An Ethical Take on Physician-Assisted Death: A Physician’s Morality

(Jenna has a Masters of Science degree in Bioethics from Harvard Medical School. She has done research at Aga Khan University in Karachi, Pakistan and currently lives in Toronto, Canada, where she is independently doing research with the Marcus Institute of Aging Research’s senior physician-scientist. She is also doing community service at a hospice, offering palliative care support.)

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As a recently graduated bioethicist and an aspiring palliative care physician, I am faced with the need to determine my ethical stance on end-of-life choices. Since the legalization of physician-assisted death (PAD) in Canada and ten US states and the District of Colombia, this has increased the demand for physicians willing to provide it. Debates persist over whether PAD is ethically permissible, even with patient cases of truly irreversible and irremediable conditions. Therefore, it is important to consider the morality of the physician: the one tasked with fulfilling the requests.

Treating the symptoms of illness to alleviate a patient’s suffering is among the fundamental duties of a physician; however, when a terminally ill patient makes a voluntary request to have their life ended as a means of indefinitely relieving their suffering, the physician is confronted with a tricky ethical dilemma. The complexity stems from the universal belief that it is inherently wrong to end a life, and the act of doing so is condemned by society. This places the physician at the center of the dilemma, whose duty is to care for the patient, but also to do no harm – an ethical tension between beneficence and non-maleficence arises.

Take into consideration the terminally ill patient, whose needs now extend beyond the mere physical treatment of symptoms. It is equally as important for a physician to tend to the emotional and spiritual needs of the patient, whom may no longer feel like they can enjoy or partake in meaningful daily activities due to the severities of their illness. This is where compassion and dignity stand as paramount values.

Being a core virtue of medicine, compassion calls for the physician to recognize, understand, and be emotionally attuned to their patient’s feelings of pain, anguish, or fear, coupled with intention and a course of action to better their condition. Preserving dignity calls for the physician to respect the patient’s autonomy and uphold their sense of self-worth by allowing them to have control over their health matters.

So, under the circumstances that a terminally ill patient makes an informed and voluntary request, PAD is a compassionate and dignifying solution for those who are desperate for relief from their suffering, as it, arguably, aligns with the physician’s duty to care and respects the patient’s right to self-determination.

Medical Care is More than an Alleviation of Physical Symptoms

The alleviation of suffering is a central aspect of the physician’s duty to care for patients; however, it should be understood that in particular instances, where a terminally ill patient does not wish to undergo treatment or accept palliative care, death may be the only desired form of relief. This raises an ethical question: In such cases, where physicians have exhausted every effort to convince the patient of treatments and symptom-management alternatives, is it in their duty as a doctor to offer assisted death as an option if it is expressed and voluntarily requested by the patient?

For a patient to make a conscientious decision to refuse any type of treatment or comfort care, there is certainly a profound underlying reason. Here is one example highlighting those reasons:

“S.M.” was my family member. He was a terminally ill patient with liver cancer and had an unfortunate history of substance use. On multiple visits to his physician, he wished to not undergo treatment, and was asked to reconsider his choice on many occasions. Given the circumstances, all that could have been offered to him were medications to ease the physical pain. As he described, it was the “soul pain” that was far from being helped. Decades ago, if he had the choice to end his suffering by physician-assisted death, he may have chosen that route over the horrific one he took.

S.M’s story highlights the fact that there are deeper needs that are simply untreatable by medical intervention, and on the grounds of compassionate care, one could argue that a physician’s duty goes beyond the preservation of life. A physician who is understanding and sensitive to the patient’s feelings and experiences of suffering, including those deep emotional and spiritual dimensions, would feel compelled to seek out every possible measure to help them. For some, death may feel like the most benevolent way to achieve the alleviation of suffering, and therefore should be considered as a valid option if it is voluntarily requested by the patient.

As Far as Autonomy Holds

Patient autonomy is a fundamental ethical principle in medicine that gives patients the right to govern their own healthcare. For a terminally ill patient to request PAD, considering their informed and voluntary request would respect their ability to self-determine, and live in accordance with their own definition of a good life or good death. For the patient to decide when or how they would like to die, it offers a sense of control in the dying process, which is central to preserving dignity.

The story of Dr. Timothy Quill and his leukemia patient, Diane, serves as a precedent case: End-stage leukemia was slowly creeping upon Diane, yet she refused to undergo chemotherapy. Her reason: She could foresee that treatment would lead her to unbearable pain and suffering, and her eventual death. To Diane, dignity meant maintaining her independence, her capacity to be in control over her life, and to be free of pain in suffering in the future course of her illness.

When she could no longer live to her standard of a dignified life, she expressed desire to end it. Dr. Quill was with her through every stage of her leukemia, and though initially grappled with his own morality, eventually he prescribed medication for her to take when she felt she was ready to go. And so she did.

Diane’s story is a satisfying one as it highlights how she was able to align her end-of-life decision with her own conception of dignity and autonomy, and her physician’s approach can be seen as a compassionate response to her objection to suffering and living a poor quality of life. Like a “good life” is subjective to each and every individual, a terminally ill patient should be in the position to decide their terms for a “good death”; therefore if voluntarily requested by the patient, physician-assisted death demonstrates total respect for patient autonomy and dignity.

Withdrawing Life-Sustaining Treatment: An Analogous Act?

There appears to be less hesitance when it comes to withdrawing a life-sustaining treatment from a patient who is terminally ill, and has requested no extraordinary measures (a DNR order). The decision on whether or not one should be “allowed to die” involves the evaluation of quality of life by both the patient and physician. It honors the patient’s autonomy, and it aligns with the physician’s duty to do what is in their best interest.

It is important to question how truly different the act of “allowing to die” is from actively ending life. The distinction between withdrawing a life-sustaining treatment and physician-assisted death is merely the difference between omission and commission, where both require a voluntary consent by the patient and will result in the ending of their life. To think there is a significant difference would be subscribing to a moral fiction that attempts to counteract inconsistent beliefs by normalizing and justifying certain practices over others. If medicine can justify one method for the humane ending of life, then all methods should be justified, inclusive of PAD, for it is as dignifying and compassionate as withdrawing a treatment from a patient who no longer wants to prolong their suffering.

To leave you with a final thought: Suffering is an incredibly subjective experience. Like the experience of pain, a physician simply cannot physically perceive the degree and intensity of the sensation, and, therefore, must fully consider the patient’s rating. However, unlike pain, there is no rating scale for suffering, nor a “suffering-relief’ pill to alleviate the intensity of the feeling.

From a morality standpoint, it would be paternalistic, and rather unmerciful, for a physician to deny a terminally ill patient the right to be free from suffering, and the right to self-determine and live in accordance of their own definition of dignity. While the physician’s morality does come into the equation, it’s important to not forget whose experience of life is on the line.

Remembering this, I will ensure my practice is always guided by empathy and a commitment to act in ways that uphold a person’s sense of dignity, even at their final moments.

I hope the considerations above will inspire those grappling with the moral weight of honoring a patient’s request, to approach these decisions with an open mind – and most importantly, an open heart.

(Please scroll down to comment.)

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Final Exit Network (FEN) is a network of dedicated professionals and caring, trained volunteers who support mentally competent adults as they navigate their end-of-life journey. Established in 2004, FEN seeks to educate qualified individuals in practical, peaceful ways to end their lives, offer a compassionate bedside presence and defend a person’s right to choose. For more information, go to www.finalexitnetwork.org.

Payments and donations are tax deductible to the full extent allowed by law. Final Exit Network is a 501(c)3 nonprofit organization.

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