Running head: PHYSICIAN ASSISTED SUICIDE

The Ethical Dilemma of Physician Assisted Suicide

Karen Hatch
University of Arizona

PHYSICIAN ASSISTED SUICIDE

The Ethical Dilemma of Physician Assisted Suicide

An ethical dilemma is a situation in which an individual must choose between two
actions that will affect the welfare of another human being, and both actions can be sensibly
justified as being good, neither action is readily justified as good, or the goodness of the action in
question is uncertain (Rich, 2013). These types of situations are seen in many areas of health care
and frequently regarding end of life care. Physician assisted suicide (PAS), also termed physician
assisted death, is one such contention that has long been at the center of ethical debate in health
care worldwide. The purpose of this paper is to address ethical principles surrounding the
legalization of PAS. Experts that are in support of the legalization of PAS, argue on behalf of
the patient, and base their argument on the ethical principle of autonomy. Experts that oppose the
legalization of PAS, argue on the behalf of the health care provider, and base their argument on
the ethical principle of nonmaleficence. This paper will provide the reader with a short
background on PAS, summarize the significance of the dilemma to health care, analyze two
conflicting ethical principles that surround this debate, and present the authors position on the
legalization PAS.
Background
The concept of physician assisted suicide and the conflicting ethical principles that
constitute the debate surrounding assisted death predate the Hippocratic Oath of 5th century BC
(Will, 2011). Although the dilemma surrounding PAS has over 2,400 years of medical
recognition and discussion it is still a central topic in the medical field today (Will, 2011).
Legalization of PAS has been at the forefront of state legislation over the last two decades. In
1997 Oregon became the first state in the nation to legalize PAS (Dyer, White, & Rada, 2015).
Washington state and Vermont passed similar legislation in 2009 and 2013 respectively (Dyer et

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al., 2015). A court ruling in 2009 in Montana established protection for doctors who assist
terminally ill patients to die (Dyer et al., 2015). The court determined that the prosecution against
doctors that assisted the terminally ill in this manner would violate the states constitution (Dyer
et al., 2015). In 2014, a court in New Mexico issued a similar ruling which was reversed several
months later (Dyer et al., 2015). Most recently, in October of this year, Governor Jerry Brown of
California signed legislation similar to that of Oregons Death with Dignity Act that will allow
for physicians to prescribe lethal doses of medications to terminally ill patients of sound mind
(Obeidat, 2015). The law will take effect sometime next year when California legislature
concludes its session on healthcare (Obeidat, 2015). At this time, 12 other States have also
considered similar legislation to legalize PAS (Obeidat, 2015). The debate over legalization of
physician assisted suicide is one of international proportion. In February 2015, Canada became
the first country with a common-law system to legalize PAS (Attaran, 2015). Several other
countries have introduced laws legalizing PAS including Belgium, Luxembourg, and Colombia
(Dyer et al., 2015). In the Netherlands, PAS is still a crime; however, physicians that assist a
patient to die are no longer prosecuted, provided that they have met certain criteria (Dyer et al.,
2015). Similar criteria are required in Switzerland but assisted suicide is not just restricted to
individuals with a terminal illness (Obeidat, 2015). Public and political debate over the
legalization of PAS is also occurring in many other countries including the UK, Australia, and
New Zealand (MacLeod, Wilson, & Malpas, 2012).
Significance to Health Care
As the right-to-die movement gains momentum and more states pass legislature
legalizing PAS an increasing number of health care providers including doctors and nurses will
be placed in situations where they are caring for terminally ill patients who are considering this

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option. For the purpose of this paper PAS will be defined as a doctor intentionally helping a
person to commit suicide by providing drugs for self-administration, at that persons voluntary
and competent request (Materstvedt et al., 2003, pp. 98). The sole concept of physician assisted
suicide actively involves the physician and the care provided to terminally ill patients concerns
all members of the health care team. Health care providers have a moral obligation to do for the
patient that which is in the patients best interest and in order for providers to do this they must
be educated on the ethical principles that surround the debate and be prepared to take action
whether for or against PAS.
Identification of Conflicting Ethical Principles
Two conflicting ethical principles that create the foundation for the debate of physician
assisted suicide are autonomy of the patient and nonmaleficence of the health care provider. The
principle of autonomy is often described as the respect for autonomy, which may be defined as
the freedom and ability to act in a self-determined manner (Rich, 2013). Autonomy supports the
right of an individual to express personal decisions and have those decisions honored (Rich,
2013). One ethical argument for the legalization of physician assisted suicide is that which
supports the autonomous choice of the patient requesting aid-in-dying. Those that argue against
physician assisted suicide base their argument on the principle of nonmaleficence and the health
care providers obligation to do no harm (Rich, 2013). Nonmaleficence is the maxim or norm
that one should not inflict harm and requires intentionally refraining from actions that cause
harm (as cited in Rich, 2013). The importance of nonmaleficence is well recognized in medical
practice (Rich, 2013). The argument against PAS based on the principle of nonmaleficence of the
healthcare provider is such that the health care provider should not be allow to prescribe a lethal

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dose of medication that would prematurely terminate a life, as this is an act which inflicts harm
on the patient.
Analysis of Conflicting Ethical Principles
Autonomy
Experts argue that physician assisted suicide must be legalized based on the ethical
principle of autonomy, or self-determination. There is no question that respect for patients
autonomy is a crucial aspect of patient care. In the domain of health care, respecting a patients
autonomy means facilitating and informing patients of their choices concerning treatment;
respecting patients rights to refuse treatment; and disclosing comprehensive and truthful
information, diagnosis, and treatment options (Rich, 2013). All of these aspects of patient care
ensure that the patient maintains as much control over their treatment and health as medicine can
allow. To deny a patient the right to die in a way that the patient chooses is to deny the patients
autonomous right to self-determination (Baezner-Sailer, 2008). Patients should have the right to
remove themselves from pain and suffering and control as much as possible the manner in which
they die (Battin, 2008). The ethical principle of autonomy focuses on the patients right to make
important decisions about their lives, including what happens to their bodies, and those rights
support genuinely autonomous forms of PAS (Quill, Lo, & Brock 2008). As Andrew Solomon
emphasized, Making someone die in a way that others approve, but that he feels is anathema is
an odious form of tyranny (Legalize Assisted Suicide: A Debate, 2014, p. 4). How much
physical and mental suffering a patient is willing to endure should be entirely in the patient hands
(Baezner-Sailer, 2008). Patients are autonomous beings and should be entitled to make their own
decisions whether about treatment, the refusal of treatment, or the decision to terminate their own
life (Legalize Assisted Suicide: A Debate, 2014). In order for healthcare providers to respect

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the patients full autonomy the decision for PAS must be left to the judgement of the competent
patient as they determine their willingness to endure suffering at the end of life (Baezner-Sailer,
2008).
Nonmaleficence
The principle of nonmaleficence, which is used to communicate the obligation to do no
harm, is as old as the organized medical practice itself (Rich, 2013). According to Daniel
Sulmasy, it is the job of the physician to help people to die with dignity and comfort but not to
assist in the premature termination of life (Legalize Assisted Suicide: A Debate, 2014). The
duty of the physician is to preserve life, protect and restore health, relieve suffering, and to be
there for the dying until death (Oduncu & Sahm, 2010). This role involves caring and
commitment to overcome suffering but does not involve an active role in ending the patients life
in order to achieve this (Paris, 2009). Traditionally health care workers are encouraged to do
good, to act on the principle of beneficence; however, if they are unable to do good they are at
the minimum required to do no harm, to ensure nonmaleficence (Rich, 2013). Killing another
human being is synonymous with doing harm. PAS requires that the physician violate one of the
most consecrated of medical ethics: doctors must not kill (Gaylin, Kass, Pellegrino, & Siegler,
1988). Generations of physicians and those highly versed on medical ethics have emphasized the
distinction between ceasing treatment, or allowing death, and active, willfully taking of life
(Gaylin et al., 1988). If physicians become executioners or are even licensed to kill, the health
care profession and its members will never again be worthy of trust and respect as healers,
comforters, and protectors of life (Gaylin et al., 1988).

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Students Personal Position

Based on the two ethical principles discussed, the authors position concerning physician
assisted suicide is that it must not be legalized. The author recognizes the importance of
autonomy and believes that the health care provider has a moral obligation to respect the
patients decision in regards to refusal of treatment even to the point of hastening death. In an
essay addressing patient autonomy and medical decision making Jonathon Will promotes the
autonomy model, stating that the patient knows what treatment decision is in line with his or her
true sense of well-being, even when the decision is the refusal of treatment and the result is the
patients death (2011). However, PAS demands far more than respect for autonomy, it demands
that physicians take an active role in terminating life. According to Prichard, an individuals right
to do with their body as they will is relevantly different than a right to demand hastened-death
assistance from a physician (2012). Even where a right to die is recognized, this recognition does
not suggest that someone assist another person to die, and so the argument for patient autonomy
in respects to PAS is limited (MacLeod et al., 2012).
Respect for the principle of nonmaleficence must be upheld. The sanctity of this principle
ensures the safety of the sick, the injured, and the most vulnerable. When the physician adheres
to the principle of nonmaleficence trust in the health care team, one of the most important
aspects of end-of-life care, can be obtained. The Haylend et al., study found that patients and
their family members felt that having trust and confidence in the doctors looking after them was
a key element of quality end-of-life care (2006). PAS contradicts established professional
medical ethical standards and if allowed would destroy the bond of trust between patient and
doctor (Oduncu & Sahm, 2010).

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8
Conclusion

Physician assisted suicide is more than just a matter of legislation, it is a complex ethical
dilemma that demands careful consideration from the physician, all other members of the health
care team, and society as a whole. While patient autonomy and self-determination remain
integral aspects of quality patient care, the desire to support patient autonomy cannot override or
compromise the basic nature of healthcare itself. Health care providers must support patients in
providing curative treatment, palliative treatment, or even in withholding treatment if that is what
the patient believes is in their best interest. However, the physician must not be placed in a
position where he or she serves an active role in prematurely terminating a human life. We as
members of society must not only expect but demand that physicians do no harm. As Gaylin et
al., said For if medicines power over life may be used equally to heal or to kill, the doctor is no
more a moral professional but rather a morally neutered technician (1988, p. 2140). The
physician is a healer, a supporter, a comforter, and a confidant; the physician is not an
executioner. In upholding the principle of nonmaleficence physician assisted suicide must not be
legalized.

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9
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