The Right or the Duty to Die: Making the Case for Physician-Assisted Suicide
By Susanne Marie Johnson, BSN, RN
In February 2013, Barbara Mancini of Philadelphia was arrested and
subsequently charged with a felony of assisted suicide. The prosecution
asserts Mancini provided her 93-year-old and terminally ill father, Joe
Yourshaw, with the bottle of morphine that allowed him to take a lethal dose in
an attempt to end his life.
Mancini’s father suffered from at least two end-stage diseases and was
under hospice care in his Pottstown home. Ms. Manicini maintains that she
provided her father with the morphine because he had requested it in an effort
to relieve his own suffering. Despite Ms. Mancini’s assertion that her father
would not want further treatment, Mr. Yourshaw was transferred to a local
hospital, resuscitated, and given even more morphine for his pain after his
hospice nurse called 911. He would die four days later.
If Pennsylvania and other states had legislation permitting
physician-assisted suicide (PAS), Mr. Yourshaw might have died comfortably at
home, surrounded by those he loved, feeling secure in the knowledge that he did
not have to succumb to his diseases but could assert his right to autonomy as a
patient and leave this world of his own accord.
The Netherlands has legally allowed physician-assisted suicide since
1992. In the U.S., Oregon made physician-assisted suicide legal in 1997 when
voters passed the Death With Dignity Act (DWDA) and Washington passed similar
legislation in 2009. The DWDA act permits a mentally competent and terminally
ill individual who is over the age of 18 and a citizen of the state of Oregon
to request a lethal dose of medication (usually an oral dose of a barbiturate)
from their physician for the purpose of ending their life.
In order for a patient to be considered eligible to participate in the
act, they must also meet the following criteria:
1. The patient must make two
verbal requests separated
by a period of at least 15 days to their attending physician .
2. The patient must also make a written
request to their attending physician in the presence of two witnesses.
3. An attending
and consulting physician must then confirm the patient’s diagnosis and
prognosis and whether or not the patient is capable of making healthcare
decisions for themselves.
4. If the patient’s judgment is believed to be impaired
either by psychiatric condition or coercion, the patient must be referred for psychological
5. The attending physician must educate the patient about
alternatives including, but not limited to, palliative care, hospice care, and
6. The attending physician must request, but must not require,
that the patient notify their next-of-kin of the request for the prescription.
Patients may retract their request at any time.
7. Physicians must report all
requests for prescriptions of lethal medications to the Oregon Health Authority
and pharmacists must be notified if the prescribed medication is used.
The right to die is not the same as the duty to die. The DWDA is not a
tool to advocate for the removal of life-prolonging treatments or devices. Many
detractors of the DWDA have asserted that this type of legislation smacks of
health care rationing and will likely prevent the terminally ill in vulnerable
populations such as the poor, the under-educated, and those without health
insurance from receiving palliative care and hospice services. The Oregon
Health Authority makes available to the public extensive yearly reports
regarding compliance with the Act, the number of individuals who request
prescriptions, and the subsequent number of deaths of individuals that occur
from use of the obtained prescriptions.
According to the 2013 report, 115 individuals obtained prescriptions
for lethal medications, but only 77 individuals died as a direct result of
using those prescriptions. Supporters of the DWDA maintain that the aim of legalizing
PAS is strictly to empower the terminally-ill patient; to provide them with a
sense of control over the circumstances of death, to diminish their feelings of
dependence on others, to alleviate the fear of dying with uncontrolled symptoms
such as intractable pain and loss of bowel/bladder control, and to allow for
better preparation for death. In fact, current literature indicates that those
who most often use the DWDA are wealthy and highly educated. Still more
opponents of PAS believe that it would become a stand-in for quality EOL care
and that patients will not be adequately informed by their physicians of other
options for symptom management, pain control, and hospice services.
There is still a widely held belief that access to quality palliative
care and hospice services will fail to improve if patients have the option to
take their own life. Oregon’s DWDA clearly stipulates that any patient
requesting a prescription for lethal medication must be informed of alternative
therapies and options by their physician to avoid this specific conflict.
Family members of those who chose PAS actually noted that their loved ones had
greater symptom control, better energy and interaction with their environment,
and seemed more prepared for death according to those who participated in a
study using a 33-item measurement tool of the quality of death and dying.
Physician-assisted suicide and the Oregon Death With Dignity Act
continue to be controversial ethical and moral topics within healthcare and the
U.S. legislature. As we move toward providing patients with greater healthcare
options in the U.S. through the Affordable Care Act, it seems that we must also
provide patients with a greater variety of options at the end of life, a time
when choice and autonomy may be most important. Physician-assisted suicide in
no way detracts from the care that terminally ill patients receive. Instead,
physician-assisted suicide may be the intervention that most meets patients’
desire for increased control in situations where they are afforded very little
determination in the outcome of their illness.
References can be accessed at www.advanceweb.com/Nurses.
Susanne Marie Johnson is
on staff at Hospital of the University of Pennsylvania and a graduate student
in the Family and Community Health Nurse Practitioner program with a focus on
Palliative Care at the University of Pennsylvania School of Nursing.