End-of-Life Discussion: What are the Roles of Physicians, Governments, and Patients?

by Gabriella Foe 

The discussion around end-of-life issues largely centers on the right of the patient to choose (to refuse life sustaining treatment, or, in some cases, to end his or her life through physician assisted suicide or euthanasia where it has been legalized) or to preserve life through invasive treatment. Patients and physicians may have their own opinions on the matter, but their decisions are limited by the government and the law.

The British Medical Journal (BMJ) recently argued for the legalization of assisted suicide because the ability of a patient to choice is paramount; the editors stated that this was “a matter for Parliament, not doctors to decide.” But do doctors have a say at all, considering they will be the ones who will have to perform the act and take responsibility for their actions? The British Medical Association, Royal College of Physicians and Royal College of GPs all oppose assisted suicide and polls show that most doctors share the same view, Daily Mail reports.

Pew End-of-Life Poll Pew PAS Poll

 

 

While we worry whether patients will be coerced into choosing physician assisted suicide or euthanasia where it has been legalized, we rarely discuss the moral distress that physicians may feel when they are required to actively assist patients in dying. It is true that patients may have a right to exercise choice regarding their own lives, but should it not be limited by the right that physicians have to refuse to participate when it is morally distressing to them? If assisted suicide is legalized in the UK, all physicians will be trained to assist patients in dying.

There is danger in going too far with the notion of patient autonomy. This is not only true for one end of the spectrum—when patients ask for assistance in dying—but also for the other extreme—when patients or their families ask for life sustaining treatment that serve only to delay death. It seems that as we start to request certain procedures on the grounds of patient autonomy, physicians and health care providers willbe viewed as service providers. As a result, healthcare may begin to be reduced to mere business transaction.


Further Reading

“Legalise assisted suicide because ‘choice’ the most important principle in medicine — says BMJ” by John Bingham – The Telegraph, July 3, 2014
http://www.telegraph.co.uk/health/healthnews/10940767/Legalise-assisted-suicide-because-choice-the-most-important-principle-in-medicine-says-BMJ.html

Borland, Sophie, “Doctors’ fears as leading medical journal backs assisted suicide: Editorial says terminally ill must be allowed to ‘call time on their lives’” by Sophie Borland – Daily Mail Online, July 3, 2014
http://www.dailymail.co.uk/health/article-2678619/Doctors-fears-leading-medical-journal-backs-assisted-suicide-Editorial-says-terminally-ill-allowed-call-time-lives.html

Gribbin, Caitlyn, and Owens, Dale, “Euthanasia advocate Philip Nitschke criticised over support for 45-year-old who committed suicide” by Caitlyn Gribbin and Dale Owens – ABC News Australia, July 5, 2014
http://www.abc.net.au/news/2014-07-03/nitschke-criticised-over-45yo-mans-suicide/5570162

One comment

  1. The decision whether to withdraw life sustaining treatment, provide palliation, or request aggressive treatment is distinct from the decision to seek physician assisted suicide. Withdrawing life sustaining treatment is typically made where patients lack capacity due to either illness or injury and their surrogate decides, in light of their dismal prognosis, aggressive care is no longer indicated.
    Palliative medicine seeks to provide comfort care for patients with severe chronic illness contemporaneously with medical treatment. Other times, palliative care may be sought where patients are at the end stages of a serious illness, traditional aggressive medical interventions are no longer indicated and the best possible dying is sought.
    Agressive medical treatment may be provided to a patient where the physician using their knowledge, skill, and training consider the ethical principal of proportionality in deciding whether the treatment sought will provide a benefit, or is outweighed by an extraordinary burden for the patient. Medical treatment that is either not indicated, or extraordinarily burdensome need not be provided to the patient.
    Physician assisted suicide involves a different calculus where the patient is seeking to end their life, possibly due to a terminal illness, or suffering, and the physician is called upon to respect the patient’s autonomy and in so doing, yield their duty of nonmaleficence.
    Respect for autonomy is within the sphere of control of the patient contrasted by the principals of nonmaleficence and beneficence are within the professional sphere of the physician.
    Withdrawing or withholding medical care are morally equivalent because they are seen as allowing the patient to have a natural death. Physician assisted suicide is an active killing which violates professional ethical norms such as, “first do no harm.” Physician assisted suicide is sure to cause moral distress for all physicians who believe actively killing is a moral wrong contrary to their personal and professional ethos. It is also an extremely narrow circumstance where a physician could refuse to act without seeking a proxy. Physicians will be confronted by different circumstances which will cause them some moral distress during their professional career. Allowing them to withdraw from care every time they are confronted with a morally distressing circumstance would create uncertainty as to the norms of the practice of medicine, and as such, should be be narrowly construed. Physician refusal to provide treatment should be limited to circumstances where the proposed act has no benefit, and will only harm the patient. In other words, it is not medically indicated, and therefore, the physician is not obligated to act. Death is best treated with palliation and compassion, not expeditiously bringing about its arrival.

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