It’s difficult to write about a respected medical journal which promotes “Aid in Dying” without resorting to emotional words such as “horrifying,” “shocking,” or “murder,” but I’ll try. However, I will not call the practice “physician aided death” or “aid in dying.” It is, at best “physician assisted suicide,” and at worst, “euthanasia,” or the use of medical technology and procedures to actively end the life – to intentionally kill – a patient. This is not “medicine” as I understand it.
Chest is the journal of the American College of Chest Physicians. These are the Internal Medicine subspecialists who focus on lung disease, cardiac care, and sleep medicine. They are likely to be the doctors who care for the most vulnerable patients, especially in the Intensive Care Unit at your hospital.
Under the heading “Medical Ethics,” in the July, 2012 issue is an article titled, “Aid in Dying: Guidance for an Emerging End-of-Life Practice,” authored by Kathryn L. Tucker, J.D. The article is available online as a web page, here, and as in pdf., here.
Beginning with a principle that virtually all of us can agree with,the right to refuse intentional medical intervention, the article quickly moves to the very controversial opinion that the first principle ensures the “right” to request “treatment” that is intended to end the life of the patient – to kill:
•A patient with decision-making capacity has the legal right to refuse or request the withdrawal of any medical treatment or intervention, regardless of whether he or she is terminally ill and regardless of whether the treatment prolongs life and its withdrawal results in death.
•A patient with decision-making capacity has the legal right to request and receive as much pain medication as necessary for relief, even if it advances the time of death.
•Principles of autonomy that underlie respecting patient rights to refuse or direct withdrawal of life-prolonging interventions or to request pain medication even if it advances time of death support the choice for aid in dying. Aid in dying is increasingly accepted in law and medicine in the United States.
•Provision of aid in dying does not constitute assisting a suicide or euthanasia. Aid in dying is a practice with growing support in the public and medical and health policy communities and is likely to become more widely requested in the future.
•A clinician cannot be compelled to provide treatment that conflicts with his or her personal values. In these circumstances, the clinician cannot abandon the patient but should refer the patient to a colleague who is willing to provide the service.
Four prima facie principles have been used to characterize most ethical concerns in medicine: respect for patient autonomy, beneficence, nonmaleficence, and justice. Respect for patient autonomy refers to the duty to respect patients and their rights of self-determination; beneficence refers to the duty to promote patient interests; nonmaleficence refers to the duty to prevent harm to patients; and justice refers, in part, to the duty to treat patients and distribute health-care resources fairly.11 When applied to the care of an individual patient, however, these principles may conflict with one another. For example, a patient’s values, preferences, and goals may be at odds with a clinician’s perception of how best to help and not harm the patient. Clinical ethics identify, analyze, and provide guidance on how to resolve these conflicts.
While I believe that there may come a time when it is ethical to stop trying to keep a patient alive – when treatment is only making the dying process longer – I will never assist in an act that can only end in the death of my patient. The way I explain this is that I will assist in removing a ventilator under certain circumstances, but I won’t then put a pillow over the patient’s face to make sure she can’t breathe on her own afterwards. The intent of medicine is to diagnose and treat disease, not to end the life of patients suffering from disease.