Physician-Assisted Dying

“There is a difference between a person who is dying and a person who is suicidal. I do not want to die. I am dying.” – Brittany Maynard.

To understand physician-assisted dying, you’ll need to understand the following; it deals with a patient suffering from an incurable terminal disease or extreme chronic pain.

Physician-assisted death is different from active euthanasia. In physician-assisted dying, the lethal substance, usually a barbiturate, is either ingested or injected intravenously by the patient himself. Whereas, the doctor administers the lethal dose in active euthanasia.

It comes as no surprise that doctors often find physician-assisted death more palatable when compared to euthanasia. It is much easier to write a prescription according to your patient’s wishes than to inject them with something fatal.

If you have primarily based your views on this subject after reading the book, Me Before You, I will have to request you to kindly forget it’s existence. I have very few nice things to say about that book. It offers a maddeningly narrow view on a much deeper and complex subject.

Terminology:

I prefer to use value-neutral language to not be hurtful or offensive to the patients. Furthermore, it encourages you to make your own views on the topic without unconscious bias and judgment. I request you to consider doing the same in your daily life by using: death with dignity, assisted dying, assisted death, physician-assisted death, physician-assisted dying, aid in dying, physician aid in dying, or medical aid in dying.

Legality of Physician-Assisted Dying:

Physician-assisted dying is currently legal in Switzerland, Germany, Netherlands, the Australian state of Victoria, and in the U.S. states of Washington, Oregon, Colorado, Hawaii, Vermont, Maine, New Jersey, California, and in the District of Columbia.

Switzerland: First country to legalize physician-assisted dying in 1942. This law applies to non-residents also. Commonly offered by non-governmental organizations (NGOs) like Exit, Dignitas, Ex International, and Lifecircle. There is extensive paperwork involved to safeguard all parties. The process takes up to 3 months. Moreover, a police inquiry is started following the declaration. Active Euthanasia is currently illegal. 

Germany: Assisted dying was legalized in Feb 2020, following a five-year ban. The legalization came after extensive criticism of the previous ban that affected palliative care. This is a particularly sensitive issue as Germany has a history of involuntary euthanasia during WWII when 300,000 people with mental and physical disabilities died under a Nazi campaign.

Netherlands: The ‘Termination of Life on Request and Assisted Suicide (Review Procedures) Act’ of 2001 legalizes both physician-assisted death and euthanasia in the Netherlands. The proceeding took root following a 1973 case, where Dr. Truus Postma following repeated requests from her mother injected her with morphine. It is commonly referred to as the ‘first euthanasia’ case in the country. It was very controversial. She was found guilty but received no/minimal punishment (two different reports). The ‘Postma case; is most commonly cited in the Netherlands when euthanasia is the topic of conversation. The ‘Groningen Protocol’ was created in September 2004 outlining the criteria under which physicians can perform “active ending of life on infants”.

Australia: ‘Voluntary Assisted Dying Bill 2017’ came into effect in the Australian state of Victoria in June 2019. Western Australia passed a similar bill in 2019 which is expected to come into effect in 2021. For a brief period between 1996 and 1997, euthanasia was legal in the Northern Territory. Currently, active euthanasia is illegal in all of Australia. Two Australian courts in 2009 and 2011 have sentenced people for providing means of death on account of the patient’s mental incompetency.

United States of America: Oregon was the first American state to pass the ‘Death with Dignity Act’ in Nov 1994. Following this, multiple states introduced similar bills but most failed. In 2014, Brittany Maynard, a public advocate for assisted death, chose to die by physician-assisted death in Oregon, thus renewing the debate nationwide. She is largely credited for the introduction of multiple bills in different states. Currently, 10 American territories including Montana have legalized assisted death.

Religious Views on Physician-Assisted Dying:

When it comes to religious views, the difference between euthanasia and physician-assisted dying is often not made. It is said that euthanasia was a common practice during the time of Hippocrates. Later, with increased proselytism to Abrahamic religions (Christianity and Islam) and their belief in absolutism, the discussion has become more complicated. Different subtypes of Christianity, different churches, and different Popes’ have issued vague but critical statements over the years. Similarly, Islam has often been critical of active euthanasia but also doesn’t believe in prolonging life using life-support machines. With a history of crusades, Protestant-Catholic conflicts, Shia-Shunni conflicts, and rise of the Islamic State, all views on this matter have always been accompanied by controversies.

One can imagine how extensive the discussion is when it comes to Hinduism, the world’s longest surviving religion which is constantly evolving with time. Hinduism is largely based on the consequences of one’s actions, known as ‘karma’ rather than the action itself. The Vedic texts and Bhagavad Gita don’t explicitly mention the acts of physician-assisted dying or euthanasia. Like Hindus, Jains also practice non-violence or ‘ahimsa’ which is again open to individual interpretation. Buddhism has opposing views since it’s foremost principle is human compassion. Indic religions give more importance to the intention behind one’s action rather than the action itself. Additionally, some religions have acceptable forms of ‘suicide’.

No religion in the world, over the period of hundreds of years, has come to a common agreement on this topic. It may be impossible to do so. Religious views on this subject are very vast. It comes down to this: Physician-assisted dying is opposed by those who believe in the sanctity of life and is supported by those who believe in compassion and respecting individual liberty.

Points Against Physician-Assisted Dying:

• Sanctity of life: This argument has strong religious and secular beliefs against taking human life. Assisted suicide is considered to be morally wrong because it contradicts these beliefs.
• Passive vs. active distinction: There is an important difference between passively “letting die” and actively “killing.” Refusal or withholding of treatment equates to letting die (passive) and is justifiable, whereas physician-assisted dying equates to killing (active) and is not justifiable.
• Potential for abuse: Certain groups of people who are financially unstable or/and cannot support a person of special needs may push the patient into assisted death. This is a grey area as these patients are also often victims of domestic abuse. So, the patient’s motives for choosing physician-assisted dying can be hard to determine.
• Professional integrity: Medical ethics strongly oppose this practice. Moreover, professional bodies like AMA stand against it. Additionally, there is concern that this could harm the public image of doctors.
• Fallibility of the profession: This pertains to the physicians’ margin of error. The diagnosis and/or prognosis may be uncertain, which, in turn, affects the treatment. Thus the government has an obligation to protect lives from these inevitable mistakes.
• Emergence of palliative care: As it focuses on making the patient comfortable towards the end of his life, the need for physician-assisted dying is largely reduced.

Ethical Safeguards:

• Patient has the power: Physician-assisted dying ultimately depends on the patient’s choice. The patient can choose to opt for or against the procedure. The patient is free to administer the dose at a time of his choosing. It also allows the patient to change his mind, even at the very last moment.
• Preferred to active euthanasia: It is emotionally easier for the physician than euthanasia as he or she does not have to directly cause the death; he or she merely supplies the means for the patient’s personal use.
• Consent: Taking written informed consent explaining the patient all the options available, and that he is free to change his mind at any point in time, reduces the risk of unwanted death of the patient. It further helps the patient consider all his options before making a decision. This procedure of obtaining consent can be recorded by the hospital to adequately protect both the doctors and the institution.
• Age: Like all medical procedures you must be of legal age (18+) for your opinion to be counted.
• Psychiatric screening: The patient’s competency to make a decision and a mandatory mental health screening to rule out any psychiatric disorders that may impact a patient’s competency must be assessed prior to the procedure. Furthermore, two different doctors must sign off on the procedure to reduce the chance of its abuse.
• Physician free to refuse: It is in the best interest of everyone involved to give the physician the freedom to refuse to participate in the procedure. It should be their personal choice. Instead they can refer to the patient to a different physician.

Points In Favor of Physician-Assisted Dying:

• Autonomy: Patient autonomy is one of the most fundamental ethical lessons we are taught in medical school. The patient has the right to make decisions about his body and health. A competent person suffering from an incurable disease in extreme pain must be given a choice to die with dignity.
• Compassion: Patients suffer. They suffer physically, mentally, emotionally, and not to mention financially. It is not always possible to relieve suffering. This helps by reducing the amount of time a patient suffers.
• Individual liberty vs. state interest: Though society has a strong interest in preserving life, that interest decreases when a person is terminally ill and has a strong desire to end his life. A complete prohibition on assisted death excessively limits personal liberty which should take precedence in such cases.
• Reduces abuse of opioid analgesics: With the legalization of physician-assisted dying, stronger measures can be taken to reduce the use of opioid analgesics in healthcare. This has a direct impact on reducing it’s addiction rates and abuse.
• Lack of palliative care: Not all countries in the world have the same laws when it comes to palliative care and not all countries pay for palliative care of its citizens. For example, in India, despite recent relaxations, most doctors never prescribe morphine in their lifetime, and fentanyl is highly regulated and is mostly used by anesthesiologists or in cases of extensive polytrauma. Even tramadol is rarely prescribed out of the ER. Patients living in similar countries suffer for years from chronic pain or are bed-ridden for the majority of their lives because they can’t afford lifelong treatment.
• Encourages a conversation: Some would argue that assisted death already occurs, although slowly and in secret. Legalization of physician-assisted dying would promote transparency and open discussion between the patients and doctors.

Every discussion has both points in support and points against it. When it comes to ‘Physician-Assisted Dying’, I firmly stand in favor of it. By that, I’m not saying every terminally ill patient should opt for physician-assisted dying. Absolutely not. 

When I say I am pro-physician-assisted dying, I mean, the patient has the right to choose. I believe a person has the right to live and the right to die on his/her own terms. They know themselves best. It is their body, their life, and it should be their decision and voice that matters.

If a patient believes in the sanctity of life, he gets to make the choice to opt-out of physician-assisted dying. If a patient believes in dying with dignity, he gets to make the choice to opt into physician-assisted dying.

We are a planet of almost 8 billion people. People who follow many different religions. People with broad and conflicting views. People with strong personal reasons to support their sentiments. This article fails to mention interpersonal relationships, the most important driving force behind most human decisions. One decision cannot apply to everyone. One decision will not make everyone happy. And it rightfully shouldn’t. Our differences are what make us human. That is why I believe having a choice is important. People should be able to decide what is best suitable for them.

Points to consider:

Please understand that this article covers a small portion of an enormous subject. There is so much more literature to read about the same. Here are some thought-provoking questions to consider as you formulate your own opinion:

• Should next-of-kin be able to consent to physician-assisted dying?
• Should physician-assisted-dying be ethically and/or legally applicable for patients suffering from chronic psychiatric conditions?
• For older patients suffering from neurodegenerative diseases?
• For infants/children born with birth defects?
• Physician-assisted death is currently illegal in all Asian countries. Why?
• Should active non-voluntary euthanasia ever be legalized? Are there circumstances in which it could be considered?
• Active Euthanasia is legal in the Netherlands, Belgium, Colombia, Luxembourg, and Canada. Out of which, only the Netherlands legalized assisted death also.  Should countries that have already legalized active euthanasia also legalize physician-assisted death?

Glossary

Physician-Assisted Dying: Physician makes the means of death available to the patient to be used by the patient himself at a time of his choosing.

Euthanasia or Mercy Killing: Act or practice of painlessly putting to death persons suffering from a painful and incurable disease or incapacitating physical disorder or allowing them to die by withholding treatment or withdrawing artificial life-support measures. (Broad definition)

Active Euthanasia: When a patient’s death is bought upon by an active intervention by the doctor. The doctor administers the lethal dose.

Passive Euthanasia: When a patient’s death is brought upon by omission. The doctor stops treatment leading to the patient’s death. DNI/DNR is a form of passive euthanasia.

Voluntary Euthanasia: When the decision of dying is made by a competent patient himself. With the patient’s consent, a doctor administers the lethal dose or stops treatment.

Involuntary Euthanasia: When the decision of dying is made for a competent patient without his consent. Patients may be unwilling to make the decision. The doctor administers the lethal dose or stops treatment. (Illegal in all countries)

Non-voluntary Euthanasia: When the decision of dying is made for an incompetent patient (brain dead/vegetative state) by the family. The next-to-kin gives consent. The doctor administers the lethal dose or stops treatment.

Palliative Care: A medical approach that improves the quality of life of patients and their families facing problems associated with a life-threatening illness, through prevention and relief of suffering. The goal is to relieve pain and suffering. The treatment may or may not be in tandem with curing the patient. Applicable to all age groups.