Select header/footer to go to
Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
1x Speed
2x Speed
11. Death with Dignity - Assisted Dying
Select Button
A physician [medical practitioner] is obligated to consider more than a diseased organ, more even than the whole patient - the physician [medical practitioner] must view the patient within the patient’s world.
~ Harvey Cushing
Dignity's Demise
The Ethics of Death with Dignity and Assisted Dying
Detective Jane was standing at the entrance of the hospital, deep in thought. She had been called to investigate a case that involved a death with dignity or assisted dying, as it was commonly known. The victim was Dr. Mark, a well-respected physician who had been practicing medicine for over 30 years. He had been found dead in his office, with a note that read “I have taken the final step towards my death with dignity.”
The case was complicated, as Dr. Mark had been an outspoken opponent of death with dignity laws. However, his patients knew him as a compassionate physician who always put their needs first. Detective Jane knew that the key to solving this case was to understand the ethical implications of death with dignity.
Detective Jane found out that Dr. Mark had a patient named Sarah, who had been diagnosed with a terminal illness. Sarah had asked Dr. Mark for help in ending her life, and he had refused, citing his ethical obligations as a physician. However, Sarah had eventually found a way to obtain the lethal medication and had ended her life. Detective Jane wondered if Dr. Mark’s involvement in Sarah’s case had led him to reconsider his stance on death with dignity.
Next, she looked into the laws in the state where Dr. Mark practiced. She found out that death with dignity was legal, but practitioners were not required to participate in the process. However, if a practitioner did choose to participate, they had to adhere to strict guidelines to ensure that the patient’s autonomy was respected, and the practitioner did no harm.
Detective Jane then spoke to Dr. Mark’s colleagues and patients. They all spoke highly of him, describing him as a compassionate physician who always put his patients first. However, some of his colleagues also mentioned that he had been struggling with the ethical implications of death with dignity, especially after Sarah’s case.
Finally, Detective Jane spoke to Dr. Mark’s family. They were shocked by his death, as they had no idea that he was considering death with dignity. They described him as a devoted husband and father, who was always committed to his work as a physician.
After weeks of investigation, Detective Jane concluded that Dr. Mark’s involvement in Sarah’s case had led him to reconsider his stance on death with dignity. He had decided to end his life on his own terms, but he had also left behind a note urging other physicians to consider the ethical implications of death with dignity carefully. The case had highlighted the complexity of the issue and the importance of respecting patients’ autonomy while ensuring that practitioners do not harm their patients.
As Detective Jane closed the case, she reflected on the words of Harvey Cushing, who had said that a physician must view the patient within the patient’s world. She realized that death with dignity was not just about medicine, but also about the patient’s values, beliefs, and priorities. It was a reminder that as healthcare providers, they must always consider the whole patient, not just their disease or condition.
Abstract
“Death with Dignity” laws, are legal in 11 jurisdictions in the US and allow individuals to make end-of-life decisions. The central issue surrounding these laws is whether or not practitioner participation in assisted dying is compatible with the medical profession’s code of ethics, core tenets, and patient trust. The American Medical Association (AMA) and American College of Physicians (ACP) do not directly address this issue in their codes of ethics. The AMA considers euthanasia, which is the direct causation of death by a practitioner, to be fundamentally incompatible with the physician’s role as a healer. However, death with dignity, which involves the patient self-administering lethal medication with a prescription, is argued to be different. The ACP prohibits cruel or unusual punishment, but if the patient’s autonomous choice, the practitioner’s best interests, and state laws are satisfied, there may be no harm to the patient-practitioner relationship or social trust in the medical profession. The question is raised as to whether medicine should only be a healing art or if the art of dying should also be part of medical practice. There is also the question of public policy and the potential effect on the patient-practitioner relationship and social trust in the medical profession if death with dignity laws are enacted.
**
Think
[11:1] Death with dignity laws, also known as ‘assisted-dying’ or ‘aid-in-dying,’ are based on the individual principle of autonomy (informed consent), in which it is believed that it is the patient who should make end-of-life decisions. Death with dignity is legal in eleven jurisdictions: California, Colorado, District of Columbia, Hawaii, Montana, Maine, New Jersey, New Mexico, Oregon, Vermont, and Washington. However, just because some action is legally permissible for a medical practitioner to participate in does not necessarily mean that the practitioner must or is obligated to participate in that action.
Assess
Patient: 1) Autonomy
[11:2] There is no contesting that there are many competent patients or persons, not necessarily patients at the time of request with full decisional capacity, who are autonomously asking for medical assistance in the planning and control of their death, and no one contests the legality of states to make such actions permissible as a social attempt to help actualize the fair distribution of benefits and burdens for the patient as a matter of justice (be fair).
Practitioner: 2) Beneficence & 3) Nonmaleficence
[11:3] The central issue concerning the death with dignity laws or practitioner-assisted dying topic is whether or not such participation by the practitioner is compatible with:
- 1. the medical profession’s code of ethics,
- 2. the core tenets of the medical profession, and
- 3. the promotion of patient trust in the medical profession.
[11:4] Starting with the question of compatibility with the medical profession’s code of ethics. Currently, no entries in the American Medical Association (AMA) Code of Medical Ethics or the American College of Physicians (ACP) directly address death with dignity or practitioner-assisted suicide. The closest reference to the ethical issues related to this topic is euthanasia and capital punishment.
[11:5] The American Medical Association (AMA) Code of Medical Ethics 5.8 defines euthanasia as:
The administration of a lethal agent by another person to a patient for the purpose of relieving the patient’s intolerable and incurable suffering.
[11:6] Euthanasia refers to the deliberate and direct causation of death by a practitioner, and the American Medical Association (AMA) continues to say in 5.8:
Permitting physicians [practitioners] to engage in euthanasia would ultimately cause more harm than good. Euthanasia is fundamentally incompatible with the physician’s [practitioner’s] role as healer.
[11:7] However, death with dignity, or practitioner-assisted suicide, is argued to be significantly different from euthanasia. Death with dignity only refers to giving a patient a prescription of lethal medication to be voluntarily self-administered by the patient, not to be administered by the practitioner.
[11:8] The American College of Physicians (ACP) prohibits practitioners from engaging in cruel or unusual punishment such as capital punishment or other types of disciplinary activities beyond those permitted by the United Nations Standard Minimum Rules for the Treatment of Prisoners.
[11:9] What is difficult in death with dignity is that if the patient is autonomously choosing to have practitioner assistance in death, in accordance with their reasonable goals, values, and priorities—autonomy (informed consent), and if under the principles of beneficence (do good) and nonmaleficence (do no harm) the practitioner determines that assistance in death would be in accordance with the core professional tenets of the patient’s best interests as determined by the patient’s reasonable goals, values, and priorities and if the patient and practitioner are in a state of jurisdiction in which death with dignity is legally permissible (justice—be fair), then all four principles of autonomy (informed consent), beneficence (do good), nonmaleficence (do no harm), and justice (be fair) would have been satisfied making it morally permissible for practitioner participation in the giving to a patient a lethal prescription to be self-administered by the patient.
[11:10] There is a 100% certainty that everyone alive will die. Of that 100%, 60% of Americans will die in acute care hospitals, and 20% will die in nursing homes, all under the care of a practitioner.
[11:11] The question arises: is death with dignity
fundamentally incompatible with the physician’s [practitioner’s] role as healer? (AMA 5.8)
[11:12] Is medicine only a healing art, or should the art of dying also be part of medical practice? Some will argue that the problem is that of the medical-provider’s deadly intent and that the ensuing negative professional reputation could result in irreparable harm to the social perception of the professional function and role of the medical profession as a healing art.
Public Policy: 4) Justice
[11:13] With public policy, the issue is whether or not practitioner-assisted death would harm the patient-practitioner relationship and decrease the social trust of the medical profession. Logically, if no violations are being made concerning the patient’s autonomous choices (informed consent), and if the practitioner is only engaged in patient-centered practices that maximize the patient’s best interests in accordance with beneficence (do good) and nonmaleficence (do no harm), and if these practices are consistent with state laws that have been enacted through the process of democratic representation of the people—justice (be fair) then it reasonably follows that there would be no adverse effect on the patient-practitioner relationship or social trust of the medical profession for the practitioner to participate in death with dignity where it is legal to do so.
Conclude
[11:14] Death with dignity or practitioner-assisted suicide is state-dependent. If the participation by the health care professional is not compatible with:
- 1. the medical profession’s code of ethics of nonmaleficence (do no harm),
- 2. the core tenets of the medical profession being a healing profession, and
- 3. the promotion of patient trust that the medical profession will only pursue life,
then that would be a sufficient argument to oppose being complicit in activities that do not promote the medical profession’s goals, values, and priorities.
[11:15] In summary, the topic of death with dignity and practitioner-assisted suicide is complex and state-dependent. If practitioner participation in assisted dying does not align with the medical profession’s code of ethics, core tenets, and the promotion of patient trust, then there is a sufficient argument to oppose such activities. However, if these practices are consistent with state laws and do not adversely affect the patient-practitioner relationship or social trust in the medical profession, it may be considered morally permissible for practitioners to participate in death with dignity where it is legal to do so.
(See also: 5. Assisted Suicide, 6. Capital Punishment - Executions, 17. Euthanasia, 27. Interrogations, and 58. Torture)
**
11. Review Questions
1. Death with dignity laws are based on the practitioner’s professional obligation to help the patient make end-of-life decisions.
2. Which of the following are the central issues concerning the death with dignity laws:
3. There are no entries in the American Medical Association (AMA) or the American College of Physicians (ACP) on the topic of Death with Dignity.
4. Death with dignity only refers to giving a patient a prescription of lethal medication to be voluntarily self-administered by the patient, not administered by the practitioner:
**
CORRECT! 🙂
[11:1] Death with dignity laws, also known as practitioner-assisted dying or “aid in dying,” is based on the individual principle of autonomy (informed consent), in which it is believed that it is the patient who should make end-of-life decisions. Death with dignity is legal in eleven jurisdictions: California, Colorado, District of Columbia, Hawaii, Montana, Maine, New Jersey, New Mexico, Oregon, Vermont, and Washington. However, just because some action is legally permissible for a practitioner to participate in does not necessarily mean that the practitioner must or is obligated to participate in that action.
Wrong 😕
[11:1] Death with dignity laws, also known as practitioner-assisted dying or “aid in dying,” is based on the individual principle of autonomy (informed consent), in which it is believed that it is the patient who should make end-of-life decisions. Death with dignity is legal in eleven jurisdictions: California, Colorado, District of Columbia, Hawaii, Montana, Maine, New Jersey, New Mexico, Oregon, Vermont, and Washington. However, just because some action is legally permissible for a practitioner to participate in does not necessarily mean that the practitioner must or is obligated to participate in that action.
CORRECT! 🙂
[11:3] The central issue concerning the death with dignity laws or practitioner-assisted dying topic is whether or not such participation by the practitioner is compatible with:
1. the medical profession’s code of ethics,
2. the core tenets of the medical profession,
3. the promotion of patient trust in the medical profession.
Wrong 😕
[11:3] The central issue concerning the death with dignity laws or practitioner-assisted dying topic is whether or not such participation by the practitioner is compatible with:
1. the medical profession’s code of ethics,
2. the core tenets of the medical profession,
3. the promotion of patient trust in the medical profession.
CORRECT! 🙂
[11:4] Starting with the question of compatibility with the medical profession’s code of ethics. Currently, no entries in the American Medical Association (AMA) Code of Medical Ethics or the American College of Physicians (ACP) directly address death with dignity or practitioner-assisted suicide. The closest reference to the ethical issues related to this topic is euthanasia and capital punishment.
Wrong 😕
[11:4] Starting with the question of compatibility with the medical profession’s code of ethics. Currently, no entries in the American Medical Association (AMA) Code of Medical Ethics or the American College of Physicians (ACP) directly address death with dignity or practitioner-assisted suicide. The closest reference to the ethical issues related to this topic is euthanasia and capital punishment.
CORRECT! 🙂
[11:7] However, death with dignity, or practitioner-assisted suicide, is argued to be significantly different from euthanasia. Death with dignity only refers to giving a patient a prescription of lethal medication to be voluntarily self-administered by the patient, not administered by the practitioner.
Wrong 😕
[11:7] However, death with dignity, or practitioner-assisted suicide, is argued to be significantly different from euthanasia. Death with dignity only refers to giving a patient a prescription of lethal medication to be voluntarily self-administered by the patient, not administered by the practitioner.
11. Clinical Vignettes
1. Mr. Emery Wright, an 82-year-old retiree is diagnosed with a terminal illness and expresses a desire to end their life peacefully. They have read about death with dignity laws and have asked their practitioner about the possibility of this option. The patient lives in a state where death with dignity is legal. What is the fundamental belief of death with dignity laws?
2. Ms. Athena Adams, a 79-year-old retiree is terminally ill patient has requested assistance in ending their life. The patient's practitioner is faced with the decision of whether to comply with the request or not. The practitioner is concerned that complying with the request would violate the medical profession's code of ethics, the core tenets of the medical profession, and the promotion of patient trust.
3. Mr. Abel Nelson, an 81-year-old retiree has requested assistance in ending their life due to a terminal illness. The patient's practitioner is unsure about the ethical guidance provided by the American Medical Association (AMA) Code of Medical Ethics and the American College of Physicians (ACP) regarding this matter.
4. Ms. Jessica Hassan, an 86-year-old retiree has been diagnosed with a terminal illness and has a prognosis of only a few months to live. They express to their practitioner that they would like to have control over the manner and timing of their death. The patient asks about the option of "death with dignity.” What is the correct definition of "death with dignity"?
5. Mr. Nathanael King, a 42-year-old sound engineer comes to a practitioner to request treatment. However, the treatment being asked for by the patient goes against the medical profession's code of ethics of nonmaleficence and the core tenets of being a healing profession. Additionally, the treatment would also negatively impact society's trust in the medical profession. Given this information, which of the following statements would be the most appropriate course of action for the practitioner to take?
Wrong 😕
Explanation: The fundamental belief of death with dignity laws is that it is the patient who should be making end-of-life decisions [11:2]. Death with dignity laws, also known as practitioner-assisted dying or aid-in-dying laws, allow terminally ill patients to request a prescription for medication that they can self-administer to end their lives peacefully [11:1]. These laws are based on the principle of patient autonomy and the belief that individuals have the right to make decisions about their own healthcare and end-of-life care [11:2]. Practitioners who participate in death with dignity laws are typically required to provide patients with information about their diagnosis, prognosis, treatment options, and the potential risks and benefits of the lethal medication [11:1]. They are also required to ensure that patients are mentally competent and have made an informed decision about their end-of-life care [11:9].
CORRECT! 🙂
Explanation: The fundamental belief of death with dignity laws is that it is the patient who should be making end-of-life decisions [11:2]. Death with dignity laws, also known as practitioner-assisted dying or aid-in-dying laws, allow terminally ill patients to request a prescription for medication that they can self-administer to end their lives peacefully [11:1]. These laws are based on the principle of patient autonomy and the belief that individuals have the right to make decisions about their own healthcare and end-of-life care [11:2]. Practitioners who participate in death with dignity laws are typically required to provide patients with information about their diagnosis, prognosis, treatment options, and the potential risks and benefits of the lethal medication [11:1]. They are also required to ensure that patients are mentally competent and have made an informed decision about their end-of-life care [11:9].
CORRECT! 🙂
Explanation: The central issue in this scenario is that death with dignity laws and practitioner-assisted dying are incompatible with the medical profession's code of ethics, the core tenets of the medical profession, and the promotion of patient trust in the medical profession [11:3]. The medical profession has traditionally been focused on the goal of saving lives and preserving health [11:1], and physicians are typically held to high ethical and moral standards in their practice [11:3]. Practitioner-assisted dying, which involves intentionally helping a patient to end their own life, goes against these traditional goals and can raise ethical and moral concerns for practitioners [11:3] [11:6]. Moreover, this can potentially erode the trust patients have in the medical profession, which depends on the belief that practitioners prioritize the patient's best interests and work to promote their well-being [11:3]. While the legality of death with dignity laws and practitioner-assisted dying can vary by state, the central issue in this scenario is not whether it is legal or not [11:2]. Similarly, while complying with a patient's request for assistance in ending their life can lead to feelings of guilt and moral distress for practitioners, this is not the central issue in this scenario [11:3]. Finally, while there may be evidence-based research to support or oppose practitioner-assisted dying, this is not the central issue in this scenario, as the main concern is the ethical and moral implications of the practice for practitioners and the medical profession as a whole [11:3].
Wrong 😕
Explanation: The central issue in this scenario is that death with dignity laws and practitioner-assisted dying are incompatible with the medical profession's code of ethics, the core tenets of the medical profession, and the promotion of patient trust in the medical profession [11:3]. The medical profession has traditionally been focused on the goal of saving lives and preserving health [11:1], and physicians are typically held to high ethical and moral standards in their practice [11:3]. Practitioner-assisted dying, which involves intentionally helping a patient to end their own life, goes against these traditional goals and can raise ethical and moral concerns for practitioners [11:3] [11:6]. Moreover, this can potentially erode the trust patients have in the medical profession, which depends on the belief that practitioners prioritize the patient's best interests and work to promote their well-being [11:3]. While the legality of death with dignity laws and practitioner-assisted dying can vary by state, the central issue in this scenario is not whether it is legal or not [11:2]. Similarly, while complying with a patient's request for assistance in ending their life can lead to feelings of guilt and moral distress for practitioners, this is not the central issue in this scenario [11:3]. Finally, while there may be evidence-based research to support or oppose practitioner-assisted dying, this is not the central issue in this scenario, as the main concern is the ethical and moral implications of the practice for practitioners and the medical profession as a whole [11:3].
CORRECT! 🙂
Explanation: The scenario describes a practitioner who is unsure about the ethical guidance provided by the American Medical Association (AMA) Code of Medical Ethics and the American College of Physicians (ACP) regarding the request of an 81-year-old retiree for assistance in ending their life due to a terminal illness. The correct option is that the AMA and ACP do not directly address death with dignity or practitioner-assisted suicide, but they provide guidance on related issues such as euthanasia and capital punishment [11:4]. This means that the practitioner will need to carefully consider the ethical implications of the situation and consult with other sources to make an informed decision.
Wrong 😕
Explanation: The scenario describes a practitioner who is unsure about the ethical guidance provided by the American Medical Association (AMA) Code of Medical Ethics and the American College of Physicians (ACP) regarding the request of an 81-year-old retiree for assistance in ending their life due to a terminal illness. The correct option is that the AMA and ACP do not directly address death with dignity or practitioner-assisted suicide, but they provide guidance on related issues such as euthanasia and capital punishment [11:4]. This means that the practitioner will need to carefully consider the ethical implications of the situation and consult with other sources to make an informed decision.
CORRECT! 🙂
Explanation: The scenario describes a patient with a terminal illness who expresses a desire to have control over the manner and timing of their death, and asks about the option of "death with dignity". The correct definition of "death with dignity" is giving a patient a prescription for a lethal medication to be voluntarily self-administered by the patient. This is a legal process that allows terminally ill patients to choose the timing and manner of their own death, and is also known as "practitioner-assisted suicide" [11:7]. The options of administering lethal medication to the patient by the practitioner, and the option where the practitioner assists the patient in ending their life through active means, are not considered legal or ethical in most jurisdictions [11:5]. The option of withholding or withdrawing life-sustaining treatment at the request of the patient or surrogate decision-maker, is a separate issue related to end-of-life care, but is not the same as "death with dignity" [11:10].
Wrong 😕
Explanation: The scenario describes a patient with a terminal illness who expresses a desire to have control over the manner and timing of their death, and asks about the option of "death with dignity". The correct definition of "death with dignity" is giving a patient a prescription for a lethal medication to be voluntarily self-administered by the patient. This is a legal process that allows terminally ill patients to choose the timing and manner of their own death, and is also known as "practitioner-assisted suicide" [11:7]. The options of administering lethal medication to the patient by the practitioner, and the option where the practitioner assists the patient in ending their life through active means, are not considered legal or ethical in most jurisdictions [11:5]. The option of withholding or withdrawing life-sustaining treatment at the request of the patient or surrogate decision-maker, is a separate issue related to end-of-life care, but is not the same as "death with dignity" [11:10].
CORRECT! 🙂
Explanation: The scenario describes a situation where a patient requests a treatment that conflicts with the medical profession's code of ethics and the core tenets of being a healing profession.[11:4] [11:8] The most appropriate course of action for the practitioner is to refuse to participate in the treatment, as it goes against the medical profession's goals, values, and priorities. [11:5] This is because the medical profession has a responsibility to prioritize patient well-being and to maintain the trust of society, and participating in a treatment that goes against these principles would be a violation of professional ethics. The option of going ahead with the recommended treatment regardless of the ethical implications is not appropriate because it would violate the core principles of medical ethics. The option of discussing alternative treatment options with the patient may be appropriate in some cases, but not in cases where the requested treatment is clearly unethical. Lastly, seeking guidance from a medical ethics committee may be appropriate in some cases, but the practitioner's first responsibility is to uphold the principles of medical ethics and to refuse to participate in unethical practices.
Wrong 😕
Explanation: The scenario describes a situation where a patient requests a treatment that conflicts with the medical profession's code of ethics and the core tenets of being a healing profession.[11:4] [11:8] The most appropriate course of action for the practitioner is to refuse to participate in the treatment, as it goes against the medical profession's goals, values, and priorities. [11:5] This is because the medical profession has a responsibility to prioritize patient well-being and to maintain the trust of society, and participating in a treatment that goes against these principles would be a violation of professional ethics. The option of going ahead with the recommended treatment regardless of the ethical implications is not appropriate because it would violate the core principles of medical ethics. The option of discussing alternative treatment options with the patient may be appropriate in some cases, but not in cases where the requested treatment is clearly unethical. Lastly, seeking guidance from a medical ethics committee may be appropriate in some cases, but the practitioner's first responsibility is to uphold the principles of medical ethics and to refuse to participate in unethical practices.
**
11. Reflection Vignettes
1. Mr. Michael Johnson was a 70-year-old retired accountant who had been struggling with terminal cancer for the past three years. He had undergone multiple rounds of chemotherapy and radiation therapy, but the cancer had spread to various organs, and his condition had deteriorated rapidly. He was under the care of Dr. Emily White, an attending practitioner who specialized in palliative care. During a routine visit, Mr. Johnson expressed his desire to end his life on his own terms. He said that the pain and discomfort were unbearable, and he did not want to suffer anymore. He requested a prescription for medication that would allow him to end his life peacefully and with dignity. Dr. White listened to Mr. Johnson's concerns carefully and empathetically. She understood that Mr. Johnson was in a great deal of pain and discomfort, and she wanted to provide him with the best possible care. She also recognized that Mr. Johnson was mentally competent and fully informed about his medical condition and prognosis.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
2. Ms. Patricia Brown was a 76-year-old retired librarian who had been under the care of Dr. Rachel Johnson, an attending practitioner who specialized in hospice and palliative care. Ms. Brown had been battling a terminal illness for several years, and her condition had recently worsened, with increasing pain and discomfort. Despite the best efforts of Dr. Johnson and her team, Ms. Brown's symptoms were becoming increasingly difficult to manage. During a visit with Dr. Johnson, Ms. Brown expressed her desire to die with dignity in the presence of her family and friends. She requested a prescription for medication that would allow her to do so. Dr. Johnson recognized that Ms. Brown was of sound mind and had been fully informed about her medical condition and prognosis. Dr. Johnson also knew that Ms. Brown lived in a state where death with dignity was legal.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
***
