAS as their only or first option of relief. Instead, after assessing the patients’ unique circumstances, physicians should consider PAS alongside other end-of-life care options that provide progress and hope towards a better life. For instance, palliative care, medical services geared at optimizing a patients’ quality of time regardless of if they have a terminal illness or not, can actually increase one’s lifespan despite physician prognoses [4]. Other options that should be considered are psychiatric evaluations or home healthcare services. Overall, physicians can continue to serve as stewards of autonomy and dignity in their own institutions to make a holistic assessment on their patients’ needs, instead of turning to death immediately.
Without strict legal safeguards on PAS, institutions put forth the idea of planned death as the first course of action, indirectly suggesting that there are no other means of salvation for those with intense suffering or terminal illness. The physician-patient relationship uniquely positions physicians to take initiative in introducing interventions for issues such as mental health, poverty, lack of housing, and extreme loneliness. Therefore, when there is a combination of vulnerability, trust, knowledge, and confidentiality, the physician-patient relationship creates a safe space for patients to disclose their concerns [5]. Such non-terminal reasons, nonetheless, have been cited in real life as reasons for PAS. If patients are turning to PAS because of unbearable mental and social burdens, then we as a society have failed to implement preventative care. Surgeon and writer Atul Gawande puts it best in his book, Being Moral: “Our ultimate goal, after all, is not a good death but a good life to the very end” [6]. Therefore, healthcare systems must focus more on improving inadequate treatment of symptoms to prevent the unnecessary end-of-life suffering that justifies PAS.
Death may seem far away enough to feel irrelevant for some of us. Yet, with more choices on how to spend our last moments, we should embrace the debate on which will be the most empowering and meaningful for ourselves. Every new end-of-life policy brings a way we could possibly close the chapters of our life. Healthcare providers, leaders, and policymakers should encourage patients to consider other treatment options to help promote a better life first rather than risk hurrying an avoidable death. Ultimately, when the inevitable comes, planned or not, we can face it as the whole person we know ourselves to be.
References:
Emanuel, E. J., & Joffe, S. (2003). Assisted suicide and euthanasia, Holland-Frei cancer medicine (6th ed.), BC Decker.
Paterick, T. J., Carson, G. V., & Allen, M. C. (2008). Medical informed consent: General considerations for physicians. Mayo Clinic proceedings, 83(3), 313-319. https://doi.org/10.4065/83.3.313
Wittenberg-Cox, A. (2022). A designed death – where & when the world allows it. Forbes.
Temel, J. S., Greer, J. A., Muzikansky, A., Gallagher, E. R., Admane, S., Jackson, V. A., Dahlin, C. M., Blinderman, C. D., Jacobsen, J., Pirl, W. F., Billings, J. A., & Lynch, T. J. (2010). Early palliative care for patients with metastatic non-small-cell lung cancer. The New England journal of medicine, 363(8), 733–742. https://doi.org/10.1056/NEJMoa1000678
Chipidza, F. E., Wallwork, R. S., & Stern, T. A. (2015). Impact of the doctor-patient relationship. The primary care companion for CNS disorders, 17(5), https://doi.org/10.4088/PCC.15f01840
Fink, S. (2014). Atul Gawande’s ‘Being Mortal.’ The New York Times.