Physician-Assisted Death in the United States
In the perspective of Quill, the inadequate supply of skilled palliative care clinicians and the problematic reimbursement of palliative care services remain a serious challenge in addressing the need of terminally ill patients who are undergoing intractable sufferings (p.17). But even if these problems are all addressed, there will always be a small percentage of cases where suffering becomes severely unacceptable and clinicians will feel obligated to treat these patients in the most helpful yet least harmful way (p.19). Some of the last options which can be laid down at the patients own disposal includes the following methods increased dosage of opioids to relieve the patient of pain, voluntarily stopping eating and drinking (VSED) and sedation to unconsciousness. According to Quill, it is better to have these options out in the open so patients can evaluate the best options for him rather than keeping it in the dark yet administering it to the patient.
On the other hand, Steinback looks at the legalization of PAD or PAS based on the risks of mistakes and abuses which go together with it. Take into consideration the case of Kate Cheeney and Michael Freeland. Kate Cheeney is an 85 years old who was diagnosed with inoperable stomach cancer. Upon seeing the difficulty her illness brought to her daughter Erika, she decided to eat the bowl of applesauce which was mixed with barbiturates that eventually lead to her death within an hour (p.238). According to some analysts, Kate was simply forced by circumstances and did not choose to take barbiturates out of free will but because of the pressure brought by her family members. Michael Freeland shares a similar case. He was diagnosed with terminal lung cancer and received a prescription for lethal drugs from Dr. Peter Reagan. The option to end his life only lead him to more psychological trouble but thanks to the Hamiltons he was able die naturally and used the remaining two weeks of his life reconciling with her daughter (p.239). Although, both cases are not show clear cut abuse of PAD or PAS, there is still a big room for mistakes and abuses in these types of last options.
In presenting his argument to support PAD or PAS, Quill provides the following factual claims. One of out 50 patients talks to their physicians while one of six talk to their family members regarding the availability of PAD or PAS (p. 20). This implies that patients are looking for other avenues on how to alleviate the extreme pain they are experiencing. The legalization of PAD in Oregon enhances other aspect of palliative and end-of-life care rather than undermines it. Oregon alone has one of the highest rates of hospice referral in the nation. It has a relatively high rate of opioid prescription per capita. Its physicians and other medical professionals have very high rates of attending training courses in both palliative care and end of life medical decision making. The Physician Orders for Life-Sustaining Treatment or POLST is a statewide form and has become a model for other states (p.20).
Other factual claims presented by Quill are based on percentage of PAD or PAS related death cases in particular states and countries. In New York where VSED is permitted, PAD accounts for less than one percent of deaths. In Netherlands, 20 percent of death is related to the prescription of opioid to patients forgoing life sustaining therapy. In a mid-1990s study, researchers found out that PAD and euthanasia accounted for approximately 1 to 2 percent of deaths. Lastly, Quill uses a legal decision to further strengthen his claim on this matter. The 1997 Supreme Court decision made it clear that alleviating suffering to the point of causing unconsciousness and hastening death is legally acceptable (p.21).
On the other side, Steinback provides these factual claims to refute PAD or PAS. 50 of conscious patients who died in the hospital experienced moderate to extreme pain in the last three days of life (p.236). Suffering is not limited to individuals who are competent to request death but extends to infants, people with developmental disabilities and the elderly senile. Educated Middle Class members are the one who chooses PAS or PAD which is in direct contradiction to the earlier assumption that members of the lower classes of society are more likely to choose this option.
She also provided some statistical information to support his arguments. These are as follow According to a report of 897 physicians who cares for cancer patients, the most common form of narcotic abuse in the care of the dying is the under treatment of pain (p. 237). Only 1 out of 100 who asked about assisted suicide carries it out in the end. In Oregon alone where PAD or PAS is legalized, only 1 percent of Oregonians die of PAS. Further studies suggests that the risk of choosing PAD or PAS is brought by economic pressures, when healthcare budgets are being cut which makes poor people, minority group members, and the disabled prone to abuses and mistakes.
In as much as Steinback has no legal decision to back up his argument, she has WHO and the New York State Task Force to support her on this matter. The World Health Organization has endorsed palliative care as an integral component of a national health care policy and has strongly recommended to its member countries that they not consider legalizing PAS and euthanasia until they have addressed the needs of their citizens for pain relief and palliative care (p. 237). In addition, the New York State Task Force characterized the treatment of severe pain in hospitalized patients as regularly and systematically inadequate amidst the contention that the availability of PAS has only addressed the other end-of-life care options more effectively.
It is apparent in both of the factual claims presented by Quill and Steinback that legalization of PAD or PAS has indeed enhanced and improved palliative and hospice care. Both of them also shares in the belief that PAD or PAS in Oregon is relatively low with just a rate of 1 percent. Nevertheless they present a different perspective with regards to the patients who seek information regarding PAD or PAS. Quill only notes of the ratio of patients who asks information pertaining to PAD or PAS but refrained in providing numerical information which provides answer to the rate of patients who forego such a method. On the contrary, Steinback went a step further by providing us information on the ratio of patients who did forego with the PAD or PAS and we found out that it is a very small percentage compared to the rate of patients who inquired. This information is vital when we make our final analysis on this matter.
Let us now proceed to the ethical claims provided by both parties. Quill presented the following ethical claims to prove his support of PAD or PAS. It is better and safer to have open conversations about PAD or PAS out in the open rather in secret because the secret practice of PAD only results in a dont ask, dont tell policy which is unpredictable and potentially dangerous (p. 21). Terminally ill patients have the right to intensive pain and symptom management but the obligation to relieve them of severe suffering will definitely warrant taking the risk of an early death (p. 18). Terminally ill patients have the right to forego life sustaining therapy but if these fail and the patient experiences extreme pain he has the right t look for options where he can escape suffering and hasten death (p. 19). Some patients who experience extreme pain will need a way out, and withholding one important option from patients whose options are so limited seems unfair (p. 21). PAD or PAS puts choice directly to the hands of the patient and thus gives them autonomy.
On the other side, Steinback presents these ethical claims
It is cruel to force a dying patient whose pain cannot be controlled with medication to continue living but it is more cruel to force someone to endure suffering for a longer period which includes infants with multiple disabilities, personal with developmental disabilities and the elderly senile but it does not mean that you can force these individual to undergo PAD or PAS. It cannot simply be possible because they are not competent individuals. (p.235).
Every competent person has the right to make momentous personal decision which involves fundamental religious or philosophical convictions about lifes value and him self but Only God has the right to determine when a person will die. PAD or PAS is a direct violation of the fundamental tenet of medicine to heal and not to harm (p.236) and administering PAD or PAS to patient is definitely doing harm to a person.
It is not possible to draft a statute that will cover all and only the justifiable cases which pertains to PAD or PAS. Man is not all knowing. Our knowledge is limited and we can only provide general statutes and because of this, changing laws in favor of PAD or PAS is more likely to produce mistakes and abuses in the future just like the case of Kate and Michael as mentioned earlier in the paper. Lastly, the duty to die only imposes the avoidance of financial, physical and emotional burden on the family member rather than an imposition on ones autonomy.
In both of the ethical arguments, we see that both parties believe that autonomy and suffering are vital in the analysis of this problem. Nevertheless, they see it in a different perspective. Quill sees individual suffering as an excuse to offer PAD or PAS. His eyes are concentrated on the individual per se. His ethical claims are grounded on individual rights and all other premises springs forth from this realization. PAD or PAS is but compassion towards the patient since there are no other forms of medication available for him. The only thing a physician can do is to lessen the pain a patient is experiencing but bear in mind that this option is only to be considered after all other life sustaining technology and medication has been exhausted. Quill does not support PAD or PAS unless a physician has extensively exhausted all resources possible to cure his patient. On the contrary, Steinback sees it in terms of the universal impact it will produce in society. Legalizing PAD or PAS gives room to extension of these practices even to those who does not need it like the elderly senile, the poor and the minority group members who simply does not have enough resources to support life sustaining technology. Steinback thus not deny the possible benefits PAD or PAS may offer to terminally ill patients but she worries that some family members or irresponsible physicians may use this as a tool to lessen the weight of responsibility on their shoulder.
Timothy Quill is an associate in the Litigation Department of Cooley LLP and focuses on general commercial litigation. This means that he is very much acquainted with legal procedures as shown in his analysis of the problem of PAD or PAS. We can also consider his approach towards this problem as a form of consequentialist approach. Consequentialism is the approach wherein the moral rightness of acts depends only on the consequences of the act or of something related to the act such as motive behind the act or a general rule requiring acts of the same kind (Sinnott- Armstrong, 2006). It can further be translated to the maxim which states that the end justifies the means. It is focused more on the good rather than the right. A physicians role is primarily to provide treatment but if treatment is not anymore applicable then he becomes the source of alleviating pain. The motive of the physician is not to do harm to the patient but only to ease him of the pain. The patient deserves all the right to be free of extreme pain. The patient considers this the best option for him, the law supports it and we are not harming anyone so why not do it. It promotes the good of the patient and whatever suits his desires should be administered especially after taking into consideration and exhausting all other medical treatments and technology which can cure him of his illness.
On the other hand, B. Steinback uses the deontological approach or the absolutist approach. Deontology originated from the categorical imperative of Kant which states that one should always act in such a way that you can also will that the maxim of your action should become a universal law. That which cannot be universalized cannot be accepted as morally right. Steinback argues until the very end that PAD or PAS cannot be universalized because we cannot create statutes that can address all possible cases which will contain the permission of this PAD or PAS. She further advocates the deontological principle, duty-based ethics, by addressing the fact that physicians have a pledged obligation not to do any harm to their patient. This obligation is further extended to the government. By constantly reiterating the need to provide safeguards which will ensure that PAD or PAS even after legalization will not pose any abuse towards any member of society, she only affirms her deontological conviction. It is also worthy to take note that Steinback is a woman and being a woman it is very much possible that she experienced discrimination compared to men. You can sense in her arguments how this greatly affects her reasoning. She has focuses on the risks of abuses PAD or PAS may bring forth to society because she herself may have experienced abuses in the past.
The deontological approach and consequentialist approach has always been in conflict with one another in as much as mans reasoning compared to a womens analysis contain differences especially in the perspective which they are looking at. The case of the legalization of PAD or PAS shares a very similar argument. It is battle between what is good and what is right. Quill argues that what is good should be legalized while Steinback argues that what is right should be implemented by law. In as much as it is very hard to make a union out of these two principles there is still certainly an avenue where both can meet and agree on something. Steinback only wishes that the risk of abuse in PAD or PAS be eliminated while Quill wants PAD or PAS to be included in list of legally medical options for terminally ill patients.
Both are not absolutists on these issues but are amenable to modifications. In the concluding words of Steinback she states, I am not suggesting that the Oregon law should be repealed. . .My point is rather that before the rest of us climb on the PAS bandwagon, there are many crucial issues to be hammered out. The discussion should continue. (p. 240). On the other hand Quill makes this concluding remark, We can simultaneously evaluate the impact of better and more widespread access to hospice and palliative care, and of more predictable and accountable availability of other last resort options. (p. 22). Apparently they share one thing they want a continued deliberation and evaluation of the different alternatives and consequences this act will produce. Both are open minded and amenable to change but make sure you allow both sides to present their arguments.
After careful deliberation of factual, ethical and post ethical analysis of these arguments I propose the following remedies which can further draw the two opposing parties together. It is best to gather factual claims which provide sufficient evidence that a great percentage of terminally ill patients will indeed prefer having several last end options which includes PAD or PAS. It is best to have a comparative analysis of the different states which already allow PAD or PAS and see the significant impacts it has on society. These ought to include the rates of cases with alleged irregularities, abuses and mistakes. On the ground of the ethical issues discussed in the two articles, I suggest that a clarification of the term harm, heal, duty and rights be further expanded. It would be better if it will include a lengthy discussion of personal rights and social rights. As for the post-ethical analytic approach, an elaborative study of what is good juxtaposed the principle of what is right would further make our analysis constructive.
Nevertheless, as of the moment I consider the Quills approach more realistic. We should indeed provide terminally ill patients all of their options. As long as they are competent to make major decisions in their life, we should respect and honor it. The individuals right is still above all other rights especially if you are not trampling on the rights of others. Nevertheless, if the physician sees that a patients decision is clouded because of ignorance of the facts, he may intervene and provide further explanations on the options provided before him. This does not mean in anyway that PAD or PAS will always be the first option whenever we are given a terminally ill patient. Palliative care still needs to be the standard of care for all seriously ill patients and the government should ensure that all its physician, clinicians and medical professional are well trained with it. Better policies and procedures which will help support a quality life should be supported and consistently discussed because it is still the governments role to ensure that its citizen has access to a quality and efficient health service.
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