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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
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5. Assisted Suicide
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Patients who are being kept alive by technology and want to end their lives already have a recognized constitutional right to stop any and all medical interventions, from respirators to antibiotics. They do not need practitioner-assisted suicide or euthanasia.
~ Ezekiel Emanuel
Ethical Dilemma
The Complexities of Assisted Suicide
Dr. Johnson was a well-respected physician at Mercy Hospital. He had a reputation for being a caring and compassionate doctor, always putting his patients first. One day, a patient named Mr. Smith was admitted to the hospital. Mr. Smith was terminally ill and had expressed a desire to end his life on his own terms.
Dr. Johnson was aware of Mr. Smith’s wishes and had engaged in numerous conversations with him about his options. Although he was hesitant at first, Dr. Johnson ultimately agreed to provide Mr. Smith with the means to end his life.
A few days later, Mr. Smith was found dead in his hospital bed. His family was devastated and demanded an investigation into his death. The hospital administration launched an internal investigation, and Dr. Johnson was suspended pending the outcome.
The investigation revealed that Dr. Johnson had indeed provided Mr. Smith with the means to end his life. However, the hospital’s policy prohibited physician-assisted suicide, and Dr. Johnson was aware of this. He had violated the hospital’s policy and had potentially broken the law.
The case was referred to the medical board, and Dr. Johnson was charged with violating professional standards of practice. He was suspended from practicing medicine and faced a disciplinary hearing.
During the hearing, Dr. Johnson argued that he had acted out of compassion for Mr. Smith and had respected his autonomy. He had believed that he was doing what was best for the patient, even if it meant violating hospital policy.
However, the medical board found Dr. Johnson guilty of violating professional standards of practice. They argued that the medical profession defines itself as a healing art, and the principles of beneficence and nonmaleficence are paramount. Assisted suicide is not part of the medical profession’s standard of care, regardless of whether or not it is legally permissible.
Dr. Johnson’s actions had violated the trust of the public and the hospital, and he had failed to uphold the profession’s foundational principles. He was stripped of his medical license and faced criminal charges for violating state law.
The case of the suspicious death at the hospital was a tragic reminder of the complexities surrounding assisted suicide. While patients have the right to autonomy, the medical profession has a responsibility to prioritize the principles of beneficence and nonmaleficence. It is essential to educate healthcare providers on the ethical and legal implications of assisted suicide to ensure that patient-centered care is always upheld.
Abstract
Medical practitioner-assisted death is legal in 11 US jurisdictions but prohibited by state law in 48 states and the District of Columbia. There is a distinction between medical practitioner-assisted death and assisted suicide, but the medical profession views both as fundamentally incompatible with the practitioner’s role as a healer and pose serious societal risks. The American Medical Association (AMA) and the American College of Physicians (ACP) do not support the legalization of physician-assisted suicide. The medical profession defines itself as a healing art and prohibits any medical options that violate this definition, such as practitioner participation in assisted suicide, which goes against the principles of doing good and not causing harm. Public trust is essential for a patient-centered profession and assisted suicide is not a professional standard of care, regardless of whether it is legally permissible.
**
Think
[5:1] Medical practitioner-assisted death or “medical aid in dying” is legal in eleven jurisdictions: California, Colorado, District of Columbia, Hawaii, Montana, Maine, New Jersey, New Mexico, Oregon, Vermont, and Washington. State law states:
Actions taken in accordance with [the Act] shall not, for any purpose, constitute suicide, assisted suicide, mercy killing or homicide, under the law.
[5:2] Medical practitioner-assisted death is defined distinctly different from “assisted suicide,” which is prohibited by state law in 48 states and the District of Columbia. However, it appears that practitioner-assisted suicide is the same as practitioner-assisted death if they are both defined as the practitioner providing the patient with the knowledge and means of ending their own life voluntarily.
[5:3] Although state law appears to be contradicting itself concerning whether or not practitioner-assisted death is the same as practitioner-assisted suicide and whether or not it should be allowed, the medical profession as a whole is consistent.
[5:4] The American Medical Association (AMA) states:
Physician-assisted suicide is fundamentally incompatible with the physician’s [practitioner’s] role as healer, would be difficult or impossible to control, and would pose serious societal risks.
[5:5] The American College of Physicians (ACP) states:
The College does not support the legalization of physician [practitioner]-assisted suicide or euthanasia. After much consideration, the College concluded that making physician [practitioner]-assisted suicide legal raised serious ethical, clinical, and social concerns.
Assess
Patient: 1) Autonomy
[5:6] If an adult patient, with decisional capacity, considers the risks of harm, and the benefits of assisted suicide, along with all the other available alternatives using their reasonable goals, values, and priorities, and the patient decides that their best interests would be maximized if they were to die, then it is reasonable and rational for the patient to ask their practitioner for assistance.
[5:7] It is also clear that civil justice has supported such patient efforts for end-of-life assistance through the legislation of death with dignity laws in several states.
[5:8] However, just because patient autonomy authorizes a practitioner to do something or to provide a particular treatment, that does not mean that the medical profession as a whole needs to comply with the patient’s autonomous choice.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[5:9] It is rationally consistent for the medical profession to define itself as a healing profession, and thereby prohibit any medical options that violate that definition for the sake of coherency. Professionally, there has been near-universal agreement that practitioner participation in assisted suicide would go against medical tradition, values of beneficence (do good), and nonmaleficence (do no harm). The professional moral principles outweigh both the autonomous patient requests and the civil justice permissibility.
[5:10] This is also the case for the professional prohibition of any medical activity that supports or even gives an appearance of support with regard to capital punishment, interrogation, torture, or any other activities that directly or indirectly brings or inflicts harm onto others.
Public Policy: 4) Justice
[5:11] Federal laws are fairly consistent with themselves as there is less chance of independent and conflicting legislation going on at the same time. The United States of America is a federal republic consisting of fifty states, one federal district (Washington DC), five major territories (1. American Samoa, 2. Guam, 3. the Northern Mariana Islands, 4. Puerto Rico and 5. US Virgin Islands), and various minor islands (loosely clustered around Hawaii).
[5:12] Each state, federal district, and major territory have their own court system. These 56 independent court systems generate numerous inconsistencies and incoherence as to what medical practices are permissible or impermissible.
[5:13] Regardless of what can at times appear to be an inconsistent legislative mess, the medical profession and society at large understand that the medical profession is a healing art and that the profession needs to protect its social image from being maligned. Public trust is essential for a patient-centered nonmaleficence (do no harm) profession, and this means that just because an action is legally permissible, that does not determine how the medical profession defines itself by professional standards of practice.
[5:14] Assisted suicide is not part of the medical profession’s medical standard of care, regardless of whether or not it is legally permissible, as the art of medicine is one of beneficence (do good) and nonmaleficence (do no harm): Primum non nocere. (Latin: “First do no harm”)
Conclude
[5:15] The medical profession prohibits practitioner-assisted suicide because:
- 1. the public’s perception of the profession as a whole will be maligned,
- 2. the patient trust in the practitioner will be diminished, and
- 3. it would be a violation of the medical profession’s foundational principles of beneficence (do good) and nonmaleficence (do no harm).
[5:16] In summary, the prohibition of practitioner-assisted suicide within the medical profession stems from a need to preserve public trust, uphold the profession’s image, and adhere to the foundational principles of beneficence and nonmaleficence. Despite the legal permissibility of the practice in some areas, the medical profession stands firm in its commitment to healing and the avoidance of harm. This stance ensures that the medical profession remains patient-centered and maintains the trust of society as it continues to prioritize the well-being of patients.
(See also: 6. Capital Punishment - Executions, 11. Death With Dignity - Practitioner-Assisted Dying, 17. Euthanasia, 27. Interrogations, and 58. Torture)
**
5. Review Questions
1. The AMA and the ACP both agree that practitioner-assisted suicide is compatible with the medical profession’s duty of nonmaleficence (do no harm) and beneficence (do good).
2. If society authorizes the permissibility of a medical procedure or treatment, then the practitioner has a social-contract responsibility to provide that procedure or treatment to the patient or person.
3. It is rationally consistent for the medical profession to define itself as a healing profession, and therefore prohibit any medical options that violate that definition for the sake of coherency.
4. Assisted suicide is not a professionally medical standard of care, regardless of whether or not it is legally permissible, as the art of medicine is one of beneficence (do good) and nonmaleficence (do no harm).
CORRECT! 🙂
[5:4] The American Medical Association (AMA) states:
Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.
[5:5] The American College of Physicians (ACP) states:
The College does not support the legalization of physician-assisted suicide or euthanasia. After much consideration, the College concluded that making physician-assisted suicide legal raised serious ethical, clinical, and social concerns.
Wrong 😕
[5:4] The American Medical Association (AMA) states:
Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.
[5:5] The American College of Physicians (ACP) states:
The College does not support the legalization of physician-assisted suicide or euthanasia. After much consideration, the College concluded that making physician-assisted suicide legal raised serious ethical, clinical, and social concerns.
CORRECT! 🙂
[5:8] However, just because patient autonomy authorizes a practitioner to do something or to provide a particular treatment, that does not mean that the profession as a whole needs to comply with the patient’s autonomous choice.
Wrong 😕
[5:8] However, just because patient autonomy authorizes a practitioner to do something or to provide a particular treatment, that does not mean that the profession as a whole needs to comply with the patient’s autonomous choice.
CORRECT! 🙂
[5:9] It is rationally consistent for the medical profession to define itself as a healing profession, and therefore prohibit any medical options that violate that definition for the sake of coherency. Professionally, there has been near-universal agreement that practitioner participation in assisted suicide would go against medical tradition, values of beneficence (do good), and nonmaleficence (do no harm). The professional moral principles outweigh both the autonomous patient requests and the civil justice permissibility.
Wrong 😕
[5:9] It is rationally consistent for the medical profession to define itself as a healing profession, and therefore prohibit any medical options that violate that definition for the sake of coherency. Professionally, there has been near-universal agreement that practitioner participation in assisted suicide would go against medical tradition, values of beneficence (do good), and nonmaleficence (do no harm). The professional moral principles outweigh both the autonomous patient requests and the civil justice permissibility.
**
CORRECT! 🙂
[5:14] Assisted suicide is not a professionally medical standard of care, regardless of whether or not it is legally permissible, as the art of medicine is one of beneficence (do good) and nonmaleficence (do no harm).
Wrong 😕
[5:14] Assisted suicide is not a professionally medical standard of care, regardless of whether or not it is legally permissible, as the art of medicine is one of beneficence (do good) and nonmaleficence (do no harm).
5. Clinical Vignettes
1. What is the position of the American Medical Association (AMA) and the American College of Physicians (ACP) regarding practitioner-assisted suicide or euthanasia?
2. Mr. Philip Hall, a 62-year-old graphic designer requests a specific treatment that is within their legal right to receive, but it goes against the medical profession's standards of medical care. What should the practitioner do?
3. What is the stance of the medical profession regarding practitioner-assisted suicide?
4. Mr. Seth Johnson, an 82-year-old retiree requests practitioner-assisted suicide, which is legally permissible in their state. What should the practitioner do?
5. Ms. Faith Park, a 92-year-old retiree comes to your clinic seeking advice on end-of-life options. They have been diagnosed with a terminal illness and are in severe pain. They express interest in assisted suicide as a means to end their suffering. What is the appropriate response for the practitioner?
Wrong 😕
Explanation: Both the American Medical Association (AMA) and the American College of Physicians (ACP) have taken a firm stance against the legalization of practitioner-assisted suicide or euthanasia, viewing them as incompatible with the practitioner's role as a healer and with the ethical principles of medicine [5:4][5:5]. They argue that such practices can erode the public’s perception of medicine being a healing profession and undermine the trust between the practitioner and the patient [5:4][5:5]. Instead, the AMA and the ACP support the provision of high-quality end-of-life care that seeks to alleviate pain and suffering, respects the dignity of the patient, and provides support for the patient and their loved ones [5:4][5:5].
CORRECT! 🙂
Explanation: Both the American Medical Association (AMA) and the American College of Physicians (ACP) have taken a firm stance against the legalization of practitioner-assisted suicide or euthanasia, viewing them as incompatible with the practitioner's role as a healer and with the ethical principles of medicine [5:4][5:5]. They argue that such practices can erode the public’s perception of medicine being a healing profession and undermine the trust between the practitioner and the patient [5:4][5:5]. Instead, the AMA and the ACP support the provision of high-quality end-of-life care that seeks to alleviate pain and suffering, respects the dignity of the patient, and provides support for the patient and their loved ones [5:4][5:5].
Wrong 😕
[5:8]Explanation: As a healthcare professional, the practitioner has a duty to provide care that is consistent with accepted medical standards of care [5:1]. However, the patient has the right to make informed decisions about their medical care, including the right to refuse or request specific treatments, as long as they are within their legal right to receive them and are in line with medical standards of care [5:6]. In this situation, the practitioner should explain to the patient the medical profession's objections to the requested treatment and provide information on alternative treatments that align with medical standards of care [5:4]. The practitioner should also ensure that the patient understands the potential risks and benefits of the requested treatment and of the alternatives, so that they can make an informed decision about their care [5:6]. The practitioner should document the discussion in the patient's medical record [5:9] and work collaboratively with the patient to develop a care plan that is consistent with the patient's reasonable goals, values, and priorities, while also meeting accepted standards of medical care [5:1].
CORRECT! 🙂
[5:8]Explanation: As a healthcare professional, the practitioner has a duty to provide care that is consistent with accepted medical standards of care [5:1]. However, the patient has the right to make informed decisions about their medical care, including the right to refuse or request specific treatments, as long as they are within their legal right to receive them and are in line with medical standards of care [5:6]. In this situation, the practitioner should explain to the patient the medical profession's objections to the requested treatment and provide information on alternative treatments that align with medical standards of care [5:4]. The practitioner should also ensure that the patient understands the potential risks and benefits of the requested treatment and of the alternatives, so that they can make an informed decision about their care [5:6]. The practitioner should document the discussion in the patient's medical record [5:9] and work collaboratively with the patient to develop a care plan that is consistent with the patient's reasonable goals, values, and priorities, while also meeting accepted standards of medical care [5:1].
Wrong 😕
Explanation: The medical profession views itself as a healing profession, and its primary goal is to relieve suffering and promote the health and well-being of patients. As such, the medical profession considers practitioner-assisted suicide to be morally unacceptable because it goes against the practitioner's role as a healer and the ethical principles of medicine [5:4]. The medical profession believes that the appropriate response to a patient's suffering is to provide high-quality end-of-life care that seeks to alleviate pain and suffering, while also respecting the dignity of the patient [5:1]. The medical profession's stance on practitioner-assisted suicide is based on the belief that preserving life and promoting well-being are central to the goals and values of medicine, and that practitioner-assisted suicide undermines these fundamental principles [5:4].
CORRECT! 🙂
Explanation: The medical profession views itself as a healing profession, and its primary goal is to relieve suffering and promote the health and well-being of patients. As such, the medical profession considers practitioner-assisted suicide to be morally unacceptable because it goes against the practitioner's role as a healer and the ethical principles of medicine [5:4]. The medical profession believes that the appropriate response to a patient's suffering is to provide high-quality end-of-life care that seeks to alleviate pain and suffering, while also respecting the dignity of the patient [5:1]. The medical profession's stance on practitioner-assisted suicide is based on the belief that preserving life and promoting well-being are central to the goals and values of medicine, and that practitioner-assisted suicide undermines these fundamental principles [5:4].
Wrong 😕
Explanation: The medical profession views practitioner-assisted suicide as antithetical to medicine being defined as a healing art, and the ethical principles of medicine. Therefore, a practitioner who is asked to assist in a patient's suicide should refuse to provide the requested assistance on the grounds that it goes against the fundamental values and goals of medicine [5:4][5:9]. It is important to note that this course of action may vary depending on the legal and cultural context, and practitioners should be aware of the laws and regulations in their own jurisdiction regarding practitioner-assisted suicide [5:1].
CORRECT! 🙂
Explanation: The medical profession views practitioner-assisted suicide as antithetical to medicine being defined as a healing art, and the ethical principles of medicine. Therefore, a practitioner who is asked to assist in a patient's suicide should refuse to provide the requested assistance on the grounds that it goes against the fundamental values and goals of medicine [5:4][5:9]. It is important to note that this course of action may vary depending on the legal and cultural context, and practitioners should be aware of the laws and regulations in their own jurisdiction regarding practitioner-assisted suicide [5:1].
CORRECT! 🙂
Explanation: The practitioner should explain to the patient that assisted suicide is not a professional standard of care and that it goes against the fundamental values and goals of medicine [5:4]. The practitioner should also discuss alternative options for managing pain and addressing end-of-life concerns, such as palliative care, hospice care, and other comfort-focused treatments [5:1]. The practitioner should offer support and guidance to the patient as they navigate these options, and should work collaboratively with the patient to develop a care plan that is consistent with the patient's goals, values, and priorities [5:1]. It is important for the practitioner to provide accurate information, support, and compassion to the patient, while also ensuring that their own ethical obligations as a practitioner are being met [5:4]. Refusing to discuss the topic or agreeing to assist the patient in ending their life are not appropriate responses, as they do not align with the fundamental values and goals of medicine and may compromise the practitioner's ethical obligations [5:4].
Wrong 😕
Explanation: The practitioner should explain to the patient that assisted suicide is not a professional standard of care and that it goes against the fundamental values and goals of medicine [5:4]. The practitioner should also discuss alternative options for managing pain and addressing end-of-life concerns, such as palliative care, hospice care, and other comfort-focused treatments [5:1]. The practitioner should offer support and guidance to the patient as they navigate these options, and should work collaboratively with the patient to develop a care plan that is consistent with the patient's goals, values, and priorities [5:1]. It is important for the practitioner to provide accurate information, support, and compassion to the patient, while also ensuring that their own ethical obligations as a practitioner are being met [5:4]. Refusing to discuss the topic or agreeing to assist the patient in ending their life are not appropriate responses, as they do not align with the fundamental values and goals of medicine and may compromise the practitioner's ethical obligations [5:4].
**
5. Cases: 5a, 5b
Instructions
1. Read Prompt, 2. Think, Assess, & Conclude (TAC), then 3. Select an answer that mirrors the TAC conclusion.
Note: After success, select each of the wrong answers to understand why each of them is wrong.
5a
A patient of sound mind wants assistance in ending their life, in a state in which it is legal. The patient is not depressed, has had a fulfilling life, and had an excellent patient-practitioner relationship with their doctor for decades. Now the patient wants to end their life and needs their practitioner to help them accomplish this end in a dignified manner by providing the patient with the knowledge and means of ending their own life voluntarily.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
5b
A patient request assisted suicide from their practitioner, in a state in which it is legal, arguing that it would not be a violation of practitioner nonmaleficence (do no harm) and that death is not harm but a transition to either a state of nonexistence or transcendent existence, and either state fulfills the moral principle of practitioner beneficence (do good).
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
***
Wrong 😕
A. Human life and death are inseparable, and therefore the practitioner has a moral and professional obligation to engage in the direct ending of human life.
Evidence-based medicine, the medical profession, and community practice determine the medical standards of care. Such practice is usually, but not necessarily, in compliance with patient autonomy and/or civil law.
Wrong 😕
B. If the patient autonomously chooses the physician to aid in their death, and assisted death is legal for a practitioner to engage in, then the practitioner is professionally obligated to help the patient end their life.
Evidence-based medicine, the medical profession, and community practice determine the medical standards of care. Such practice is usually, but not necessarily, in compliance with patient autonomy and/or civil law.
CORRECT! 🙂
THINK (Question)
Should a practitioner help a patient end their life?
ASSESS
- • Patient Autonomy (informed consent)
Practitioners have a moral and professional obligation to the patient to offer the accepted standard of medical care. - • Practitioner Beneficence (do good) &Nonmaleficence (do no harm)
The American Medical Association (AMA) states:
“Physician-assisted suicide is fundamentally incompatible with the physician’s [practitioner’s] role as healer, would be difficult or impossible to control, and would pose serious societal risks.”
[5:5] The American College of Physicians (ACP) states:
“The College does not support the legalization of physician [practitioner]-assisted suicide or euthanasia. After much consideration, the College concluded that making physician [practitioner]-assisted suicide legal raised serious ethical, clinical, and social concerns.”
It is rationally consistent for the medical profession to define itself as a healing profession, and therefore prohibit any medical options that violate that definition for the sake of coherency.
Practitioners professional obligations of beneficence (do good) & nonmaleficence (do no harm) and the importance of public perception of the medical profession outweigh patient autonomy and legality under such circumstances. Assisted suicide is not a professionally medical standard of care, regardless of whether or not it is legally permissible, as the art of medicine is one of beneficence (do good) and nonmaleficence (do no harm): Primum non nocere (Latin: “First, do no harm”). - • Public-Policy Justice (be fair)
Medical practitioner-assisted death or “medical aid in dying” is legal in eleven jurisdictions: California, Colorado, District of Columbia, Hawaii, Montana, Maine, New Jersey, New Mexico, Oregon, Vermont, and Washington.
CONCLUDE
Regardless of patient autonomy and legality, the medical profession does not engage in the direct ending of human life.
Wrong 😕
D. The medical profession must conform its practices to the wishes of the autonomous patient and make available treatments that are not illegal, including the ending of human life.
Evidence-based medicine, the medical profession, and community practice determine the medical standards of care. Such practice is usually, but not necessarily, in compliance with patient autonomy and/or civil law.
Wrong 😕
A. Ethics for medicine is relative and should be per the patient, practitioner, and civil liberties, allowing practitioner-assisted suicide.
Ethics for medicine is not relative because evidence-based medicine, the medical profession, and community practice each help determine the medical standards of care. The medical practice standard may be or may not be in accordance with patient autonomy and civil law.
Wrong 😕
B. Assisted suicide is a decision to be made by the patient, practitioner, and civil society, and associational and institutional groups, like the medical profession and hospitals, should comply with such decision-making liberties.
The following categories of restraint progress from the general to the specific. Each plays its role in determining the medical standards of care.
1. Civil law, established by legislation, provides the social framework of liberties practitioners have within society.
2. Institutional structures, like hospitals, limit practitioners’ behavior within the institution’s mission and vision.
3. Associational structures, like the medical profession, establish professional expectations.
4. Patient autonomy, as exemplified by informed consent, determines what can and cannot be done to one’s body.
Wrong 😕
C. Patient autonomy always carries more weight than the practitioner's professional obligations, justifying the practitioner's compliance with assisted suicide.
It is true that patient autonomy has the most specific limiting power of what acceptable treatment options it is permissible to provide the patient. However, it is a misunderstanding to think that that authority of specific restriction has anything to do with the determination of the medical standards of care.
1. Civil law, established by legislation, provides the social framework of liberties practitioners have within society.
2. Institutional structures, like hospitals, limit practitioners’ behavior within the institution’s mission and vision.
3. Associational structures, like the medical profession, establish professional expectations.
4. Patient autonomy, as exemplified by informed consent, determines what can and cannot be done to one’s body.
CORRECT! 🙂
THINK (Question)
Is it permissible for a practitioner to assist in the suicide of a patient, if the patient provides a compelling argument that assisted-suicide is coherent with practitioner beneficence (do good) and nonmaleficence (do no harm)?
ASSESS
- • Patient Autonomy (informed consent)
Patient autonomously desires assisted suicide. - • Practitioner Beneficence (do good) &Nonmaleficence (do no harm)
The medical profession prohibits practitioner-assisted suicide because:
1. the public’s perception of the profession as a whole will be maligned,
2. the patient trust in the practitioner will be diminished, or
3. it would be a violation of the medical profession’s foundational principles of beneficence (do good) and nonmaleficence (do no harm).
The medical profession has determined that the potential negative effects such as public perception, and abuse, outweigh other philosophical justifications that might be made. Assisted suicide is considered to be antithetical with the healing art of medicine. - • Public-Policy Justice (be fair)
The patient’s request is in a state in which assisted suicide is legal.
CONCLUDE
The medical profession has determined that assisted suicide is not an medical standards of care.
