The mission of this hospital is rooted in our emphasis on the
individual, and directed toward providing the highest level of autonomy,
beneficance, comfort, healing, privacy and respect for the dignity of the
patient. With these as our guiding principles, we evaluated Physician Assisted
Suicide (PAS) as a possible treatment option at this institution. We have
concluded that PAS can be a viable treatment option after making the following
considerations: 1. Defing the elements of justified PAS, 2. Consideration of
moral justifications, 3. Why personal autonomy is important, 4. Informed
consent, and 5. The benefits of the approach of causitry to issues of biomedical
ethics. The elements of PAS are an agreement between a physician and the patient
on the treatment option after consideration of all other options, (informed
consent) conditions consistant with the Oregon state law and the asurance of the
agent choosing this course of action in an autonymous nature. Moral arguements
question the validity of PAS as an option. We make the determination that PAS
can indeed be considered equivelent to other medical decisions regarding whether
or not continue treatment in cases where the prognosis is immenent death, or
prolonged intense suffering followed by death. If for example, a patient with a
terminal illness such as lung cancer has a choice between hospice care, and
being made comfortable, or PAS, we can not say that the two approaches are
inconsistant with eachother. A patient who refuses treatment and accepts death
as a consequence has the right self determination by law. If this action is
acceptable under law, it is not unfair to consider PAS as an equivelent means to
the same end. Therefore, there will be cases where PAS is most certainly a valid
option for the patient. To reach our decision, it is important to understand our
view of personal autonomy. We will elaborate on it's relevance and worth in
addressing PAS. Finally, criteria for PAS candidates is intricate, and
established. Though we justify PAS as a viable treatment option, we do not take
issue with the legal criertia established by the state of Oregon. Personal
Autonomy Personal autonomy can be characterized as self-determination or the the
extent to which an individual actively participates in in how his or her life is
lived. Autonomy, therefore, requires some elements of control and choice.
Defining autonomy in a being that is both rational and passionate can prove
complex and problematic. A differentiation of first and second order volitions
will help us conclude the what the exact nature of what defines autonomy.
First-order desires are those passions to which the agent is subject to as a
living being. The desire to live, procreate, feel secure and content are some
examples of these desires. While they are certainly expressions of human
passions, they do not account for man's rational capacity, a fundemental facet
of human nature. Second-order desires are wants about wants, or the desire to
have certain desires. We will focus, however, on second order volitions, which
differ from second order desires. Second order volitions involve the wish of an
individual that certain first-order desires will motivate him to action. It is
the rational choice of the agent which characterizes this, and therefore we will
conclude that second-order volitions represent contemplation of a choice by the
agent, which leads to a choice that by virtue of this process, is an indication
of his true-self. Therefore, it is through these second-order volitions that we
exercise autonymous action.1 The expression of rational choice in relation to a
first-order desire is what we will define as the main component of an autonymous
action. There are those who would oppose this view in lieu of other moral
considerations. If the agent has a lack information, or choices, the action in
relation to the first-order desire is then no longer autonymous. Therefore, we
will require that another dimension to autonomy is the range of options
availible to the agent. In order to promote autonomy, it is absolutely essential
that informed consent is a focal point of treatment. It is the concept of
autonomy which is our guiding force in our formulation of a policy on PAS. PAS
as a treatment option has no universal application. In Oregon, where it is
legal, two patients with the same doctor, the same illness and the same
prognosis can make opposite decisions regarding treatment. If one patient simply
chooses to wait for death to occur after stopping treatment, and the other
chooses PAS, both of these autonymous actions are therefore equal. They have the
same end, and individual considerations of quality of life, and an array of
potential first-order desires explain the difference in choices. Therefore, it
is the execution of the choice by the informed agent which constitutes the
autonymous decision. With personal autonomy as the primary consideration, the
patient then has the right to PAS as a treatment option, and denial is
deprivation of self-determination. (Indeed this constitutes deprivation of
freedom, which is intrinsically wrong, and contrary to the patients natural
right to self determination. PAS in a Clinical Setting In relation to PAS, the
agent must act "1) intentionally, 2) with understanding, and 3) without
controlling influences that determine their action."2 As an institution
concerned with autonomy as a central right of the patient, we are supporters of
requested withdraw of treatment (as well as PAS,) as there is no difference in
the matter of allowing to die and killing. Killing is any form of
"deprivation or destruction of life", and allowing to die is
"intentional avoidance of causal intervention so that a natural death is
caused by a disease of injury,"3 which in itself is deprivation. Therefore,
there is no distinction between allowing to die and directly intervening to
bring about a patient's death. Moral Jusifications Compassion is a focal virtue
in our practice. Compassion is defined as a feeling of profound sympathy and
sorrow for another who is affected by misfortune, accompanied by a strong desire
to ease the suffering. Sometimes in healing the terminally ill suffering from
profound pain, assisting the patient in suicide is the only means of alleviating
his/her suffering. Those who oppose PAS are not subject to judgement or
coercion. PAS is a matter of choice and is not an alternative to be suggested by
the physician. It is a procedure which is only regarded among request and acute
investigation thereafter. Patients are protected from non-voluntary euthanasia
because, again, physicians will only address the option of PAS upon the request
of the patient and the physician cannot physically be the cause of the death
(euthanasia). No actions will act out of accordance with such, especially in
situations of life and death. It is clear that opposition to PAS is rooted in
the execution of normative judgements, which object to the action unequivically
and universally. This view neglects the secular and universal standard of
self-determination and autonomy in patient care. This is not a criticism of
religous institutions which find PAS intrinsically wrong. The standard which we
adhere to leaves these considerations in the hands of the agent and physician.
Central to the hypocratic oath is the principle of beneficance, which holds that
the physician is obligated to act in the agents best interest. As technology has
increased and advances have been made, what constitutes beneficance in any given
action is becoming trivial; quality of life issues and painful but successful
treatments have clouded what constitutes beneficance to the point that the 1960s
saw the emergence of Biomedical Ethics as a field. Indeed it is difficult to
simply decide whether or not PAS should be considered universally a medical
treatment or universally suicide. Rather than make this judgement, we hold that
it is not a black and white issue, and that right action through policy requires
consideration of all applications and scenarios. We further offer that causistry,
or the evaluation of correct choice on a case by case basis, is essential to any
approach hoping to yield just results. Requests to Withdrawl Treatment
"[Any] person who is above [18 years old] and of sound mind has the right
to exercise control over his/her body."4(p.279). This implies a right to
refuse medical treatment even if the deprivation of treatment results in death.
The right to refuse treatment is fundamental to principles of autonomy such as
privacy. Therefore, this rule is not conditional, and all requests for treatment
withdrawal are honored upon completion of an informed consent. This particular
type of informed consent acts independent of any previous informed consent
(particularly ones such as advanced directives which will be spoken about in the
next section) and only pertains to the task at hand. The document affirms that
the physician and the patient had a discussion about the consequences and
benefits of withdrawing from treatment as well as those with proceeding of
treatment. It will also affirm that the physician told the patient all possible
alternatives to the situation and all the patient's questions were answered and
understood. Most importantly, the patient has a sufficiently clear understanding
of the situation in its entirety. Upon association with our hospital, all
competent persons are encouraged to fill out an advanced directive indicating
"treatment directives (documents such as a living will stating the person's
treatment preferences in the event of future incompetence), proxy appointments
(documents such as a durable power of attorney appointing a proxy decision
maker), or both."5 This hospital makes a continuing effort to educate
patients about directives and, most importantly, to educate physicians in their
obligation to honor them. Because there is room for interpretation and the
advanced directives are not always case sensitive, a decision regarding
treatment withdrawal will be one that proceeds from a collaboration of the
proxy's views and the patient's preferences stated on the advanced directive. In
cases of incompetence where no advanced directives exist, the legal right of the
patient to consent to any procedures is handed over to the next of kin. If there
is no next of kin, the attending physician will use his sound judgement to
assess the situation. Continuing Treatment When There is No Hope For Recovery It
is the belief of this institution that mere quantity of life does not eventuate
in quality of life. The desire to continue treatment when there is no hope for
recovery is indicative of fear in the patient. Healing is key to the mission of
our hospital. Therefore, diminishing fears in our patients, particularly fears
involving such natural processes as life and death, is of surmounting
importance. In such cases, we will do everything possible through palliative
care to assess the spiritual, emotional, and mental needs of the patient while
we continue to respect the autonomous decision of the patient to continue
treatment when there is no hope for recovery. In cases where the individual is
deemed incompetent, the advanced directive of the patient should be honored if
one exists. Otherwise, the decision will be handed over to the next of kin. This
will be treated similarly to the previous competent-patient-decision process in
that if the decision is fear-based then palliative care will be appropriated to
ensure the most accurately desired procedure. A beating heart or a pair of
working lungs does not assert an individual among the living, rather
consciousness is what distinguishes an individual as alive. Lawrence O. Gostin
assesses the Cruzan case stating that, "when asked, very few people would
choose to be kept physically alive when all conscious life is over."
Particularly in cases of perpetual vegetative state (PVS), where all
consciousness is gone, our hospital does not agree with life prolonging
procedures and therefore will perpetuate palliative care among decision makers,
whether it is the next of kin, or the attending physician. Although each case is
different and should be assessed individually, the general view of the hospital
stands. REQUESTS FOR PHYSICIAN ASSISTED SUICIDE (PAS): In accordance with The
Oregon Death and Dignity Act, terminally ill adult Oregon residents are
permitted to request drugs from their physician with the intent to end his/her
life. This act ensures the removal of any criminal penalties for qualifying
physician-assisted suicides. All of the following strict guidelines are
pertinent to a qualifying PAS: 1) physicians predict patient's death within 6
months; 2) the patient makes 3 requests for PAS, 2 oral, and 1 written; 3)
15-day waiting period after requests; 4) second physician's opinion; and, 5)
counseling if either physician believes that the patient has a mental disorder
or impaired judgement from depression. It is our view that meeting this
criteria, PAS has a stong case for legitimacy as a medical procedure and
treatment option. Conclusion Implementation of PAS as a legal medical treatment
in Oregon aroused the passions of so many. As the public debate continues, and
as other initiatives work their way through state legislatures, it is clear that
their is no answer that will apease both sides of this very difficult issue. As
caregivers, it is essential to take a much longer consideration. In order to
find what we believe to be the right approach to PAS by an institution, it was
inevitable that we had to make a clear decision regarding what principles were
to guide us. Compassion and beneficance are required. They are also desired;
every caregiver wants to help his patient, deliver treatment with excellence,
compassion, and with the intent of beneficance. These principles in and of
themselves require us to consider their purpose: the benefit of the agent. With
this, we hold that autonomy is the expression of the human self. It is the
manifestation of human rationality, and therefore, should be held in the highest
regard. The right to self determination is the key to this. As we hold this as
our central virtue, it follows that beneficance in any action is contingent upon
upholding personal autonomy. Violation of this constitutes deprivation of
freedom, and is in turn, intrinsically wrong.