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Physician Assisted Suicide Essay, Research Paper

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)

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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

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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

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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.

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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.

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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

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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.

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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

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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

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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

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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.

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.

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