Assisted Suicide.

Assisted Suicide. I INTRODUCTION Assisted Suicide, a person's voluntary suicide with help from another individual. A suicide is an intentional, self-caused death. Individuals who elect to kill themselves with the assistance of another person typically have an incurable illness or are experiencing extreme physical suffering. The term assisted suicide may also refer to the act of providing an individual with the means to commit suicide, knowing that the recipient plans to use these means to end his or her own life. If a doctor provides medications or other means of committing suicide with the understanding that a patient may intentionally use them to end his or her own life, this action is referred to as physician-assisted suicide. The remainder of this article deals primarily with physician-assisted suicide. II CIRCUMSTANCES AND METHODS Some people who face acute illness wish to refuse treatments offered by doctors, even if refusing such treatment may cause them to die. Like people who commit suicide, patients who refuse treatment often intend to end their lives because of their grim prospects for a healthy recovery. On the other hand, many people who desire assisted suicide seek relief from their suffering and do not seek death as an end in itself. Therefore, distinguishing a suicide from a refusal of treatment merely by the patient's intention can be difficult. Nonetheless, the belief that those who commit suicide with a physician's assistance are in a very different category from those who simply refuse treatment is widely held. Assisted suicide also differs from euthanasia, in which a person other than the patient ends the patient's life as painlessly as possible for merciful reasons. Euthanasia may be active, such as when a doctor administers a lethal dose of medication to a patient, or passive, such as when life-sustaining treatment is withheld or removed. In either case, someone other than the patient is the final cause of the patient's death. Assisted suicide involves a more direct action by the person who dies than does euthanasia. For example, in a case of assisted suicide, although a physician may prescribe a lethal dose of medication, the patient administers the medication to himself or herself. III THE ASSISTED SUICIDE DEBATE Since ancient times philosophers have contemplated the concept of a merciful and acceptable death. However, individual choice in dying did not become a widespread social issue and legal concern until recently. As technological advances in medicine have enabled doctors to keep patients alive for longer periods of time, legal rights to forgo medical intervention have developed. Although a mentally competent patient's right to refuse treatment is now widely accepted, until the 1970s physicians and lawmakers disputed the propriety and legality of treatment refusal. Doctors typically assumed control over a patient's length of hospitalization and type of treatment. Often no serious discussion of alternatives took place. A patient who refused a useful life-sustaining treatment was considered to have requested something medically unacceptable. This view changed during the 1970s, when the right to refuse treatment was established by various court cases. Today the dispute over patient autonomy extends beyond the right of treatment refusal to issues of active euthanasia and assisted suicide. People who believe that assisted suicide should be legalized maintain that individuals should have control over the timing and manner of their own deaths. Some argue that actively bringing about one's death is no different legally than refusing life-sustaining treatment. However, opponents contend that legalizing assisted suicide will cause many problems. They fear that vulnerable individuals may be coerced into suicide as a result of financial pressure or fear of burdening their families. Religious opposition to assisted suicide is often based on the belief that God, not humans, should make the choices regarding death. The legalization of assisted suicide has been a subject of intense public debate. In the early 1990s, the actions of retired Michigan pathologist Jack Kevorkian brought extensive attention to the issue. Kevorkian began to help suffering individuals end their lives with a "suicide machine" he designed. The device administered an anesthetic and then a lethal injection of potassium chloride through an intravenous line. Although prosecutors in Michigan have charged Kevorkian for various crimes, juries consistently refused to convict him for his assistance in the deaths of numerous individuals. However, in 1999 a jury found Kevorkian guilty of second-degree murder and delivery of a controlled substance. In this case Kevorkian himself administered lethal drugs to an incurably ill person who Kevorkian indicated had asked to be put to death. Kevorkian was sentenced to 10 to 25 years imprisonment. Kevorkian's actions provoked sustained controversy. His opponents viewed him as a maverick operating outside mainstream medicine and without legal precedent. They maintained that neither the constitutional right to privacy nor any other recognized legal right supports the practice of assisted suicide. However, those who supported Kevorkian's actions contended that no valid distinction can be drawn between the acts of disconnecting life-support equipment and connecting equipment designed to cause death. They viewed the patient's right to control his or her medical treatment and time of death as the sufficient justification in both cases. IV LEGAL ASPECTS In the United States and Canada, a mentally competent patient has a legal right to refuse treatment. A valid refusal obligates the physician to forgo treatment, even if honoring the refusal will result in death. A physician's compliance with the refusal is never considered a legal offense, and how the death occurs as a result of the refusal is irrelevant. However, the law also attempts to distinguish between allowing a person to die and assisting a person to die. Laws permit the former under many circumstances and typically prohibit the latter. Assisting suicide has long been a crime in both the United States and Canada. However, in 1994 and again in 1997 voters in Oregon approved a law allowing physicianassisted suicide. Governments have often punished suicide assistance as a form of murder or manslaughter and have sometimes specifically defined the action as a separate offense. For instance, in response to Kevorkian's activities, in 1993 the Michigan legislature adopted a law prohibiting suicide assistance and making it a felony punishable by up to four years in prison. Today the majority of U.S. states have legislation defining suicide assistance as a felony, punishable by several years in prison. (Several other states continue to punish assisted suicide under the common law, which is based on judicial decisions rather than on specific statutes.) The Criminal Code of Canada also prohibits suicide assistance, providing for up to 14 years in prison as punishment. However, in recent years those who favor legalizing assisted suicide in the United States and Canada have challenged the constitutionality of these laws. A Constitutional Issues In 1997 the Supreme Court of the United States ruled that state statutes prohibiting assisted suicide do not violate the Constitution of the United States. In the decision of State of Washington v. Glucksberg, the Court determined that the federal constitution does not guarantee an individual the choice to end his or her life. At issue was the 14th Amendment, which provides that government shall not deprive an individual of life, liberty, or property without due process of law. This clause guarantees that the process used to deprive an individual of certain freedoms must be fair (procedural due process) and also that certain fundamental liberties may not be infringed regardless of the fairness of the procedures used (substantive due process). In the Glucksberg case, the Court indicated that the liberty interest protected by the 14th Amendment does not encompass the right to determine the timing and manner of one's own death. The Court's decision means that each state may determine whether or not to prohibit or permit (and otherwise regulate) assisted suicide. In 2006 the Court upheld Oregon's law permitting physician-assisted suicide. In a 6-to-3 decision, the Court rejected an attempt by the administration of President George W. Bush to bar doctors from helping terminally ill patients die by threatening to prosecute them under the Controlled Substances Act of 1970. In the majority opinion written by Justice Anthony Kennedy, the Court ruled that the federal government did not have the right to overrule Oregon voters. Canada does not allow assisted suicide and the Supreme Court of Canada has concluded that Canada's ban is not unconstitutional. In 1993 Sue Rodriguez, a 42-yearold woman diagnosed with amyotrophic lateral sclerosis (Lou Gehrig's disease), an incurable illness, petitioned the court to allow her the option of physician-assisted suicide. Rodriguez argued that the statutory prohibition of assisted suicide violated the rights of personal liberty and autonomy guaranteed by the Canadian Charter of Rights and Freedoms. In a 5 to 4 decision, the Canadian Supreme Court rejected Rodriguez's challenge to the criminal code. The court ruled that society's interest in preserving life and protecting those who are vulnerable outweighed the interests of the individual in cases of assisted suicide. However, several judges suggested in their opinions that the laws in Canada might need reform in order to provide help to patients like Rodriguez. (In early 1994 Rodriguez killed herself with the assistance of an anonymous physician.) B Legislation Supporters of assisted suicide have also attempted to enact laws permitting and regulating the practice. In 2001 The Netherlands became the first country to legalize assisted suicide and active euthanasia. Under the Dutch law, physicians who perform euthanasia or assist in a patient's suicide must follow strict guidelines: The patient must make a voluntary, stable request to die and have a clear understanding of his or her condition and prognosis; the physician must carefully review the patient's condition; the patient must be suffering unbearably with no hope of improvement; and a second physician must be consulted and must agree with the decision to help the patient die. In the United States, only one state, Oregon, has adopted a law specifically allowing physician-assisted suicide. In November 1994 voters in Oregon approved a ballot measure adopting the Death with Dignity Act, which authorized physicians to prescribe lethal doses of medication for terminally ill patients. However, opponents of assisted suicide challenged the constitutionality of the law and prevented its enforcement. In 1997, after the U.S. Supreme Court determined that the states have the authority to regulate this issue, the voters of Oregon again approved the act. In 1998 voters in Maine and Michigan rejected laws that would have legalized assisted suicide. Under the provisions of Oregon's Death with Dignity Act, physicians are legally allowed to hasten the death of a patient who has been declared terminally ill by two physicians and who wishes to escape unbearable suffering. The patient must have requested a prescription for lethal drugs three times (one of these requests must be made in writing). The two verbal requests must be separated by at least 15 days. Contrary to predictions by opponents of assisted suicide, implementation of the law did not result in a flood of assisted suicides. By the end of 2005, more than 200 people had taken lethal drugs obtained through a physician since the law took effect in 1997. V ETHICAL ISSUES The fundamental ethical issue regarding assisted suicide is whether acts by physicians that help others kill themselves (or let others die) can be morally justified, not whether these acts should be legalized. Those who believe assisted suicide is morally prohibited maintain that it is impermissible for a doctor to kill a patient and that a defensible distinction exists between killing a person and letting a person die. However, this distinction has proved difficult to define and explain precisely. Those who support assisted suicide maintain that any distinction between killing a person and letting a person die that may exist is actually irrelevant to the question of whether assisted suicide can be justified. Advocates of assisted suicide note that it is generally agreed that killing is justified under some conditions--for example, in cases of self-defense. Therefore, they argue, correctly applying the label "killing" or the label "letting die" to a set of events does not, by itself, indicate whether an action is acceptable or unacceptable. Instead, supporters argue, rightness and wrongness depend on the justification underlying the action. Medical ethicists agree that physicians may forgo treatment when a patient or the patient's authorized representative refuses treatment. Thus, valid refusals justify physicians to "allow" a patient to die when the patient could be kept alive with treatment. Supporters of assisted suicide believe that some acts of assisting in bringing about death can be framed similarly to refusals of treatment. Such actions could then, in principle, be justified by a request of the patient. They contend that a patient's request for a fatal medication is analogous to a patient's refusal of life-sustaining medication. However, the traditional view in professional medical ethics is that a request for assistance in dying by a competent patient does not have the same authority and obligatory force in law and morality that a valid refusal of treatment has. Therefore, such a request does not justify an action of physician-assisted suicide. Major medical professional organizations--including the American Medical Association (AMA) and the Canadian Medical Association (CMA)--maintain that physicianassisted suicide is not justified by a patient's request under any circumstance. However, this conclusion is controversial. Others believe that whether physicians are either morally permitted or morally required to honor requests for direct assistance that will lead to death depends on the nature of the request and the nature of the patient-physician relationship. One of the most critical issues underlying the question of justified killing in medicine is whether the act of assisting persons in bringing about their deaths causes them a loss or, rather, provides a benefit. If a person chooses death and sees that event as a personal benefit, then helping that person bring about death may neither harm nor wrong the person and may provide a benefit or at least fulfill the person's last important goal. On the one hand, avoidance of intentionally causing the death of patients is a deep and primitive restraint encouraged by many reservations that society has long had about killing innocent persons. To change this perspective would seem to be sweeping and dangerous. Opponents of assisted suicide fear that doctors will become less committed to saving lives, that families may respond to financial pressures by subtly encouraging suicide, and that limitations in the resources of the health-care system might dictate decisions of life and death. On the other hand, some people question whether physicians should be restricted by law and morality if they may benefit patients in ways other than just by healing and providing noncurative pain relief. Contributed By: Tom L. Beauchamp Microsoft ® Encarta ® 2009. © 1993-2008 Microsoft Corporation. All rights reserved.