Medicine and Society Curriculum Contents

Section Four: Physician-Assisted Suicide And Capital Punishment: What Role Should Physicians Play?

Although all physicians learn Hippocrates’ admonition to “first, do no harm,” they may be faced with situations in which they are asked to compromise this principle. Physician-assisted suicide and capital punishment are two such situations.

Physician-Assisted Suicide and Euthanasia

Patients experiencing severe pain and suffering sometimes ask physicians to help them end their lives, to free them from further agony. In physician-assisted suicide, the physician provides the patient with the knowledge or means to die, for example, by prescribing a lethal dose of sleeping pills which can then be taken by the patient.¹ In euthanasia, it is the physician who administers the lethal agent.²

The American Medical Association (AMA) considers euthanasia and physician-assisted suicide unethical on the grounds that actively ending a patient’s life is "fundamentally incompatible with the physician’s role as healer."³ Rather than aiding in suicide, it holds that physicians "must aggressively respond to the needs of patients at the end of life." On the other hand, the AMA holds that withholding or withdrawing treatment—sometimes called "passive killing"—is permissible if requested by a competent patient or, if the patient is not competent, the patient’s family.⁴

United States laws generally concur with this position. In 1990, the U.S. Supreme Court ruled that individuals have a constitutional right to refuse unwanted treatment. In June 1997, however, it ruled that individuals do not have a constitutional right to physician-assisted suicide, leaving the legal status of physician-assisted suicide to individual states. In most states, this practice is illegal.

Oregon is the only state that has legalized physician-assisted suicide. Although this measure was passed in 1994, challenges postponed its enactment. In November 1997, Oregon voters defeated an initiative to repeal the law, thus reaffirming their initial decision to legalize the practice. Assisted suicide laws are under scrutiny in several other states.

For the remainder of this section, the term physician-assisted suicide will be used to refer to any circumstance in which a physician actively helps a patient die, whether directly (euthanasia) or through the sharing of medical knowledge (physician-assisted suicide).

Arguments AGAINST Permitting Physician-Assisted Suicide

1. Killing is Inconsistent With the Principle to “Do No Harm”
Physicians are ethically bound to use their training to heal and prolong life, and physician-assisted suicide contradicts this professional duty.^5,6 Hospice and palliative care are sufficient to ease the suffering of the terminally ill.

2. Legalized Killing Leads to Abuses
Condoning one type of killing, whether it be merciful of not, will lead to the acceptance of increasingly inappropriate deaths, including those of patients who are not terminally ill and who do not wish to die.^6,7 Physician-induced death may be used against those who have difficulty advocating on their own behalf, such as people with mental illnesses, people with disabilities, and the elderly.^5,7 The motivation to prolong life could be further eroded in cases where potentially transplantable organs may be involved.

3. Doctor-Patient Trust Will Be Compromised
If physicians are legally permitted to end another person’s life, patients may find it more difficult to trust them in challenging treatment situations.^6,8

4. The Mental Health of the Patient May Affect Decision-Making
Often patients who request suicide do so as a result of clinical depression.⁵ Once the depression is treated, the individual’s desire to die usually disappears.

5. Euthanasia May Be Used for Its Economic Rather Than Medical Benefits
If legalized, physician-assisted suicide may be inappropriately used as an economically efficient way to “manage” the seriously ill.^5,6 Rather than spend the large amounts of money that it costs to maintain the life of a seriously ill individual, the person’s life could be ended to save taxpayers’ money. Some have estimated that active euthanasia would save about $16,500 per patient.⁹ Others are concerned that the legalization of physician-assisted suicide would “undermine public support and funding for hospice programs.”⁵

6. The Patient May Be Motivated By Non-Health-Related Factors
Many terminally ill patients report wanting to die in order to relieve the burden that their illness has placed on their loved ones.⁷ This feeling is better addressed through counseling.

Opponents of physician-assisted suicide propose that practitioners can adequately serve the needs of patients with painful or terminally ill conditions through the use of proper pain treatment and, when appropriate, withholding or withdrawing life-sustaining treatment.⁶

Arguments FOR Permitting Physician-Assisted Suicide

1. Patients Have the Right to Decide for Themselves
Individuals have the right to die.¹⁰ If competent patients do not possess the physical means to carry out the act themselves and request assistance, it should not be denied.

2. Physicians Must Ease Suffering
In addition to doing no harm, physicians have a duty to ease human suffering.⁸ In some situations, helping patients end their lives is a more humane option than forcing them to continue to live in agony.¹⁰ As one scholar has said, “Respect for the person, who finds his or her continued existence intolerable, takes precedence over respect for the person’s embodied life.”¹⁰ Physicians should be responsible for helping patients “achieve a peaceful death,” and physician-assisted suicide might be the best way to achieve this goal.

3. Palliative Care Is Often Inadequate
While physicians are obligated to use palliative techniques to the fullest extent possible, these techniques are not always effective in treating pain and suffering.⁵ Sometimes death may be the only way to relieve pain.

4. Standardization Will Lead to Increased Safety
If legalized, physician-assisted suicide would become safer through the implementation of regulations and standards.⁵

5. Increased Communication About Death Will Lead to Better Solutions
If legalized, patients may feel more comfortable talking to physicians about their desire to die. This open communication may lead to the discussion of alternatives to death.⁵

If physician-assisted suicide is legalized, strict guidelines must be implemented so that the practice is not abused. Oregon’s Measure 16 provides a good example of such guidelines. This legislation dictates that doctors can prescribe lethal doses of medication for patients who are mentally competent and have been determined to have less than six months to live.¹¹ This assessment must be confirmed by another physician, and the patient must have no history of depression. To ensure that death is voluntary, the patient must initiate the request and then wait two weeks to complete a consent form.

When physicians consider assisting in patient suicides, several practical issues become relevant.¹² The patient’s mental status must be assessed to rule out depression, psychosis, substance abuse, or other conditions that may affect the patient’s desire to die. Additional sources of the patient’s motivation to die should also be assessed. To determine the appropriateness of the procedure, another physician must confirm the terminal or intractable nature of the patient’s illness. Finally, physicians must receive extensive training in methods of suicide.

Since there is no established protocol for physician-assisted suicide, physicians asked to assist in suicide will be faced with difficult decisions:¹²

• As the patient’s physician, should you discuss the patient’s wish to die with his or her family?
• Should you inform the patient’s other healthcare providers?
• If you would not perform the procedure yourself, would you refer the patient to another physician?

Capital Punishment

Physicians have played a part in capital punishment for hundreds of years, a role that has been debated for just as long.¹³ The recent utilization of lethal injection, a method of execution which requires medical skill, has heightened this debate.

In the United States, methods of capital punishment vary by state.¹³ (See Table 1.) Twenty-seven states use lethal injection, 12 use electrocution, 4 use lethal gas, 3 use hanging, and 2 use firing squads. The United States is the only country to use lethal injection.

While physicians are legally sanctioned to participate in executions, the AMA opposes such participation, stating that, “A physician, as a member of a profession dedicated to preserving life when there is hope of doing so, should not be a participant in a legally authorized execution.”¹⁴ The AMA also opposes physicians from attending executions in a professional capacity. The only action that the AMA sanctions for physicians is the certification of death, since this can be accomplished apart from the scene of the execution.

The American Medical Student Association (AMSA) not only opposes physician participation in capital punishment, but condemns the practice of capital punishment altogether.¹⁵

Arguments AGAINST Physician Participation in Capital Punishment

1. Killing is Inconsistent with the Principles of Medical Ethics
The main argument against physician participation in capital punishment is the same as that of physician-assisted suicide: it violates a physician’s duty to “do no harm.”¹³

The pain caused by various methods of execution lends further support to the argument that participation in capital punishment conflicts with the physician’s role as healer. In many methods of execution, death does not come immediately.¹⁶ In hanging, if a rapid fracture-dislocation of the neck does not occur, the prisoner will die from asphyxiation, a slow and agonizing death. Patients facing the electric chair may be electrocuted several times if the first electric jolt does not result in death. Lastly, while lethal injection is often believed to be pain-free and therefore the most humane method, catheter insertion often proves difficult, especially in prisoners who are obese, resistant, or have a history of intravenous drug use.

2. Capital Punishment Does Not Serve the Medical Needs of the Patient
Executing prisoners clearly serves the needs of the state and has no relevance to the medical condition of the prisoner. The image of physicians working solely for the needs of the state is reminiscent of the mass killings carried out by doctors in Nazi Germany.

3. Lethal Injection Can Be Performed By Non-Medical Personnel
Catheter insertion and barbiturate administration are easily performed with minimal training, and physicians need not be involved.

Arguments FOR Physician Participation in Capital Punishment

1. Capital Punishment is Necessary to Maintain Social Order
The main argument for physician participation in capital punishment is that it is warranted for the good of society.¹³ Physicians hold the expertise necessary to carry out the procedures (executions) that are mandated by the public and the U.S. justice system.

2. Lethal Injection Spares Patients from Further Pain
Lethal injection is consistent with basic medical ethics because it prevents prisoners from being subjected to less humane methods of execution.¹³ By administering or supervising lethal injection, physicians are acting in accordance with their duty to ease suffering.

Clinical Vignettes

The following vignettes will help you explore the issues involved in physician-assisted suicide and capital punishment.

Five patients are described below. For each vignette, what is your best course of action?

Physician-Assisted Suicide
1.     David is a 78-year-old alcoholic male experiencing chronic pain from multiple spinal fractures and severe arthritis. He is also incontinent. His condition is not terminal. Methods of pain control continue to be inadequate. He recently attempted suicide with an overdose of pills. David has no family and desperately wants to die. Maintaining his medical treatment is very expensive. Do you fulfill David’s wish to die?

2.     Jessica is a 63-year-old woman suffering from advanced Alzheimer’s disease. She spends most days in a state of delirium and must be kept under constant surveillance so that she doesn’t get lost or harm herself. Jessica used to have coherent moments, but now these are almost nonexistent. One day, her husband brings you a letter that Jessica had written during the early stages of her disease. In this letter, she discussed how frightened she was to lose control of her mental state. She wrote about how devastating it would be for her husband, children, and grandchildren to watch her deteriorate to the point that she no longer recognized them. In the letter, she asked that if this day ever came, she would want her physician to ease her suffering and that of her family by ending her life. Her husband and children ask you to carry out her wish. What would you do?

3.     Jerome is a 45-year-old male with prostate cancer that has spread to his ribs and spine. He is no longer responding to treatment. To ease his intense pain, Jerome has been taking the maximum dosage of narcotic analgesics. While this medication does relieve his pain, it leaves him groggy and incoherent. Several nurses have heard him say that he’d rather be dead than continue living in a vegetative state. When he is lucid, he discusses his concern about how his wife will be able to pay his mounting medical bills, and feels that this lingering death is agonizing for his children. On your last visit, Jerome asked you to prescribe him an overdose of narcotics. What questions would you ask?

Capital Punishment
1.     Morgan, a 38-year-old male, has been convicted on two counts of murder and three counts of sexual assault. He is scheduled to be executed in three weeks. Morgan has been in and out of the criminal justice system since adolescence. He regularly threatens other prisoners and guards and often initiates physical confrontations. He has admitted to raping fellow inmates on at least two occasions. Along with a recent suicide attempt, he frequently engages in self-mutilation and abuse, often scraping his hands on the floor until they bleed, and burning himself with cigarettes. Lethal injection is the only method of execution used in Morgan’s state of residence. Would you assist in Morgan’s execution?

2.     C.J. is a mentally retarded, 17-year-old boy who has been sentenced to death for the barbaric murder of his 3-year-old sister. C.J.’s history of violent behavior began with torturing neighbor’s animals and setting fires both at home and in school, and has recently spiraled out of control. One day while his parents were next door at a neighbor’s house, he repeatedly stabbed his two sisters, resulting in the death of one and permanent blindness and neurological injury in the other. Lethal injection is ordered. Do you participate?

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References
1. Council on Ethical and Judicial Affairs. Physician-assisted suicide. In: Code of Medical Ethics. Report of the Council of Ethical and Judicial Affairs of the American Medical Association. Chicago: American Medical Association. 1996-7:56.
2. Council on Ethical and Judicial Affairs. Euthanasia. In: Code of Medical Ethics. Report of the Council of Ethical and Judicial Affairs of the American Medical Association. Chicago: American Medical Association. 1996-7:55.
3. Physician-Assisted Suicide. Board of Trustees of the American Medical Association. BOT Report 59, June 1996.
4. Quality care at the end of life. Board of Trustees of the American Medical Association. BOT Report 48, December 1995.
5. Anonymous. Physician-assisted suicide: toward a comprehensive understanding. Report of the Task Force on Physician-Assisted Suicide of the Society for Health and Human Values. Acad Med 1995;70:7:583-90.
6. Kelly DF. Alternatives to physician-assisted suicide. Am J Otolaryngol 1995;16:3:181-5.
7. Nyman DJ, Eidelman LA, Sprung CL. Euthanasia. Crit Care Clin 1996;12:1:85-96.
8. Loewy EH. Healing and killing, harming and not harming: physician participation in euthanasia and capital punishment. J Clin Ethics 1992;3:1:29-34.
9. Wrable J. Euthanasia would be a humane way to end suffering. Am Med News 1989;1:37-8.
10. Miller FG, Brody H. Professional integrity and physician-assisted death. Hastings Cent Rep 1995;25:3:8-17.
11. Claiborne W. Death with dignity measure may make Oregon national battleground. Washington Post. June 27, 1997. A19.
12. Drickamer MA, Lee MA, Ganzini L. Practical issues in physician-assisted suicide. Ann Intern Med 1997;126:2:146-51.
13. Michalos C. Medical ethics and the executing process in the United States of America. Med Law 1997;16:125-67.
14. Council on Ethical and Judicial Affairs. Capital punishment. In: Code of Medical Ethics. Report of the Council of Ethical and Judicial Affairs of the American Medical Association. Chicago: American Medical Association. 1996;7:11.
15. The American Medical Student Association Principles Regarding Capital Punishment. 1996-1997 Preamble, Purposes, and Principles. The American Medical Student Association.
16. Hillman H. The possible pain experienced during execution by different methods. Perception 1993;22:745-53.

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