August 19, 2019 Feature

Physician-Assisted Death: A Slippery Slope or the Ultimate Patient Autonomy?

By Louise Derevlany

Does the right to life does include a right to choose the time and place of one’s own death? In the United States at the present time, seven states—California, Colorado, Oregon, Hawaii, New Jersey, Vermont, and Washington—and the District of Columbia have laws permitting physician-assisted death (PAD). There is also one state, Montana, where the practice is legal by way of a court ruling. Such end-of-life options are likely under consideration in many other jurisdictions. Recently, it has come under consideration in New York, this writer’s state.

The slippery slope of physician-assisted death is one where a fear exists that society may take advantage of the terminally ill, urging them toward their demise under a false compassion that such a final act is the best way to ease their suffering. On the other hand, physician-assisted death is arguably a patient’s true expression of autonomy: The dying patient decides when to die rather than wait for nature to determine when their life ends. Should the law permit everyone the autonomy to have this choice? Or, should the law protect individuals from being able to make this decision?

The Risk of Coercion

If PAD were to become the acceptable norm in every state, what is to prevent familial or physician coercion? PAD arguably raises the potential for coercion by friends, family members, or even the patient’s physician, any of whom may urge the dying patient to choose PAD to end prolonged, burdensome, and expensive care. The sick patient may feel compelled to ease the burden of friends and family members caring for him or her. The weak and marginalized in society may be encouraged to choose an early death rather than palliative care. Insurance companies could conceivably propel patients toward PAD as a cheaper alternative to prolonged and fruitless medical care.

In many cases, patients requesting PAD may really be seeking the doctor’s help to relieve suffering. All options to manage pain should be explored by both the patient and the treating physician before exploring PAD. All physicians must work with their patients to provide appropriate palliative care to ease suffering. The patient receiving good pain relief may opt to continue living, more able to enjoy their life.

Violation of the Hippocratic Oath

The physician opposed to PAD can honestly defend this position and argue that PAD is against the Hippocratic oath: “I will neither give a deadly drug to anybody who asked for it . . ..” To request a physician to prescribe medication that will end the patient’s life if taken as prescribed requires the doctor to betray the oath. Additionally, physicians cannot ignore the opinion of the American Medical Association, which has unequivocally stated that PAD is a violation of the physician’s duty to preserve life. (AMA Opinion 2.211 Physician Assisted Suicide.) The very profession of medicine exists to save people, not to help them die. PAD is arguably the very antithesis of medical beneficence.

Physicians in Favor of PAD

The physicians in favor of PAD will argue that this final “treatment” makes them a true hero to their patients. They may even try to argue that they are treating the patient with complete respect for patient autonomy, recognizing an individual’s right of self-determination. With PAD, a terminally ill individual can exercise the right to life by choosing their own death. PAD allows the patient to die when and how they choose, before they are completely robbed of dignity and self-worth. Those who support physician-assisted death will argue that even if the individual chooses not to take the lethal prescription, this power to end life in a dignified manner, at the time and place of one’s own choosing, is true autonomy.

Other issues to consider regarding PAD in venues where the practice is legal include whether PAD should be part of a patient’s advanced directives. Even if a patient’s state of residence has legalized PAD, there is no guarantee that the patient will be able to find a physician willing to prescribe this “treatment” or a pharmacy willing to dispense the medication as part of the end-of-life option. Assisted dying is a low-frequency but high-risk procedure, and the health professions must treat it as such. The legalization of PAD may require specialists to address patient requests for end-of-life assistance. A specialist can provide both counseling, support, and—when chosen—the prescription for assisting the patient to die.

End-of-Life Statutes

The common theme in the end-of-life statutes is a requirement that death be imminent: it is expected to occur within 6 months or less. The statutes generally require that the patient (1) is 18 or older, (2) files more than one request (oral and written), (3) is competent at the time of the request, (4) is able to self-administer the medication, and (5) is a resident of a state with the end-of-life option. These laws clarify that the end-of-life option is not a suicide, and cause of death listed will be the patient’s disease at the time of death.

The end-of-life laws are completely voluntary and are carried out by the patient once the statutory qualifications have been met and a physician has prescribed the medication. The choice remains the patient’s on whether to proceed. The patient is not required by law to go ahead with hastening death simply because they have qualified and actually obtained the prescribed medication. This choice remains the ultimate exercise in patient autonomy.

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By Louise Derevlany

Louise Derevlany is the associate executive director of risk management at NYC Health + Hospitals/Elmhurst in New York. She is certified in bioethics and medical humanities and was previously in private practice, focusing her practice on health care defense, product liability defense, and medical malpractice defense. She may be reached at laderevlany@gmail.com. This article does not reflect the views of the NYC Health + Hospitals.