FREE ESSAY ON PHYSICIAN ASSISTED SUICIDE

PHYSICIAN ASSISTED SUICIDE

Many voters throughout the United States are taking the measure to legalize physician
assisted suicide to the polls. If it is legalized, the United States will have legalized
a much quicker, more humane method(as opposed to terminal sedation) of ending the
suffering of terminally ill patients. The only legal process of this sort in the United
States is terminal sedation, a method that can oftentimes add to a patient's problems.
Although Oregon is the only state to have successfully passed such a bill for the
legalization of physician assisted suicide, the pressure to confront this issue is
growing along with the movement for legalization. Opponents of the Oregon bill, mostly
Christian conservative groups, are planning to appeal this case to the Supreme Court in
hopes of a reversal of the Oregon Supreme Court's decision. Though the emotional battle
of physician assisted suicide is the prerogative of voters on both sides of the issue,
the fundamental question that will have to be answered by the Courts is whether or not
the liberty observed by the due process clause of the fourteenth amendment contains a
right to perform suicide, which itself includes a right to assistance in doing so. This
clause states, "No State shall make or enforce any law which shall abridge the privileges
or immunities of citizens of the United States; Nor shall any State deprive any person of
life, liberty, or property, without due process of law." (United States Constitution,
Amendment 14)
Tierce, 2
In order to constitutionally create a previously unspecified "right" the Supreme Court
must conclude that such a "right " is either deeply rooted into the nation's history and
tradition, or is fundamental to sustaining the liberty provided in the Constitution. The
court should also have a very specific description of what is to be entailed within this
"right". The difficulty in arguing for assisted suicide is that since the justification
for assisted suicide is not historical or necessary for ordered liberty, the state must
only prove that assisted suicide is within the perimeters of exercising what is best for
the nation as a whole. The Supreme Court has earlier stated that, "This requirement is
unquestionably me here," citing as concerns: preserving human life; preventing suicide;
protecting the integrity and the ethics of the medical profession; protecting vulnerable
groups from abuse, neglect, and mistakes; and preventing a start "down the path to
voluntary and perhaps even involuntary euthanasia." (Annas, 1100) The possibility of
legalization is, however, still quite probable, especially as one uses the Dutch
government as an example, where physician assisted suicide is illegal but not
prosecutable if executed under certain specified legal guidelines. 
The practice of physician assisted suicide in the Netherlands has been defined over many
years of legal processes 
Tierce, 3
and medical ethics, beginning in 1973, when the first case against physician assisted
suicide went to trial. The courts found the physician guilty of the crime, but suspended
her sentence and effectively ruled out the threat of future prosecution. In many Dutch
cases between 1973 and 1984 the courts established necessary conditions for not
prosecuting a physician for assisting in a suicide. The patient must first make the
request for euthanasia, and then repeat the request explicitly acknowledging their desire
to die. The patient must also be suffering from a disease that has brought about severe
physical or mental pain with no hope of recovery. The final case in 1984 resulted in the
addition of a third guideline which required a physician to consult a colleague to verify
the diagnosis, and to design the plan for euthanasia as to not inflict unnecessary
suffering on others concerned. 
Nevertheless problems arose in the Netherlands concerning the legality of euthanasia.
Thus in 1993 the Dutch Parliament passed measures to clarify the state of physician
assisted suicide laws. Under the new law physician assisted suicide is still punishable
by up to 12 years in prison, but if the established guidelines are followed, the practice
is safely shielded by the legal system. The law requires that patients be euthanized in
accordance with the following "carefulness 
Tierce, 4
requirements." (Russell, 781) The first requires that a request for death must be made
entirely of the patient's free will and could not be made by family or friends. The
second requirement states that the request must be expressed repeatedly and show lasting
longing for death. And finally both the patient and doctor must regard the patient's
suffering as perpetual, unbearable, and hopeless.
Classic instances where euthanasia should clearly have been an acceptable method of
treatment have brought much attention to this once ignored movement. One such case was
that of Cruzan v. Director, Missouri Department of Health. Nancy Cruzan was a woman in a
persistent vegetative state whose parents wanted her artificial feeding discontinued. The
case set the precedent for a constitutional right to refuse medical treatment. The court
noted, however, that suicide "has never enjoyed similar legal protection," and that the
"two acts are widely and reasonably regarded as quite distinct." (Hoeffler, 1102) The
court reiterated the fact that patients have throughout history, invariably maintained
the right to demand their bodies not be invaded without their agreement. The court's
objective in the Cruzan case was to make the clear distinction between the right to
refuse undesired medical treatment and the right to physician assisted suicide. 
Tierce, 5
Another such case was that of Quill v. Vacco, which in the opinion of the second circuit
of appeals, stated that New York's regulations against physician assisted suicide were
unconstitutional when applied to terminally ill patients who are not sustained by
life-support systems, because the laws do not accommodate these patients with balanced
protection. In this case the court drew strong distinctions between what could and could
not be considered when addressing the issue of physician assisted suicide. The court
officially stated that patients connected to life-support systems can withdraw treatment
and bring about their deaths, however, patients who are not connected to life-support
systems are unable to exercise the same legal right to hasten their own death. The Quill
case represents a preliminary example of the courts handling of terminal sedation. 
Death brought about by the method of terminal sedation, it is argued, is practically
acceptable because the death is caused by the withdrawal of food and water. The courts
have consistently recognized that it is ethically and legally permissible for patients to
die due to the discontinuation of life-sustaining treatment. In the case of Vacco v.
Quill the court heard oral argument, which focused on the topic of terminal sedation, or
sedation of the imminently dying. 
Tierce, 6
Terminal sedation is the introduction of a barbiturate-induced coma, followed by the
withdrawal of food and water, thus leaving the patient to starve to death. The court
concluded that a state can legally countenance this form of palliative care if it is
"based on informed consent and the double effect. Just as a state may prohibit assisting
suicide while permitting patients to refuse unwanted lifesaving treatment, it may permit
palliative care related to that refusal, which may have the forseen but unintended
'double effect' of hastening the patient death." (Annas, 1104) Although it has explicitly
endorsed the principle of the double effect, the Court did not directly apply the
principle to the practice of writing drug prescriptions. The logic of the opinion
supports the conclusion that physicians can continue to write prescriptions for medically
indicated drugs even with the knowledge that the patients might use the drugs to commit
suicide, as long as the physician's intent is to prolong the patient's life and prevent
suffering. The dismissal of physician's ability to use their own discretion on
determining who is and who is not a candidate for euthanasia has maintained a legal
loophole for physicians.
The theory that is the framework for terminal sedation is that it is appropriate for
physicians to treat the pain and other suffering of patients aggressively, even if doing
so is 
Tierce, 7
likely to bring about death. On a closer examination however, terminal sedation can at
times be equal to euthanasia, or a variety of slow euthanasia. Terminal sedation equates
to assisted suicide, in that the sedated patient dies from the combination of the
unconsciousness and the withholding of food and water. Without these two interventions on
the part of the caregiver the patient would live longer before weakening to the illness.
Thus in its fundamental actions terminal sedation bears a greater resemblance to
euthanasia that to mere mercy killing.
The withdrawal of life-sustaining treatment has been invariably allowed, because the
patient dies from the underlying illness, not from the active applied interference of a
physician or of a chemical substance. A person who is in a persistent vegetative state
dies when a feeding tube is withdrawn, because the patient's condition is responsible for
their inability to eat and drink. That, however, is not the case in terminal sedation
accompanied by the denial of nutrition and hydration. Assisted suicide requires the
active participation of the patient; terminal sedation, however, can be induced without
the patient's knowledge thus making it more difficult to monitor and to maintain
standards of procedure. 
Tierce, 8
As it stands now, patients have the right to be sedated for the relief of pain, but once
sedated, they would lose the right to have nutrition and hydration withheld or withdrawn.
Now that the courts have essentially left open a back door for the perpetuation of
terminal sedation, many have abandoned the movement for legalized assisted suicide.
However the distinctions between the two cases are more symbolic than factual, and the
hazards posed by terminal sedation far outweigh those which would be posed by physician
assisted suicide. The hazards and indignities imposed by terminal sedation are still
fundamentally unnecessary when one looks to assisted suicide for comparison. Terminal
sedation serves fewer of the purposes of a "right to die" law than assisted suicide or
euthanasia. And although terminal sedation ensures a painless death, it forces patients
to accept a dying process that is prolonged when compared with what it would be in the
instance of assisted suicide or euthanasia. Terminal sedation requires that patients
linger in a condition that may profoundly compromise their dignity as well as destroy the
memory they would choose to leave behind. Terminal sedation also prevents patients from
maintaining control over when and how they will die. Essentially terminal sedation is not
giving solution to these 
Tierce, 9
problems which the right to die movement originated in order to protect.
Under the court's ruling it appears that terminal sedation can be limited to appropriate
cases. So similarly is it not possible that the government should be able to limit
assisted suicide to its appropriate cases? Whatever regulations that physicians apply
when deciding that terminal sedation is an appropriate therapy, can also be used to
decide when assisted suicide is also appropriate treatment. The court's decision for
terminal sedation and against assisted suicide implies that it cares as much about the
reasons a patient desires to die, as about how the patient physically attains death. In
approving terminal sedation regardless of the fact that it often amounts to euthanasia,
the court is in essence saying that the right to die primarily reflects a concept of
morality which states that people who are dying, as well as suffering intolerably, should
be allowed to die simply through refusal of life-sustaining treatment.
Although the debate for and against physician assisted suicide is far from over, the
recent legal conclusions leave a rather vague understanding of the Supreme Court's
intentions for the future of physician assisted suicide, euthanasia, and terminal
sedation. In their rejection of a constitutional right 
Tierce, 10
to physician assisted suicide, the Court has preserved a long-standing tradition in the
distinction between the withdrawal of life-sustaining treatment and assisted suicide and
euthanasia. The Court has, however, undermined such a distinction by sanctioning terminal
sedation. Though terminal sedation seems consistent with traditional medical care, it is
often carried out as a form of euthanasia. The practice of terminal sedation is ethically
more problematic than assisted suicide or voluntary euthanasia because it can be
perpetrated without the explicit consent of the individual being sedated. The Court seems
to be implying that within the Constitution there is something to the effect of a "right
not to suffer" at least when death is approaching. Although progress has been made, the
Court has not truly broken new ground in the decisions affecting physician assisted
suicide. Their concurring opinions can, however, be read as a warning to the individual
stated that they should not attempt to adopt any restrictive statutes that would prohibit
instead of inhibit physicians from doing everything in their medical power to prevent
suffering. Clearly the legalization of physician assisted suicide rather than terminal
sedation is the better choice for the United States. The United States should follow the
example of the Netherlands and establish certain guidelines associated with physician
assisted suicide in order 
Tierce, 11
to make the process less painful and less apt to commit any wrongdoing throughout the
process. 
The patients who undergo terminal sedation are required to embrace a form of death that
is less expedient and that is more vulnerable to abuse, and they are being placed in
situations of possible peril by a government whose supposed intention in creating such an
environment is to afford greater protection to them. This question and other questions
like it will have to be answered in future attempts to bring this movement to the
forefront of America's conscience.
Bibliography
Works Cited
Annas, George J. "The Bell Tolls For a Constitutional Right to 
Physician Assisted Suicide," The New England Journal of 
Medicine. 337, 1997, 1098
Hoeffler, James M. Deathright: Culture, Medicine, Politics, and 
the Right to Die Movement. Westview Press, 1994.
Humphrey Derek and Ann Wickett. The Right to Die: Understanding 
Euthanasia. Harper, 1986.
Meier, Diane E., Carol-Ann Emmons, Sylvan Wallenstein, Timothy 
Quill, Sean R. Morrison, and Christine K. Cassel. "A National Survey of Physician
Assisted Suicide and 
Euthanasia in the United States," The New England Journal of Medicine. April 23, 1998.
Orentlicher, David. "The Supreme Court and Physician Assisted 
Suicide," The New England Journal of Medicine. 337, 1997, 1236.
Russell, Ruth O. Freedom to Die: Moral and Legal Aspects of 
Euthanasia. Human Sciences, rev. 1977.