Duke Medical Ethics
Death with Dignity or Insult to Injury?
Euthanasia and physician assisted suicide are ways of relieving pain and suffering for patients in their most vulnerable state, by inducing or speeding up an already impending and painful death. Although these practices accomplish the same thing, there is a critical difference between the two: in physician assisted suicide, the doctor prescribes a lethal medication, in which the patient themselves has to fill and self-ingest on their own terms. Within 48 hours, the doctor then administers a compounded medication containing sedatives and opiates that cause the patient to fall into a coma and die in their sleep. In euthanasia, a lethal dose is solely administered by the physician at the repeated and voluntary request of the patient. Both euthanasia and physician assisted suicide provide a humane way of ending patient suffering in the midst of death; however, it is important to consider how the legalization of these practices may put the most vulnerable patients at risk: the elderly, the disabled, and the mentally ill.
The legalization of euthanasia is a bit of a double-edged sword: while it grants autonomy to terminal patients who are conscious and capable of making the decision, it can also create a space where vulnerable patients that feel like a burden to their family and society are pressured into choosing euthanasia. In the 2017 report on patients requesting physician assisted suicide in Oregon, 55% stated being “a burden on family, friends, and caregivers” as an end of life concern (Public Health Division, 2017).
Especially in the United States, where health care is extremely expensive, patients would more
Often than not feel as though they ought to choose euthanasia for the sake of limiting costs to their family. Insurance companies in the U.S. have already taken advantage of the End of Life Option Act California, passed in 2016. In the case of Stephanie Packer, a woman who was terminally diagnosed with scleroderma and undergoing treatment, asked her insurance company to cover her switch to a different chemotherapy drug. At first, they said it would be covered at the suggestion of her doctors; however, only a week after the assisted dying act passed, the company denied her treatment coverage. When she called to ask why, they remarked that “suicide pills” are covered, and would only be a $1.20 co-pay (O’Neill, 2015). The health systems and legislatures in which euthanasia and physician assisted suicide exist are central to whether or not lines are crossed and vulnerable populations are harmed, while both private and public insurances benefit.
Euthanasia and assisted suicide is also controversial amongst patients with disabilities. In many countries, basic and affordable health care is not accessible for the average citizen, let alone for disabled and chronically ill patients. In an article by Craig Wallace, the former president of People with Disability and leader of the advocacy group Lives Worth Living, Wallace argues that offering euthanasia to the disabled is in no way an act of equality, but rather a stand-in for offering accessible health care to the disabled. Instead of providing adequate health-care and meaningful alternatives, euthanasia is “a fake cruel one-way exit for vulnerable people locked out of basic healthcare” (Wallace, 2017). For patients that are not terminally ill, but require chronic care throughout their lives, the question should not be one of eligibility for euthanasia. Instead, it should be of how to provide the best health care and social services to them in order to create a better quality of life. Without at least attempting to eliminate the want for suicide in disabled patients, euthanasia runs the risk of being used as a treatment option, rather than an end-of-life choice. Economic factors and health care resources play a bigger role in legislature of euthanasia than one would like to admit, but it is clear that chronic, life-time, health care services for one disabled person is exceedingly more expensive than the cost of euthanasia.
The mentally ill are perhaps the most vulnerable population when it comes to euthanasia and assisted suicide (EAS). As a population of patients that is historically taken advantage of, it would make sense that there is legislature to protect those with mental illnesses. Oregon and California specifically mention how psychiatric illnesses are not cause for assisted suicide, and if doctors suspect mental illness to be impairing their judgement they can refer them to a psychiatric evaluation to ensure it is not their reasoning for the assisted suicide request. Conversely, in the Netherlands and Belgium, non-terminally ill patients with psychiatric disorders can request euthanasia (Evenblij, 2019). The very basis of EAS is that patients are mentally competent and capable of consent. However, patients with mental illnesses are mentally ill—how could they be eligible for EAS? In the case of dementia, patients are not considered to be capable of making that decision. There were 166 Dutch cases in 2017 that involved patients with early-stage dementia—when they were still aware and capable of making an informed decision (Dutch Regional Euthanasia Committees, 2017). However, the line becomes blurred when these same patients request the doctor to euthanize them at a later stage, when they are no longer mentally capable of expressing their wishes. In 2017, there were three cases of late-stage dementia patients that were in this exact position. In one case, the physician drugged the woman’s coffee without her knowledge, and when she awoke the doctor had to have her physically restrained while administering lethal medication (Boffey, 2018). The entire case is under investigation, but the fact that this is not a clear and unequivocal breach of consent in the Netherlands is the prime example of the “slippery slope” euthanasia implicates.
The central belief of medicine is to help people, to relieve suffering, and to do what is in the best interest of the patient. Patient autonomy is a key factor in all of these, and laws that serve that autonomy can be both useful and abused. Both euthanasia and assisted suicide provide a sense of dignity and control in the midst of death. However, the capability to consent to these practices can be blurred, especially in cases with elderly patients, those that are unable to express their wishes at that moment, and those with disabilities or mental illness. These are some of society’s most vulnerable populations, and the regulations surrounding euthanasia and assisted suicide need to be able to protect them from the very health care systems and insurances that should be serving them.
This article was written by Jenelle M. Safadi of Cornell University. References and acknowledgements can be found in our journal, under "Current Issue."