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In 2018, Andy Jurtschenko received a standard procedure: a heart transplant (1). But after 24 hours, Jurtschenko hadn’t woken up. After investigation by a neurologist, Andy was found to have suffered immense brain damage and would likely remain in a vegetative state for the rest of his life. Faced with a difficult decision, Andy’s children requested a do-not-resuscitate order (DNR), which mandates physicians must not administer emergency care if one’s heart stops beating or breathing ceases (2). Yet, the primary physicians declined their request only eventually relenting after immense pushback. Later, Andy recovered consciousness – but in limited form. Andy’s story is one of many that reveals the ethical dilemmas of DNRs. 


DNRs do not allow for resuscitative treatment, such as CPRs, defibrillators, and the delivery of certain drugs in the event of cardiac or respiratory arrest (3). While in-hospital DNRs affect the decisions of physicians, out-of-hospital DNRs apply to EMTs. Though different from physician-assisted euthanasia, where physicians actively induce death, like euthanasias, DNRs have significant ethical and legal complications.


Legally, DNRs lack legislation and policies regarding administration and decision-making. Within the U.S., DNRs require the explicit signature of a physician in order to be issued. Typically, those with terminal illnesses request DNRs, although fully healthy individuals can also do so. Ethically, DNRs pose a challenging question to healthcare providers, physicians, and patients. The American Medical Association ambiguously states that patients have the right to reject care, while doctors can also reject certain needs on a reasonable basis (4). But this oxymoronic statement leads to great debate in the medical community about whether DNRs are examples of withdrawing or withholding care. These debates lead to the pivotal questions: Are DNRs a form of passive euthanasia? Subsequently, with euthanasia being entirely outlawed in the U.S., should DNRs be illegal as well? Importantly, how do you consider patient autonomy? As seen in the story of Andy, if a patient is not mentally capable of making a decision, who makes the decision for them? With no clear guidelines for decision-making in DNRs, if a patient is incapable, conflict between the wishes of family members and friends can certainly occur, as it did with Terri Schiavio’s case in 2005 (5).


Lastly, there are also significant moral complications with doctors taking advantage of DNR orders. Investigations have found that during the height of the covid-19 pandemic, many doctors sought to impose illegal DNR orders on those with learning disabilities – also known as a blanket DNR that targets a certain group of people (6). Samuel R. Bagenstos, a law professor at Michigan Law School, best stated the implications of such actions as “caus[ing people with disabilities] to experience less full lives” (7).


Ultimately, as emergency and medical care continue to improve, the complexities behind DNRs will only become more dynamic. Thus, medical professionals and ethicists must continue to thoroughly evaluate this dilemma.


Reviewed by Bowen Kim

Design by Ting Ting Li


Citations

  1. Chen, C. (2019, December 31). The family wanted a do not resuscitate order. the doctors didn’t. ProPublica. https://www.propublica.org/article/the-family-wanted-a-do-not-resuscitate-order-the-doctors-didnt 

  2. U.S. National Library of Medicine. (n.d.). Do-not-resuscitate order: Medlineplus medical encyclopedia. MedlinePlus. https://medlineplus.gov/ency/patientinstructions/000473.htm 

  3. Miceli, M. (2016). Bioethics in practice: Unilateral do-not-resuscitate orders. U.S. National Library of Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4896650/#:~:text=The%20answer%20is%2C%20generally%2C%20no,of%20cardiac%20or%20respiratory%20arrest

  4. 31, J., & Jr., J. R. (2023, January 31). Physicians, not judges, should direct patient care. American Medical Association. https://www.ama-assn.org/about/leadership/physicians-not-judges-should-direct-patient-care#:~:text=Physicians%20are%20expected%20to%20provide,of%20medical%20treatment%20or%20intervention

  5. Weijer, C. (2005). A death in the family: Reflections on the terri schiavo case. Canadian Medical Association Journal, 172(9), 1197–1198. https://doi.org/10.1503/cmaj.050348 

  6. Alexiou, G. (2023, September 12). Doctors issuing unlawful “do not resuscitate” orders for disabled Covid patients “outrageous.” Forbes. https://www.forbes.com/sites/gusalexiou/2020/06/23/unlawful-do-not-resuscitate-orders-for-disabled-covid-patients-outrageous/?sh=3079ecdc6cf1 

  7. Ibid.

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It’s ingrained in physicians to save lives. They dedicate their entire career to helping and healing others. However, this role is called into question when it comes to the topic of physician-assisted suicide. According to WebMD, physician-assisted suicide is defined as when “a doctor gives a patient a prescription for a lethal dose of medication that they can use to end their life when they’re ready”. Patients seeking this procedure have to meet certain criteria, which includes: being 18 or older, being of mentally sound mind, having a terminal illness with a prognosis of less than 6 months to live, and being able to ingest the medicine themselves. Additionally, patients have to gain approval from multiple doctors and affirm this request multiple times (1). 


There are obvious reasons for physicians to be opposed to this procedure. Namely, it directly contradicts the role of physicians as healers. To help someone die goes directly against their code. Further, this can be a slippery slope and can be hard to control if more common. For example, the criteria may become more relaxed, allowing more and more patients to elect to go through this procedure. 


However, there are those who champion physician-assisted suicide. The foundation of these arguments lie in the belief of the “Right to Die”. Proponents believe that this procedure respects the patient's autonomy. When given all the necessary amount of information needed to make this decision, patients can make informed decisions about how they want to proceed with their lives, even if this means choosing physician-assisted suicide (2). Additionally, some people believe that this is actually merciful, by giving patients an end to their suffering. People in severe pain, with no hope for improvement, will have a low quality of life, and continue to suffer. Further, some people don’t have access to the necessary care for their terminal illnesses, whether this is because of lack of money or other resources. Proponents argue that by allowing these patients to choose physician-assisted suicide, physicians are actually acting in a compassionate and humane way, partly fulfilling their role as healers (2). 


This topic still remains highly controversial within the medical community. In fact, of the 50 states, only 11 have legalized this procedure (3). Other states, such as Florida even criminalize physician-assisted suicide, charging any physician who participates with second degree manslaughter (4). Ultimately, at its core, this issue highlights the complexity of navigating ethical issues within the medical community, especially in palliative care. As the medical community continues its discourse, it’s critical to engage in thoughtful dialogue, informed by ethics, empathy, and a commitment to the well-being of patients. 


Reviewed by Sophia Zhang

Design by Soojin Lee


Citations

  1. Jordan, C. (2024, January 8). What to Know About Physician-Assisted Death. WebMD. https://www.webmd.com/a-to-z-guides/what-to-know-physician-assisted-death

  2. Dugdale, L. S., Lerner, B. H., & Callahan, D. (2019). Pros and Cons of Physician Aid in Dying. The Yale journal of biology and medicine, 92(4), 747–750. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6913818/

  3. Compassion & Choices. (n.d.). States Where Medical Aid in Dying is Authorized. https://www.compassionandchoices.org/resource/states-or-territories-where-medical-aid-in-dying-is-authorized

  4. Patients Rights Council. (2017, January 6). Assisted Suicide Laws in the United States. https://www.patientsrightscouncil.org/site/assisted-suicide-state-laws/

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Do people have the right to willingly die? 



This question has sparked numerous debates around the process of Physician-Assisted Suicide (PAS). PAS involves a physician providing a competent, terminally ill patient with the means to end their own life [1]. At the heart of the controversy surrounding PAS is a clash of fundamental ethical principles: the respect for autonomy versus the sanctity of life.


Proponents of PAS argue with autonomy and compassion in mind. They believe that individuals facing terminal illnesses should have the right to choose the timing and manner of their death, especially to avoid facing unnecessary suffering and loss of quality of life [2]. This goes hand in hand with the belief that people should have control over their own bodies and decisions related to their health, which can include the decision to end their life in certain circumstances [3]. As such, advocates of PAS emphasize the importance of individual suffering and the moral imperative to alleviate it, suggesting that in certain cases, helping someone die can be an act of profound kindness.


On the other hand, opponents of PAS draw upon the sanctity of life principle, claiming that life is inherently valuable and should be preserved at all costs. They argue that normalizing PAS would undermine this intrinsic value of human life and may also lead to coerced death in vulnerable populations (i.e. the elderly, disabled, etc.) who might feel pressured to choose death over being a burden to their families or society [2].


Central to the debate over PAS beyond the patient is the role of the physician themselves. Since the medical profession is guided by the Hippocratic Oath to "do no harm," PAS raises questions about whether it supports  or contradicts the fundamental duties of a physician. PAS, as a compassionate response to suffering, aligns with a physician's duty to alleviate pain. However, it could also compromise the doctor-patient relationship, transforming healers into “agents of death” [3]. 


All in all,  the ethical debates around PAS are likely to only intensify as society’s attitudes towards death and autonomy shift. Therefore, going forward, we must find common ground that honors both the sanctity of life and the dignity of death.


Reviewed by Laila Khan-Farooqi

Design by Acelo Worku


Citations:

[1] American Medical Association. (2016). Physician-Assisted Suicide | ama-coe. Code-Medical-Ethics.ama-Assn.org. https://code-medical-ethics.ama-assn.org/ethics-opinions/physician-assisted-suicide


[2] Goligher, E. C., Ely, E. W., Sulmasy, D. P., Bakker, J., Raphael, J., Volandes, A. E., Patel, B. M., Payne, K., Hosie, A., Churchill, L., White, D. B., & Downar, J. (2019). Physician-Assisted Suicide and Euthanasia in the ICU. Critical Care Medicine, 45(2), 149–155. https://doi.org/10.1097/ccm.0000000000001818


[3] American Medical Association. (2016). Physician-Assisted Suicide | ama-coe. Code-Medical-Ethics.ama-Assn.org. https://code-medical-ethics.ama-assn.org/ethics-opinions/physician-assisted-suicide

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DMEJ

   Duke Medical Ethics Journal   

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