Psychological Perspective on Assisted Suicide

One of the most hotly debated topics going on now is the one concerning the ethics of assisted suicide and euthanasia. Nowadays with all the progress that the medical profession has gained, people who are terminally ill have more options, and there have been continued efforts to give them the â€Å"right to die† when they choose this option. I was interested in researching this topic because I think the debate has a lot to do with psychology, which I am very interested in. This dilemna has been hotly debated and I was open to seeing how this movement was progressing. Basically, in the beginning I was a proponent on this issue, and believed people should not be denied their wishes when they wanted to end their pain. However, I was open to learning more about the opposite stance and what the reasons for opposition were. It always seemed unusual to me that suicide was not illegal, but yet it was illegal to assist in one even with a consenting party. I wondered how this could be, and how people could deny people this right in unending pain. There never seems to be a prosecution of doctors who participate in these acts, even though they frequently go to court. I wondered why this occured and what the laws really said regarding this. I also wondered how people distinguished between forgoing medical interventions and actually assisting in the suicide. As I approached the research, my main questions were regarding opposers. I really did not know all the problems that could occur. Research about this brought to light many things that are not discussed in the media, although this is a highly publicized subject. I found that it is very difficult to bring the debate to an end because all the arguments are really just matters of opinion. Opposers and protestors have good arguments. No one really knows what would happen, so they just use opinions to predict it. Because of all the media attention, I will try not to discuss the many things that are already known. I found myself intrigued at what I didn't know, and found my views profoundly affected. After reading current articles about what was going on legally and about cases, reviewing the history of this topic, and reading books showing the two opposing viewpoints, I have made my conclusions. I will show how people are currently handling this and how they are being viewed. I will discuss the main arguments on both sides. Finally, I will show what I concluded from this and how my views have been altered by information that I did not know before. I will begin by explaining how the terms are defined. Euthanasia is taken from Greek roots and means â€Å"good death. â€Å"3 Active euthanasia is a direct and deliberate intervention to kill the patient. It is â€Å"intended to end the life of the competent, terminally ill patient who makes a fully voluntary and persistent request for aid in dying. â€Å"8 Voluntary euthanasia is when the patient requests the action, and it is involuntary if the patient is not mentally competent enough to make the right choice. Passive euthanasia is witholding treatment from a patient. A physician assisted suicide is when the patient does the actual act, but the physician provides either enough information or the means to do it. 8 One source defines it as a â€Å"desperate measure, justified only in exceptional cases where every effort has first been made to care for a dying person by other means. â€Å"4 The terms euthanasia and physician-assisted suicide are usually used for the same thing and are not usually distinguished from one another. Usually the means of suicide is lethal doses of a poison such as pills, an injection, or gas. Motive causes euthanasia to be distinguished from murder, because its intent is merciful and is done out of kindness. The physician's intentions can make considerable difference in regard to how their act will be classified. The most common reason for a patient to want this aid is because of a terminal illness. Unbearable suffering has caused the person to become intolerant of the physical and/or emotional pain. The other reason is a physical handicap that is debilitating and the patient would rather die than live with it. Most people are able to cope with this, but in some cases it is impossible for the patient to do so. In ancient times, euthanasia was encountered often. However, suicide was condemned. During the sixteenth century, some people began to see it as more of a personal choice. It eventually became decriminalized, but assisted suicide and euthanasia are still crimes in most countries. 3 The introduction of powerful analgesics caused a rise in the interest in the â€Å"right to die† movement. It was advocated in the late 1800's, and has been a topic for debate since the early 1900's. Doctors have been helping patients die for centuries. Some cultures today have people that will stop eating and wait to die when they become seriously ill. 13 The â€Å"right to die movement† is encouraged by several factors. Modern technology has come along so as to extend human life. The fear of the dying process is of great concern to some people, especially when it accompanies physical and psychological suffering. Patients are becoming more in charge of their own fate and have more of a voice. Finally, there is concerns about the high health care costs. They cost more than 60 billion annually, and 1/3 of Medicaid payments go to patients in their last year of life. 13 Medicine's main goal has always been the preservation of life. Now, this is being challenged in an attempt to change it. The two sides of the issue are being debated. On one side are the people who think it is not a physicians place to kill a patient, because he/she should only help, not harm. The opposition thinks that suffering is the real harm. The debate comes at the point of the onset of the terminal illness, when it will be time to decide on the means. This is sometimes called the â€Å"Kevorkian moment. â€Å"2 Proponents give examples of people who could be helped, while opponents give counterexamples of people who may be harmed. There are many moral and legal considerations. The support for a physician's participation is increasing. According to opinion polls, about 60% of people in the U. S. are supporters. About 15% of physicians practice it when it is justified. 7 It is actually impossible to know for sure how much takes place because incidents are usually kept secret to avoid prosecution. Most people who have reported that they would consider it give reasons such as that they would not want to be a burden, would not want to live in pain, or would not want to depend on machines or others. The main argument for the support of euthanasia and physician-assisted suicide is that people should have the right to control their life and death, and should be able to end their lives when they wish if they are suffering needlessly. It is argued that it is a private choice and society has no right to be concerned. They usually portray it as a case of individual liberty. One source states that â€Å"euthanasia, if legalized, would be the ultimate civil liberty, since it would secure the freedom to determine and to control our own death. â€Å"8 Physicians must then decide if they are willing to take part in either directly killing the patient or by assisting the patient in suicide. The physician should follow the demands of the patient, even if it means killing them, because that would respect their wishes and the rights of the patient. Physicians treat patients with the purpose of restoring health. If the patient can't be restored to a reasonable level of living, it shouldn't be wrong to discontinue it. Euthanasia supporters often try to get sympathy by relating stories to make one feel like suicide is the only option in their case. The media has sparked a lot of interest, and continues to show stories like this. Simi Linton, psychologist, says, â€Å"I'm disturbed at how the media treats it, as: here are these poor folks; let's help them end their lives† (qtd. in 1). It makes it seem as if would be inhumane to deny anyone this option. Basically, it is the quality of life that is the main concern of the patient. They may feel that life is not worth living in their state. It would not be humane to insist that every means be taken to keep someone alive. A physician's main concern is to relieve suffering, so sometimes there is only one way to achieve that goal. At the time that efforts are no longer doing any good, the main concern is to make the patient comfortable and alleviate symptoms such as pain. 6 Drugs do not always get rid of all the pain, especially when it is excruciating. Sometimes a patient will be drugged into unconciousness with severe pain that cannot be controlled. 9 This does not seem like effective pain management to me. I don't believe people will be satisfied living in such a state as that. They would want to be put out of their misery. Legalization would cause many changes. It would give rights to the person who does it, rather than the person who dies. It is about the right to kill, rather than the right to die. 9 Physicians would need to be trained in more areas regarding this, such as information about medications and dosage, and about the mentality of the patient. They will need to gain expertise in understanding patients' motivations for requesting it, assessing their mental status, diagnosing and treating depression. The medical profession is developing greater expertise in managing terminal illness but would need to develop similar expertise in responding to requests for physician-assisted suicide. The debates over assisted suicide have forced clinicians to be more aware of what can be done to relieve suffering. Doctors are improving pallitive care and their own behavior. Patients are becoming more aware of their options. The problems associated with legalizing assisted suicide are usually not talked about when the proponents make their argument. The discussion of the potential for abuse, the ways it could be prevented or better helped are put on a backburner. The main argument against legaliziation is that human life is sacred, and it is not a human right to take it away. Some say that there is no need for suicide, because health care should resolve all problems and pain management has come a long way. Most people who commit suicide suffer from depression, so it is often debated whether this could be the reason for someone wanting assisted suicide. Often, when their depression is treated, the patient responds well, and would like to live. A regular physician cannot make the determination of whether a patient is suffering from depression. This is something that is difficult to diagnose in terminally ill patients. Just because a patient requests suicide, doesn't mean this will be an appropriate solution. Sometimes, a patient may even request suicide, but when the time draws near, they change their mind because it did not seem so imminent before. The will to request the suicide must be voluntary, but this decision is left up to the physician. How can a physician judge whether it is voluntary or not? It is also difficult to determine what terminal is. When people say that it should be reserved for people who are terminally ill, they cannot define it. It is used to mean someone whose death will occur in a relatively short time. Some people may say that if they will die in 6 months it is considered terminal, but it is difficult to determine exactly how long someone has to live. They may live much longer than that. A person could also be terminal who is in a vegitative state, but will live for years in that state with continued medicine. People cannot reach an agreement on what the definition of terminal would be, some even say old age is terminal. Marianne Smith, Program Development Director of the Death with Dying National Center defines it as â€Å"an illness in which there is no chance of recovery and that death is imminent. â€Å"15 Activists of euthanasia use the demonstration that suicide is the only means to control unbearable pain. Most pain is supposed to be able to be eliminated, or greatly reduced. Many people do not get enough pain control. 6 One reason is the underknowlege many physicians have about this, and that they are afraid the patient will become addicted. Also, too much pain medication can cause symptoms that may be worse than the disease was itself. One source says that â€Å"patients and physicians alike may be unaware of the options available in the medical system, including advances in pain control that could help patients but are not routinely provided. â€Å"3 There may be no solution to these problems, but some things can be done. Better health care education, more access to health care, and informing patients of their rights. 6 Everyone has the right to pain relief. Patients should get adequate health care, and not killed. Physicians argue that if good care of the dying is being provided, then a request for suicide would be rare. 4 Some patients may want to consider suicide, but are incapable of administering medicine. Some people may also lose their mental capabilities, and will be unable to request it. It is difficult to assess fairness in cases like these. Some people use a form of advance directive and make their request before deterioration occurs. It is hard to extend the same rights to all patients without causing abuse. If someone is unable to communicate their request, it would be frightening for someone to make that decision for them and to say that their life is not worth living, so we must kill them. There is great potential for abuse if it were to be legalized. Depressed people, elderly, and very frightened people would be greatly affected. People may feel pressured into giving up. Elderly are especially vulnerable to this. Now that there are more people living longer, this problem will increase. They may tend to feel they are a burden on their families, or are selfishly consuming resources. If a physician advocates it, they also may be swayed. People may also feel distrustful of the physician's advice. This may cause a hardship in getting appropriate care. 10 Legalization will only encourage more people to take part in it. It does not seem as if we would be ready for this to occur, because we are only just beginning to explore some realms of the medical world. It took a long time to figure out about adequate care for many patients and when is the right time to withdraw life support, so it would not seem that we would be ready for this step. The â€Å"slippery slope† argument is used by opponents, saying that legalization will lead to involuntary euthanasia. My own opinion is that if assisted suicide were legalized, we may not be as inclined to advance medical progress and knowlege. It would seem easier to just put the patient out of his/her misery. They may not use their experience to increase what we know about medicine and learn how to help the illness, or better cope with it. Proponents have said that euthanasia should be considered â€Å"medical treatment. † If this is so, there could be great potential for abuse. Then it may be more likely to be administered to people who cannot make the request. Some decisions that have gone to court say that assisted suicide is a constitutional right and that someone else can make the decision for the patient. If direct killing can be legalized by someone else, someone who is not competent could be euthanized without ever expressing that wish. It seems to be inevitable that patient are going to be killed without permission if legalization occurs, even with rules about consent. The main argument of how abuse of the practice could occur is called the â€Å"slippery slope argument. † It says that â€Å"even if particular acts of killing are sometimes morally justified with particularly pain-ridden patients, sanctioning practices of killing would run serious social risks of abuse, misuse and neglect. 3 The bad consequences of legalization would occur over time as this practice became more used. Another potential form of abuse lies in the fact that it would be cheaper to euthanize a patient than to continue medical treatment. It is thought that it could become a means of health care cost containment. Some of the main supporters of euthanasia are people concerned about lowering health care costs. 6 Religion has caused many people to debate it. Most churches are adamantly opposed to the idea of suicide. However, some Christians believe that God would not want them to suffer. 9 Although most religions and churches disagree with intentionally killing a patient, many people who hold this stand will allow the withdrawal of life support. It is believed that there is a difference between killing and letting die. Someone who is against euthanasia may agree with letting someone die who is being kept alive solely by life support that is not really helping them. 3 People feel that the intent in these cases is different. The more accepted approach does not involve killing. One interpretation of the difference shows that the intent is different because actively killing is aiming at death, and withdrawing support simply accepts that we are limited to help the dying and cannot reverse the process. 8 However, some peole believe that since death is the outcome no matter what, there is no moral difference between them. Another matter of intent distiction regards what is called the â€Å"double effect. † A physician will administer a pain medication to relieve pain, but knows that it may cause death. The patient would be in pain without it, but it may cause death if it is administered. It is usually believed to be moral if the doctor's intent is to relieve the suffering, and not to cause death. It is allowed if the death is foreseen but not intended, because it is the intent that makes it wrong. Although suicide is no longer a crime, giving assistance in it is, everywhere except for Switzerland, Germany, Norway, and Uraguay. In Australia, a law was passed that allows terminally ill patients to ask for assistance by injection or taking drugs themselves. 7 There is a debate about it because Parliament wants to overturn the statute, which is the world's only voluntary euthanasia statute. In the Netherlands, it is actually a crime, but it has been ruled that physicians may assist in death under certain conditions. Some of these are that the patient must be ruled competent, and two doctors must conclude that the patient has less than 6 months to live. 8 The United States has used them as an example to see what would happen if it were to occur here. They are having problems with it, mainly with abuse. The physicians there have reported that the main reasons people request it are â€Å"low quality of life, the relatives, inability to cope, and no prospect for improvement. Some sources show that people are requesting it for physical symptoms that it is almost ridiculou that they would go to such an extreme measure for. I think that the potential for abuse here may be great, because it is getting out of hand over there. People are becoming afraid to go to hospitals because euthanasia is becoming so commonplace. It now accounts for 15% of deaths. 1000 unconsenting deaths occur each year. 1. In 1994, the state of Oregon passed a ballot that gives limited physician-assisted suicide legality. This makes it the first in the nation to do so. A doctor must determine the patient has less than six months to live. A second doctor must decide that they are mentally competent and not suffering from depression. The patient must request it in writing with two witnesses, and then 48 hours before the doctor delivers the prescription the request must be repeated orally. 1 It must be a voluntary act. However, those jugements are left to the physician. So far, it has never been put into action. Other states are considering similar legislation, such as California which has proposed a law that is similar to the guidelines that the Dutch have adopted. Lawsuits in Washington State and New York were ruled by the 9th and 2nd U. S. Circuit Courts of Appeals that laws prohibiting physician-assisted suicide are unconstitutional. The legal fate will be determined by the Supreme Court. In 1990, the decision of Cruzan v. Missouri Department of Health resulted in people having the right to avoid unwanted medical treatment, including food and water. 5 It recognized the right to terminate unwanted medical treatment even when death would be the result. 14 People often use the Constitution as a basis for argument. The 14th amendment prohibits the state from depriving â€Å"any person of life, liberty, or property without due process of law. † So to deny a dying patient medical assistance when requested is to â€Å"threaten this patient's request for help is judged denial of constitutionally protected due process. â€Å"4 As the courts were in session to hear a case about whether terminally ill people have a constitutional right to physician assisted suicide, demonstrators sang and picketed outside a Supreme Court building. The emotions of the rights issue has been compared to that of abortion. Both of these issues dig into whether we have the right to choose such personal issues. People can feel very strongly about the issues of mercy killing, whether they oppose or support it. The lack of laws cause people to avoid prosecution for assisting in a suicide. Kevorkian has escaped prosecution because there is not a state law prohibiting it, according to a Michigan judge. 9 People are afraid that activities such as his would become widespread if assisted suicide were legalized. His actions have been opposed not because of the assistance, but because he had no real relationship with his patients and had not given them any kind of clinical evaluation. Many were also not terminally ill. 3 It seems to show what is lacking in the medical sysytem, or what could become of it. Every case of assisted suicide is not convicted or prosecuted, even in states that make it illegal. However, the fact that there are many landmark â€Å"right to die† cases, shows that the law is commited to the prohibition. However, the procedures are not described as killing. If this were the case, the act would have to be justified similar to killing someone out of self defense. 4 It is hard to define the conditions that there must be in order to make it legal, because there is so much that we do not know. For euthanasia to be ethical, there must be certain guidelines. The person must be a mature adult, and has been shown to be mentally competent and willing to make the decision. Some medical help will have already been given, and it should seem that the fight is hopeless. 9 Many organizations have beliefs on this and they try to educate the public on euthanasia and what their views are. I contacted Marianne Smith, the Program Development Director of the Death with Dignity National Center. 15 She explained to me in e-mail how the organization feels about euthanasia and what they do to educate the public about it. The organization is working toward better health care for paients. She feels that assisted suicide should be legal, but that â€Å"physician-assisted dying should be the response of last resort,† and â€Å"when all other options fail to relieve unbearable suffering, when the patient is acting on his or her own initiative, is not clinically depressed, and is capable of administering the medication personally. The people who could be elgible are â€Å"only terminally ill, competent adults with decisionmanking capacity. † I also asked whether euthanasia could be avoided with adequate pain medicine. Her response was that â€Å"Physicians, medical associations and hospices all have stated that not all pain can be controlled. † Their view, which is one I encountered a lot, is that the medical professionals have not been trained adequately in pain management. Regarding the issues of potential â€Å"slippery slope† abuse, she says that physician's aid in dying is more common than people realize, and legalization would just make it happen openly, instead of secretly. However, the state regulation should provide strict guidelines and penalties for violations. I think that it is hard to make sure that the decisions are correct, so it should be carefully thought out. We are dealing with a very serious issue, which is death. It should not be an easy decision to make or to carry out. Becaue death is the consequence, the decision to kill oneself, and carrying it out should be very difficult and carefully thought out. This would help ensure that people have thought about it enough and know that this is the best decision. I don't know how a solution can be thought of to deal with the debate, but things such as more health care education and informing patients of their rights should be a consideration. I hope that if legalization ever were to take place, that they would carefully restrict who qualified for euthanasia. After all my research, most of my questions have been answered. It is difficult to come to a conclusion because there is no right or wrong answer. I don't know how anyone can determine what should be done. Who can put a price on life and say who has the right to die? The basic choice is whether to let doctors help people die, and if so, how? I have found many great arguments either opposing or protesting this issue, which has led me to my final conclusions. When I began this paper, I dived into it thinking that I was going to condone the idea of assisted suicide. I knew I could convince someone that it should be the moral and legal thing to do. I could not imagine a life without the ultimate choice or having to endure great suffering. I was going to defend this side, but also show the opposing side. Once I got into the research, I found many facts that I had not known before about why it has not yet been legalized. Many questions and opinions showed me that there were many things I had not even bothered to think about before. What a surprise to me that I could begin a project as a supporter, and then turn around my views. I now see where the opposers are coming from. There are just too many problems and considerations to think about before this could ever happen, and there are alternate solutions. I cannot say that this has given me a complete turn in the opposite direction, but I am definitely leaning toward the opposing side except in extreme circumstances when nothing could ever help the patient.