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Assisted suicide and nursing ethics.

Assisted suicide, particularly in the health care context, exists amid a continuum of end-of-life interventions. Any analysis of the ethics of assisted suicide therefore must begin by making clear exactly what is at issue. Assisted suicide refers to making available to an individual the means (for example, pills or a weapon) to take his or her own life. Assisted suicide is distinguished from euthanasia in that it necessarily involves an individual who is capable physically of taking his or her own life and does so with means provided by another person. Euthanasia, on the other hand, refers to the situation where another person not only may provide the means but actually performs the specific act that causes an individual's death (for example, injecting a lethal dose of medication). Euthanasia may be voluntary (the individual has requested that another act to bring about his death) or involuntary (the individual is incapable of making such a request but death is deemed to be in his best interest) (Angell, 1997). No jurisdiction in the United States has legalized euthanasia.

The case of Washington v. Glucksberg, decided in 1997, sought to establish that dying patients have a constitutional right to end their lives with the assistance of a physician (Angell, 1997). The United States Supreme Court held that there is no such right under the 14th Amendment's guarantee of liberty. Nonetheless, the court noted that while states are not required to permit physician-assisted suicide, they are free to do so through their legislatures and/or courts if they so choose. To date, only the state of Oregon has passed a law legalizing physician-assisted suicide (the Oregon Death with Dignity Act).

On May 26, 2004, the United States Court of Appeals for the 9th Circuit (which includes the state of Oregon) rejected the efforts of Attorney General John Ashcroft to, in effect, nullify Oregon's voter-approved assisted suicide law. The court held that Attorney General Ashcroft may not penalize a physician by revoking his/her federal license to prescribe controlled medications for dispensing a lethal dose of drugs as permitted by, and in accordance with, the provisions of Oregon's Death with Dignity Act. In supporting its decision, the court noted that setting standards for the proper practice of medicine is a responsibility of the individual states, rather than the federal government. The court further reasoned that Congress's intent in passing the Controlled Substances Act was to control illegal drug trafficking by physicians and not to supercede the states' authority to regulate medical practice.

At this time, it remains to be seen if the attorney general will appeal the Circuit Court's decision to the United States Supreme Court. However, few people believe that the driving force behind this litigation is a concern for the legal issue of a state's right to set standards of medical practice. Rather, the issue that gives this case its urgency is the parties' deeply held and opposing views of the moral acceptability of the practice of physician-assisted suicide. These views, in turn, reflect matters of religious belief, notions of personal and political liberty, and convictions about the value of life for its own sake and about what manner of life is worth living. Indeed, this case is in keeping with a long tradition of using the law as an instrument, and the court as a forum, for resolving what is essentially a moral conflict.

Suicide and the Ethics of Assisted Suicide

Any effort to explore and assess the ethics of assisted suicide necessarily begins with an examination of beliefs about the moral permissibility of an individual's taking his or her own life in the first place. Implicated are views about the origin and source of life (Is our relationship to our life one of stewardship or ownership?); the value, if any, of suffering (Is the elimination of suffering always a highest goal or can suffering have meaning and purpose?); the obligations of relationship (Do I have a duty to my family, my community, my society, or even to my God to refrain from taking my own life or is suicide in fact a purely individual of decision?); and personal virtue (Is suicide an act of courage or of cowardice?). If someone concludes, based upon consideration of these and other values, that suicide is wrong, it would follow that it is also wrong to assist in the commission of such an act. In general, an individual would be hard pressed to argue that it is right to assist in the commission of an act that is in and of itself wrong. Conversely, it stands to reason that if a person believes, based upon moral values including free will, autonomy, and liberty, that we each have the moral right to end our life if we so choose, that individual would also believe that assisting in such a suicide is morally justifiable. On its face, it makes little sense to say that it is morally impermissible to help someone to do that which is morally permissible.

The above overview of the general relationship between the moral permissibility of suicide and of assisted suicide has assumed that attitudes toward suicide are absolute; that is, that suicide is either an ethical or an unethical act under all circumstances. For many people, however, the moral acceptability of suicide is contingent rather than categorical; that is to say, for many, the ethical rightness or wrongness of an individual's choice to end his or her life (and thus the rightness or wrongness of providing assistance in the effectuation of that choice) depends upon the circumstances surrounding the decision. Circumstances that might affect the moral acceptability of suicide include, for example, the degree of suffering and pain the individual is experiencing, the possibility/probability for change in the situation or condition causing the suffering and pain, the availability of effective treatment or palliation (psychological and/or physical), the person's age, and the existence of a caring support system.

No formula exists, of course, for determining when circumstances support suicide as a moral choice. Any effort to specify the conditions under which one individual's choice to end his or her life and other's provision of assistance in carrying out that choice would be ethically justifiable will reflect beliefs about individual autonomy, obligations to self and others, personal virtue, and the nature of life itself. Such a discussion is well beyond the scope of this article. Nevertheless, it remains the case that there is in general a logically based link between a person's belief about the ethical acceptability of suicide and his or her belief about the ethical acceptability of providing assistance in a suicide.

Assisting Suicide and the Moral Foundations Of Nursing

The question to be explored here is whether that link holds in the particular situation where the individual who is being asked to assist in the commission of a suicide is a nurse. In other words, is there something intrinsic to the nursing role that makes it ethically impermissible for a nurse to aid a patient in committing suicide even if the suicide itself were ethically acceptable? Alternatively, is a nurse morally required, by virtue of her or his relationship to the patient, to assist in a suicide that he or she believes to be morally wrong?

It should not be surprising that there is not unanimity of thought on these questions. Indeed, these questions raise issues over which there is much controversy; strong and influential voices are to be heard on both sides. Among the most authoritative sources of guidance to nurses on their professional ethical obligations regarding assisted suicide are the publications issued by the American Nurses Association (ANA). Among its other functions, the ANA establishes standards of nursing practice and ethics that bind members of the state nursing associations constituting the ANA. The Code for Nurses, published by the ANA in 1976 and revised in 1985 ("the Code"), serves to inform both the nurse and the public of the profession's expectations and requirements in ethical matters. It offers general principles to guide and evaluate nursing practice.

In addition to the Code, the ANA from time to time issues position statements that articulate its position on specific ethical or practice issues encountered by nurses in the course of their work. The ANA expressly acknowledges in its statement on the ethics of nurse participation in assisted suicide that "nurses witness firsthand the devastating effects of debilitating and life-threatening disease and are often confronted with the despair and exhaustion of patients and families" and that "at times, it may be difficult to find a balance between the preservation of life and the facilitation of a dignified death" (ANA, 1994). Nonetheless, the ANA Code for Nurses (1985) states clearly and unequivocally that "the nurse does not act deliberately to terminate the life of any person" (Sec. 1.3, "The Nature of Health Problems").

In its Position Statement." Assisted Suicide, the ANA (1994) further expands upon the meaning and ethical basis for the Code's proscription against "terminating the life of any person." First, the ANA notes that the historical role of the nurse has been to "promote, preserve and protect human life." It observes that the profession itself is built upon the Hippocratic tradition of "do no harm" and moral opposition to killing another human being. The ANA further states that the Code's prohibition against deliberately terminating a life is grounded in the profession's covenant with society at large to respect and protect human life. It therefore concludes that participation in assisted suicide is inconsistent with the norms and attributes of the nursing profession as reflected both in the terms of its covenant with society and in its relationship of trust with individual patients. The ANA also supports its moral objection to nurse participation in assisted suicide based upon concern for the potential for serious societal and professional consequences and abuses. "While there may be individual patient cases that are compelling, there is a high potential for abuses with assisted suicide, particularly with vulnerable populations such as the elderly, poor, and disabled ... in a time of declining resources the availability of assisted suicide could forseeably weaken the goal of providing quality care for the dying" (ANA, 1994).

While unequivocal in its statement that nurse participation in assisted suicide is morally objectionable, the ANA expressly distinguishes participation in assisted suicide from the withholding or withdrawal of life-sustaining treatment such as mechanical ventilation, cardiopulmonary resuscitation, chemotherapy, antibiotics, and artificially provided nutrition and hydration. The ANA concludes that such withholding or withdrawal is acceptable ethically based upon the patient's right to exercise decisional authority to forego such treatments (1985, 1994). The ANA also draws a distinction between providing a lethal dose of medication to the patient for the purpose of enabling him to end his life and providing medications with the intent to promote comfort and relieve suffering. "The nurse may provide interventions to relieve symptoms in the dying client even when the interventions entail substantial risks of hastening death" (1985, 1994).

Other Voices Regarding Nursing and Assisted Suicide

As suggested earlier, deep, principled division exists on the question of the moral appropriateness of health care professionals' participation in assisted suicide. The opposition to such practice expressed by the ANA is consistent with the position taken by virtually every health care professional association. Indeed, no health care professional association has unequivocally endorsed its members' participation in assisted suicide. Nonetheless, there are well-respected and authoritative voices that advocate for the moral, and legal, acceptability of health care professionals' assisting terminally ill patients who have chosen to end their lives (Angell, 1997; Quill, 1996; Szasz, 1999). Some have even suggested that nurses and other nonphysician professionals should take the lead in assisted suicide, arguing that physicians' qualifications in end-of-life care are not unique or even exemplary.

Faber-Langendoen and Karlawish (2000), while not taking a position on the ethics of assisted suicide per se, assert that the "current predominance of physicians in assisted suicide may be misdirected, misleading, and even unnecessary. Although physician involvement is necessary, [they] argue that it is not sufficient to ensure that patients requesting assisted suicide receive the best care" (p. 483). While they acknowledge the role of physician expertise in the initial assessment of a request for assisted suicide based upon his/her responsibility for communicating information about diagnosis, prognosis, treatment options and so forth, they contend that "other critically important tasks are far outside physician expertise and can be accomplished only through the expertise of others" (p. 484). They argue for the need for a multidisciplinary approach similar to the one taken by rehabilitation and hospice programs. They note that it is often the hospice nurse who coordinates the care and ensures that emotional, financial, relational, and medical issues are addressed. They suggest that, similarly, in a model of an assisted suicide with a non-physician health care professional overseeing and coordinating the process, a physician might assess the request and a multidisciplinary team, led by a nurse, might perform the other tasks. Thus although the team would include a physician, it would not need to be led by a physician.

Faber-Langendoen and Karlawish (2000) suggest that although no health care profession is likely to unequivocally embrace the provision of lethal medications for assisted suicide, support may exist for developing a new health care structure analogous to hospice that could include physicians, nurses, clergy, social workers, and pharmacists. This new structure could be charged with the goal of defining the standards and training required to fulfill a person's request for assisted suicide. They conclude that "the willingness of other health care professionals--including nurses, social workers, and clergy--to participate and even take the lead in assisting suicides is critical to meet society's interest that assisted suicide should be humane, effective, and confined to appropriate cases" (p. 486).

Refusing to Participate in Assisting a Suicide

Earlier, two questions were posed regarding the ethics of a health care professional's participation in assisted suicide. The first was whether that person's role as a health care professional makes participation morally objectionable. While the official voices of the health care professions have taken the position that it does, as we've discussed, other commentators continue to argue that health care professionals of all disciplines have an important role to play in assisting patients who choose to end their lives. The second question was whether health care professionals have an obligation to assist in a suicide even if they believe it to be wrong. Here there is no controversy. Should a nurse be asked or directed to participate in a patient's suicide (which is unlikely in light of the general legal and ethical proscriptions outside of Oregon), she or he may, as an ethical matter, decline to do so as a matter of conscience. Such appeals to conscience, which may be asserted in circumstances beyond the issue of assisted suicide, reflect a desire to "preserve one's integrity or wholeness as a person" (Benjamin & Curtis, 1992, p. 119). They are based upon personal standards that do not necessarily apply to others; thus, an individual may refrain from negatively judging the patient who wishes to commit suicide while believing that his or her participation would violate personal moral beliefs. A nurse may appeal to his or her conscience and refuse to participate in a particular procedure, certainly including a suicide, as a last resort when all other arguments to support refusal have been exhausted.

Conclusion

The role of the health care professional in general, and the nurse in particular, in assisting the suicide of a patient continues to be controversial. While the official ethics statements of health care professional organizations continue to proscribe their members' participation in a suicide, respected members of the medical and bioethical communities, as well as patient advocates, argue strongly and effectively for the moral appropriateness of providing such assistance. Certainly, the issue will continue to be visited not only within professional bodies but in state legislatures. It is incumbent upon each nurse, therefore, to examine personal beliefs and consciences in order to contribute to a conversation with profound moral implications for us all.

References

Angell, M. (1997). The supreme court and physician-assisted suicide: The ultimate right. New England Journal of Medicine, 336(1).

American Nurses Association. (1994). Position statement: Assisted suicide. Washington, DC: Author.

American Nurses Association. (1985). Code for nurses. Washington, DC: Author.

Benjamin, M., & Curtis, J. (1992). Ethics in nursing (3rd ed.). New York: Oxford University Press.

Faber-Langendoen, K., & Karlawish, J.H.T. (2000). Should assisted suicide be only physician assisted? Annals of Internal Medicine, 132(6), 482-487.

Quill, T. (1996). A midwife through the dying process: Stories of healing and hard choices. Baltimore: Johns Hopkins University Press.

Szasz, T. (1999). Fatal freedom: The ethics and politics of suicide. Westport, CT: Praeger Publishers.

Michele M. Mathes, JD, is Ethics Education Coordinator, Center for Advocacy for the Rights and Interests of the Elderly, Philadelphia, PA.
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Title Annotation:Ethics, Law, and Policy
Author:Mathes, Michele M.
Publication:MedSurg Nursing
Geographic Code:1USA
Date:Aug 1, 2004
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