1 Assisted Suicide and Euthanasia Michael Wassenaar, PhD February 16, 2012

Goals Identify arguments on both sides of ethical debate Understand significant ethical distinctions Practice respectful conversation 2

Withholding/withdrawing life support No ethically relevant distinction between withholding and withdrawing. Both are question of harms and benefits. W/w life support is not assisted suicide or euthanasia. Intention matters: intention is not to kill, but to prevent harm and allow disease/condition to run its course Killing vs. letting die

4 “[W]hen a patient refuses life- sustaining medical treatment, he dies from an underlying fatal disease or pathology; but if a patient ingests lethal medication prescribed by a physician, he is killed by that medication.” US Supreme Court, Vacco v. Quill, 1997

The principle of double effect Is it ever morally acceptable to administer a drug that may hasten the patient’s death? Does this count as assisted suicide? 5

Principle of double effect 6 ACT EFFECT 1 (intended) EFFECT 2 (unintended) Principle of double effect: there is a morally significant difference between A-E1 and A-E2.

Principle of double effect 7 Administration of IV morphine Relieve symptoms Hasten death

Continuous deep sedation Evidence suggests CDS hastens death Does the principle of double effect apply? It depends: Is unconsciousness, or death, the means to symptom relief? If death is intended as the means, then it counts as killing (ie, double effect does not exonerate). Palliative vs. terminal sedation

Terminology Suicide: Intentionally ending one’s own life Assisted suicide: Clinician assists patient to perform an act that is intended to end his/her life Euthanasia: Clinician acts intentionally to end a patient’s life ■ From the Greek: eu (good) + thanatos (death) 9

Historical context ■ Ancient Greece and Rome tended to be tolerant ■ Hippocrates represented the minority view: ■ “I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect” (Hippocratic Oath) ■ Historically, Christianity opposed suicide and endorsed Hippocratic view 10

Contemporary context ■ Legal in 6 countries: Albania, Switzerland, Belgium, Netherlands, Luxembourg, Columbia ■ Legal in 3 US states: Oregon (1994), Washington (2008), Montana (2009) ■ Between 1994 and 2010, there were 75+ legislative bills to legalize assisted suicide in at least 21 states ■ AMA, ACP, ASIM do not support legalization ■ MedScape.com survey, 2010 “Should physician-assisted suicide be allowed in some situations?” Yes: 45.8% No: 40.7% It depends: 13.5% 11

Motivations Loss of autonomy Loss of dignity Inadequate pain/symptom control Depression Abandonment Burden on family Self-image Prospect of long-term care Finances

In Oregon Oregon Death with Dignity Act passed in 1994, implemented in Safeguards:  Terminally ill (6 month prognosis)  Mentally competent  Confirmed by a second opinion  Waiting period of two weeks Lower rates than rest of nation (?) 13

Main arguments: Pro Killing is not always murder (e.g. self-defense, warfare, capital punishment). Respects the patient’s autonomy. Relieves the patient’s suffering. Safeguards can mitigate abuse. 14

Main arguments: Con It is not our right Corrupts traditional role of health provider Erodes trust Risks abuse Slippery slope 15

Ethical vs. Legal If one believes assisted suicide may be justified in some cases, it does not necessarily mean it should be legal. Recall utilitarianism: What would the consequences be if something became a general rule?

How to respond? Clarify the Request Determine the Root Causes Affirm Your Commitment to Care for the Patient Address the Root Causes of the Request Educate the Patient About Legal Alternatives for Control and Comfort Consult With Colleagues 17 Source: Endlink Resources for End of Life Care Education.