The right-to-die, sometimes termed “death with dignity” is fraught with legal and moral issues. Currently in the United States, there are seven states plus the District of Columbia where there is a “right-to-die”, defined as “suicide by a patient facilitated by means or information (as a drug prescription or indication of the lethal dosage) provided by a physician aware of the patient’s intent” (Merriam-Webster Dictionary). This definition is vital to the case of Jane Doe, a woman who wishes to end her life due to chronic illness and pain. Jane Doe has cerebral palsy, is nearly entirely paralyzed (save for her right hand and face), and suffers from degenerative arthritis which causes constant pain that cannot be relieved entirely, even with medication, including morphine. She requires constant care, which her family will not provide. On top of this, she has no job (and no income), no home, and no hope of getting help (except through public assistance). Being forced to continue to live would be physical, and likely emotional, agony. She wants to undergo a sort of physician-assisted-suicide; she asked to be given pain medicine and hygienic care while she slowly commits suicide by starving herself.
Before we can determine whether Jane Doe’s choice to die should be granted to her, we must examine whether she has the right to make this choice at all. In “The Refutation of Medical Paternalism” Goldman states “paternalistic assumption of authority… is…unjustified…the independent value of self determination or freedom of choice” (Goldman, 98) and establishes that the value of the choice lies not in the choice itself, but in the very ability to make the choice for oneself. To be denied choices of her own body when she is already limited in what she can and cannot do is cruel, and while Ackerman claims in “Why Doctors Should Intervene” that sickness can impede autonomy, this thought is based in the “transforming effects of illness….autonomous behavior is governed…through deliberation” (Ackerman, 99). Ackerman also specifies that autonomy can be regained; that illness can impede autonomy is a thought that stems from the effects of a recent diagnosis. Jane Doe’s is not a recent diagnosis but one she has lived with and deliberated over for years, having done everything at this point that a physician can do to give her back her autonomy. Jane Doe has been declared mentally competent, and is not suffering from anxiety or depression. Thus, Jane Doe’s autonomy is not to be intervened with.
In terms of autonomy directly in cases of assisted-suicide, in “Against the Right to Die” Velleman establishes that patients shouldn’t be offered the choice of physician-assisted suicide or similar means of ending their lives, but should have the ability to request it, legally and morally, and it is up to the physician to grant that request or not. While he establishes autonomy in this case differently he does establish that morally “I strongly believe that a person’s life can sometimes be made worse by being prolonged, and that a swift and painless death can then be a benefit.”(Velleman, 667). Jane Doe is asking for the doctor not to interfere with her choices, a choice established by Robert Misbin that “Proponents of…physician-assisted suicide claim that the principle of respect for autonomy requires that patients be allowed to choose the manner of their death.” (Misbin), a choice established by Velleman as one that, though she may not have the right to demand, she does has an innate right to request, because it is her body, her life, and her choice.
Jane Doe has the right to request to die, though not to demand it, which takes us to the physician’s right to refuse to grant physician-assisted suicide. Established by Velleman is that “physicians should have permission to administer voluntary euthanasia, but patients should not have a right to receive it.” (Velleman, 1) establishing the right to refuse, but Ackerman specifies all choices at the physician’s discretion should be made with the patients intentions and interests in mind – not the doctor’s. The physician’s right to stick to their own morals and values stems from the promise of “first do no harm.” (Thomas Sydenham). But is physical or emotional harm worse? What constitutes harm at all? In a similar vein, Goldman states the that the “concept of harm independent of individual differences…when the development of an individual capable of freely and creatively formulating and acting to realize central life projects is blocked, that person is harmed” (Goldman, 94). In other words, while the doctor may wish to prolong Jane Doe’s life, morally he is doing her a disservice because it is not where her interest lies. Her interest lies in not being in pain, and in not burdening society because she has no family willing to care for her. She is of sound mind and has not been coerced or pressured into her choice of death by having it offered to her, and by being forced to live against her will, the physician in inflicting more harm on her, physically and emotionally. This directly counteracts the moral claim of “first do no harm” (Thomas Sydenham) because harm in medical contexts should be defined by what the patient considers harm, even if the doctor is the one who took the oath. Moreover, if the physician’s moral concern is being complicit in her death, this is not a usual physician-assisted-suicide case.
There are key differences between her plan and legally termed physician-assisted-suicide, most notably that she did not actively ask the medical practitioner to assist in her death — lethal medication, etc. — she asked to not be interfered with. How does this differ from something like hospice care for a patient with a Do Not Resuscitate Order (DNR)? A DNR is defined medically as “do not resuscitate (used in hospitals and other health-care facilities to indicate to the staff the decision of a patient’s doctors and family, or of the patient by a living will, to avoid extraordinary means of prolonging life).” (Random House Unabridged Dictionary). In the case of Jane Doe, the physician’s idea of forcing a feeding tube on Jane Doe to prolong her life (so she would not starve) would be considered extraordinary, an interference to the natural state she wishes her body to remain in.
Jane Doe did not request physician-assisted-suicide in the traditional way it is thought of. She did not ask for assistance with the direct act of ending her life, she did not request a lethal dose of medication or information of a lethal dose. She requested palliative and hygienic care while she ended her own life through starvation. She requested pain management while her life came to an end, and for that end to not be interfered with by means such as force feeding. You could argue that this is the same as requesting a DNR. DNRs are very common for patients under hospice care who want to die naturally. A doctor cannot be forced to comply with right-to-die because of their own morals, but they do have to adhere to a DNR. Jane Doe did not ask for help in her death, she simply asked for palliative care, similar to a DNR, a request for death not to be interfered with, not a request that her suicide be assisted (ie. not a request for euthanasia – doctor is not directly complicit in her death). Patients can choose a DNR and can choose not to undergo a treatment even against medical advice. While a patient cannot demand assisted-suicide, a physician cannot force treatment on a patient that is not wanted; patients cannot demand treatment but can object to treatment. In Jane Doe’s case, she is rejecting help eating, likely a feeding tube of sorts. This treatment cannot be forced on her without violating her autonomy. She her request must be granted, as it doesn’t fall exactly under the parameters of assisted-suicide and thus cannot be denied.
If Jane Doe were in a right-to-die state, this case would never end up in front of the ethics board, because of set guidelines in place for dealing with cases where a physician denies a request for physician-assisted-suicide. Among other options another doctor in the hospital would likely grant her request. A request that she legally has a right to, though her doctor could refuse it. So let us assume she is not in a right-to-die state, and that her specific request does not qualify for right-to-die. Physician-assisted-suicide, as defined earlier, is dependent on active involvement on the physician’s part, ranging from lethal dosage of a medication to providing information of what a lethal dosage would be. Jane Doe is asking for even less action – she is requesting an inaction. Jane Doe’s request to be allowed to starve herself is the definition of an inaction on the physician’s part. The physician is asked to do nothing to interfere with her natural death – the very definition of a DNR. Her request should still be granted, because voluntary physician participation is based on the key component of death with dignity that puts the physician directly responsible for the end of the patient’s life – which is not the case for Jane Doe who is not asking for physician assistance and is actively asking for non-interference.
A non-medical example of this can be seen in having someone you care about move to another country. You don’t have to agree, you don’t have to help them move, but you can’t tie someone down and make them stay – they will just find a worse, more dangerous way to do it. If you stop someone from getting on a large airline, they might get on a less legal one if they are very determined. If someone is denied a visa, they may illegally sneak into a country. No matter how bad an idea you think it is, you cannot stop a legal adult from moving to another country, because it is their life, and they feel the benefits outweigh the risks or problems. This can be likened to legally seeking physician-assisted suicide, or in Jane Doe’s case, to starve herself in the hospital with pain management and hygienic care, which if refused, can lead to a person trying to take their lives outside of the controlled setting, leading to worse outcomes like overdoses, failed attempts, longer more painful deaths, and the emotional toll on whoever will find the body.
The case of Jane Doe’s request for assistance in her death is brought before the ethics board of the hospital. We’ve established that she has the right to request assisted suicide, but that in the case of assisted suicide, the physician has the final say in granting said request. While this is true, and a physician cannot be forced to grant a request for assisted suicide even in a right-to-die state. However, Jane Doe’s case is closer to a request for hospice care and a DNR rather than the exacting parameters of physician-assisted-suicide, and as a DNR cannot be denied, the physician is obligated to grant her request, even if he disapproves.
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Goldman, Alan. “The Refutation of Medical Paternalism.” In Bioethics: Principles, Issues, and Cases, edited by Lewis Vaughn, 2nd ed., 93–98. New York: Oxford University Press, 2013.
Misbin, Robert I. “Physicians’ Aid in Dying | NEJM.” New England Journal of Medicine, 31 Oct. 1991, http://www.nejm.org/doi/full/10.1056/NEJM199110313251811.
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Smith, C M. “Origin and Uses of Primum Non Nocere–above All, Do No Harm!” Current Neurology and Neuroscience Reports., U.S. National Library of Medicine, Apr. 2005, http://www.ncbi.nlm.nih.gov/pubmed/15778417.
“Take Action – States with Assisted Dying Laws.” Death With Dignity,www.deathwithdignity.org/take-action/.
Velleman, J. David. “Against the Right to Die.” The Journal of Medicine and Philosophy 17 (1992): 665– 81.
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