Journal of Nursing
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Why Nurses Should Not Participate In Physician-Assisted Suicide

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Physician-assisted suicide
In case of a physician assisted suicide, a doctor helps a patient to take his or her own life; Euthanasia denotes the intentional termination of a patient’s life by a doctor who thinks that death is of benefit to the patient; involuntary euthanasia denotes euthanasia being carried out against the wishes of a competent person. Non-voluntary euthanasia denotes euthanasia being carried out on non competent patients. In Countries and States where euthanasia has a legal validity, it is an act on purpose, performed by a third person, in order to end life of a person who has requested for this act.  Only a physician can perform this act.  The doctor can perform euthanasia only when the patient is of major age or an emancipated minor. The doctor can perform euthanasia also only when the patient is of full legal capacity and conscious; the request is voluntary, well considered and repeated; the patient is dealing with unbearable and consistent physical or psychological pain or suffering as  a  result of an illness or an accident and cannot be cured(Mc Skimming,1997). Example of a case of physician assisted death in USA is that of terminally ill Karen yanoch who took a dose of lethal barbiturate in Oregon, which has a law that provides for assisted suicide or Euthanasia. This Oregon law allows adult with terminal diseases who are likely to die within six months to obtain lethal doses of drugs from their doctors. This case is of a patient who has been allowed to die as per the “Death with Dignity Act” passed in 1994 in the State of Oregon, U.S.A.

Why nurses should not be involved in physician assisted suicide?
It should be brought to light that euthanasia or physician assisted suicide cannot be truly autonomous acts which requires consent and the accurate assessment of competence of the patient is not adequately guaranteed. Further, it is to too difficult to ensure a truly voluntary decision and it is impossible to regulate euthanasia or physician assisted suicide. Euthanasia and the legalization of clinically assisted death would create a policy drift away from the principle of inviolability of life, thus opening the door to further liberalization of the law. The Right to Life is the corner stone of human rights law, which has the protection under the Article 3 of the Universal Declaration of Human Rights 1948 and Article 6 of the International Covenant on Civil and Political rights 1966 (www.lawcf.org).Thus, it is the duty of the state to recognize that the right to life, especially with regard to a terminally ill or dying person is guaranteed and a terminally ill or dying person’s wish to die never constitutes any legal claim to die at the hands of any other person. The Supreme Court of USA ruled in the Nancy Curzon case that ‘a state requires‘clear and convincing evidence’ of the patient’s wishes for withdrawal of life-support (Mc Skimming, 1997).
It is literally difficult to decide if someone has given free and informed consent for an assisted death. The ‘mental competence’ of the patient is a ‘crucial factor’ in such decisions. It is better if enough attention is drawn to the high degree of mental competence required to consent to a procedure that will cause death and the procedural insufficiency to decide on the competence. Further, informed consent in a competent individual is an expression of his right heeding to his/her wishes or desires. In an incompetent individual expression of his/her right is done in their “best interests” from a psychological and medical viewpoint. However, there seems to be a group of individuals who are marginally competent. This group seems to lie in-between the two extremes of competence and incompetence and competence in this case thus appears to be a matter of degree. Marginal competence seems to occur in individuals in adolescence where competency is still in the developmental stage thus bringing age factor into the argument.
It should also be remembered that fifty percent of the patients killed under the Dutch euthanasia programme were suffering from depression and thus, depression is a crucial factor for assessing competence (Emanuel et. al, 2000). Further, there is no guarantee that the physician assisted death decision will be free from external pressure, giving apprehensions about the true reasons for a request for euthanasia. There is a real danger in some cases, when patients are under pressure to request euthanasia or physician assisted death from their relatives. The health care professionals cannot recognize such external pressures effectively nor there any legal psychiatric provision to investigate such an influence. The influence may be in such a way that the patient himself may feel himself a burden and go for a request of death (www.lawcf.org).
Thus, a nurse assisting such a death will do so with only insufficient information and insufficient time after fulfilling his/her duty as a nurse to care. When there is never any need of physician assisted death due to the availability of palliative care, it is difficult to see why a fully informed patient would request euthanasia for reasons other than being dependent on or being a burden to others. Such requests for deaths are “a cry for relief or help rather than a wish to die” (http://sfgate.com).  Studies have shown that even in Oregon, USA, there have been reports of retraction of request for death after the patients being initiated into palliative care or hospice (http://sfgate.com).  Thus, patients can only be considered fully informed about a decision to request assistance to die where they have experienced good symptom control. The state should ensure that all available steps were taken to relieve distress before an application for assisted suicide or voluntary euthanasia could move forward. Euthanasia or physician assisted death is not an alternative to palliative care. In a 1998 survey, nearly two-thirds of Americans have opined that the federal government should not allow controlled drugs to be used for the purpose of physician-assisted suicide (www.euthanasia.com).
In Netherlands, there have been three official Select Committee Reports on euthanasia from 1991 through 2001. Legalization of voluntary euthanasia will lead to non voluntary euthanasia and involuntary euthanasia as reported in Netherlands and thus, would constitute murder as per present US law. As per reports, 1,000 lives have been ended in Netherlands in 1991 without request for euthanasia, 950 lives were ended without consent in 1995-96 and 1000 in 2001(www.lawcf.org). The existing safeguards on physician-assisted death are insufficient because there is no provision in the law for an adequate system to ensure the practice of these safeguards. Reporting the assisted deaths to a monitoring committee as in Dutch experience will again fail in USA too because of a chance of the health care professionals, not reporting the assisted deaths due to the inconvenience of an investigation and chances of euthanasia deaths being reported as normal death due to natural causes. 

Conclusion
Legalizing assisted suicide will mean that sick and disabled people, who do not want to die, would be killed definitely (Verhagen et al, 2005). After Netherlands essentially decriminalized the practice of assisted suicide and euthanasia, a government report conducted by Jan Remmelink found that 1,000 patients were killed without requesting to die in 1990 and 900 in 1995 (Verhagen et al,2005). More recently, The British Medical Journal has estimated that in 2001, among some 140,000 Dutch deaths, doctors had euthanized some 3,000 patients, assisted in the suicide of about 140 patients -- but ended "life without patient's explicit request" for some 840 patients. To be specific, 840 patients who wanted to live were killed by physicians (http://sfgate.com). There is no doubt that the patients have a right to refuse care and say no to therapies, drugs, feeding tubes. But assisted suicide changes the role of nurses from care givers and protector of the sick and the disabled into licensed professional killers. Hence, nurses who are part of the healthcare team should not be involved in the practice of physician assisted death or euthanasia.

Reference 

  • Emanuel et.al (1996).Euthanasia and physician assisted suicide: attitudes and experiences of oncology patients, oncologists and the public. Lancet 347 (9018):1805.
  • Hazebroek et. al (1993).Withholding and withdrawal of life support from surgical neonates with life threatening congenital anomalies. I pediatr Surg 28(9):1093-7.
  • http://www.euthanasia.com/survey.html.
  • http://www.lawcf.org/index.asp?page=
    Christmas%20Greetings%20from%
    20LCF%20Public%20Policy%20Unit.
  • http://www.nrlc.org/news/2001/NRL10/alaska.html.
  • Karen Street et al (2000).The decision making process regarding the withdrawal or withholding of potential life saving treatments in a children’s hospital. J .Med Ethics 26:346-52.
  • Kubler – Ross E (1969).On death and dying. Macmillan, New York.
  • Mc Skimming S.A, Super, A., Driever, M.J, Schoessler, M., Franey S.G & Fonner E (1997).Living and Healing during life–threatening illness; Portland.
  • Michel Fertleman (2003).The law of Consent in England as applied to the sick neonate. The interned journal of Pediatrics and Neonatology 3(1).
  • Mulcahy, L (2003) Disputing Doctors – The socio-legal dynamics of disputes between doctors and patients, Open University press, Milton Keynes. 
  • Verhagen et al (2005). End of life decisions in new born: An approach from the Netherlands. Pediatrics 116 (3): 736-39.


Copyright 2008- American Society of Registered Nurses (ASRN.ORG)-All Rights Reserved



 
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