“Physician-assisted Suicide (PAS), n. – orig. U.S. suicide carried out with the assistance of a physician (whose role is typically to provide a lethal dose of a drug at the explicit, voluntary request of a mentally competent patient considered to be incurable)”

(Oxford University Press, 2013)

• An Aging Population• Legislation allowing for patients to choose end-of-life

care preferences has helped lead to this discussion• PAS is Tied to Other Healthcare Debates– Desire for more Autonomy– High End-of-life Care Costs– Difficulty Obtaining Insurance Coverage for the Terminally

Ill• Patient Concerns Include– Desire to Reduce Pain & Suffering– Desire to Die with Dignity– History of Inadequate Pain Control

(United States Census Bureau, 2010)

• Physician Prescribes or Provides the Means

• Patient Administers Lethal Medication

• Legal in 3 U.S. States• Request Process & Wait Period

• Physician Administers Lethal Medication

• Active or Passive• Currently Not Legal in the U.S.• No Determined Process

5th Century B.C. to 1st Century B.C. – Ancient Greeks and Romans often complied with voluntary death requests while still abiding by the Hippocratic Oath

1984 - Advance care directives begin to be recognized

1984 - The Netherlands Supreme Court approves voluntary euthanasia and physician-assisted suicide under strict conditions.

1984 - American Medical Association adopts the formal position that with informed consent, a physician can withhold or withdraw treatment from a patient who is close to death, and may also discontinue life support of a patient in a permanent coma.

June 4, 1990 - Dr. Jack Kevorkian assists in the death of Janet Adkins, a middle-aged woman with Alzheimer’s disease. Kevorkian subsequently flaunts the Michigan legislature’s attempts to stop him from assisting in additional suicides.

(ProCon.org, 2012)

1990 - Congress passes the Patient Self-Determination Act, requiring hospitals that receive federal funds to tell patients that they have a right to demand or refuse treatment. It takes effect the next year.

1997 - Oregon Death With Dignity Act Passed- becoming the first law in American history permitting physician assisted suicide.

1998 - Dr. Kevorkian shares a video on national television of him administering a lethal injection to Thomas Youk, a man suffering from Lou Gehrig’s disease. He was convicted for the murder of Youk and is sentenced to 10-25 years in prison.

2008 - Luxembourg legalizes physician assisted suicide and euthanasia. 2008 - Washington becomes the second state to legalize physician-assisted suicide.

2012 - Massachusetts voters rejected the Death with Dignity ballot by less than 60,000 votes.

(ProCon.org, 2012)

Year Case / Law Description

1976 In re Quinlan Right to remove person in a vegetative state from ventilator

1990 Cruzan v. Director Missouri Department of Health

Right for states to grant families the right to remove feeding tubes from a person in a vegetative state

1990 Patient Self-Determination Act

Health care facilities must provide information to patients about advance directives

1997 Oregon Death with Dignity Act

Allows terminally ill Oregon residents to obtain and use prescriptions from their physicians for self-administered, lethal medications

2008 Washington Death with Dignity Act

Allows terminally ill Washington residents to obtain and use prescriptions from their physicians for self-administered, lethal medications

(Guido, 2009)

• Dr. Jack Kevorkian (1928-2011)– Nicknamed “Dr. Death”– Pathologist in Pontiac, MI

• 1980s: Developed PAS Machine• 1990: Janet Adkins

– Alzheimer's Patient granted PAS

– Charges Dropped• 1998: Thomas Youk

– Lou Gehrig’s Patient– Administered by Kevorkian &

Aired on “60 minutes”– Found Guilty of murder

• 10-25yr sentence• Served 8 yrs.

(Hosseini, 2012)

• Believed Pt.’s Right to Avoid Prolonged & Painful Death– Should Die with Dignity– Wanted to be charged and arrested to bring about a

national debate• Poll on Kevorkian’s Punishment (Hosseini, 2012)

– 39% Felt he should not be punished– 27% Felt he should be charged with a lesser crime– 19% Felt the charges were appropriate

• Brief Videos On Dr. Kevorkian– Information on Dr. Kevorkian– 60 Minutes Tape of Thomas Youk (Graphic)

(Hosseini, 2012)

• Opposed by the U.S. Supreme Court• Legal in only 3 States• Legal in 4 other Countries– Belgium– Luxembourg– Netherlands– Switzerland

(ProCon.org, 2012)

Montana*Oregon - 1994Washington - 2008

NevadaUtahWyoming

(ProCon.org, 2012)

• 1997 in Oregon• First Person Received legal PAS in 1998

– Mid-80s with Metastatic Breast Cancer to the Lungs

• Requirements– ≥ 18 yrs.– Resident of Oregon– Legally/medically competent– Terminal illness with ≤ 6 mos. to live– Two oral requests & one written (two witnesses)– Confirmed diagnosis by two physicians

• Annual Report 2012– PAS only accounted for 23.5 deaths per 10,000 total deaths– 673 patients have died under the DWDA

(Hendin, Foley, & White, 1998)

(Oregon Public Health Division, 2012)

(Oregon Public Health Division, 2012)

• Death with Dignity National Center in Oregon

• Exit International (Australia)• Euthanasia Research &

Guidance Organization (ERGO)

• World Federation of Right to Die Societies

• Final Exit Network

• American Nurses Association (ANA)

• American Medical Association (AMA)

• Care Not Killing• Not Dead Yet• Roman Catholic Church• United States Conference of

Catholic Bishops

• Most Common Reasons Loss of Autonomy– Decreased Ability– Loss of Dignity– Fear of Adequate Pain Control

• Other Reasons– Right to end life on own terms– Prolonging the unavoidable– Less medical bills– Don’t want to be a burden to

family

• “Slippery Slope” belief that PAS will move onto disabled and more vulnerable populations

• Perceived as murder• Against Religion• Reductions in medical

coverage for elderly & terminally ill as a result of legalizing PAS

• Forced PAS in the future

(Guido, 2009: Hosseini, 2012; ProCon.org, 2012)

(Lachman, 2010)

• By 2020, 2.5 Million Aged ≥ 65 yr. will die each year

• In 2008 Medicare Spent $55 billion on End-of-life care during the last two months of patients’ lives.– Estimated that 20-30% of these expenses had very

little health impact.– 18-20% of patients spend their final days in an ICU

which can be painful & expensive(CBS News, 2009)

• Available Options Include– Withdrawal of Treatment

• Removing Ventilator & Feeding Tube• Chemo & Medications

– Advance Directives• Living Will• DNR• Power of Attorney

– Hospice Care– Palliative/Terminal Sedation– PAS (Only where it is legal)

• “Presents a Moral/Ethical Dilemma” Cases can be made for both sides using the following ethical principles

• Autonomy– Patient’s right to choose– Should there be limits to a patient’s autonomy?

• Beneficence/Non-Maleficence– Do No Harm– Minimize Suffering & Pain– Are we doing this?

• Justice– Fair & Equal Treatment– Are we being fair by prolonging the inevitable for terminally ill patients?

(Hosseini, 2012)

• Deontological vs. Utilitarian– Deontological

• Black & White• Either always wrong or always right• PAS would be considered always wrong

– Utilitarian• Consequences weighed for the individual and society• Focused on providing happiness• PAS may be considered right for only some

• Doctrine of Double Effect- Principle argued frequently in End-of-life care debates for PAS- Explains that a harmful action is permissible if it promotes a good side

effect- Ex. Killing a human being to bring about a good end

(Webb, 2013; McIntyre, 2004)

• Classical Oath• “I will neither give a deadly drug to anybody who asked for it, nor will I

make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art. I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.”

• Modern Oath– “Most especially must I tread with care in matters of life and death. If

it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.”

(Tyson, 2001)

• Sedation prior to death from actual illness

• Used when other treatments cannot relieve pain & suffering

• Nutrition supplementation is typically withdrawn

• Often the last resort in most states

• Shown to be 71-92% Effective based on family perceptions of patient’s relief

• 3 Types for End-of-life• Medical Power of Attorney

– Patient designates person to make end-of-life decisions

– Anyone can have this• Out-of-hospital DNR Order

– Refusal of life-sustaining treatments by first responders

– Copy carried at all times• Directive for Physicians and

Family– Specifications on withholding or

withdrawing all or certain life-sustaining procedures

– Certified by a physician

(Olsen, Swetz, & Mueller, 2010) (Texas Hospital Association, n.d.)

Care recipients under age 65 yrs. Were less likely to have any AD than those aged 85 and over

• New health care revisions• Clear definitions of PAS and

requirements– Process of application– Location of lethal drug

administration– Diagnosis Inclusion Criteria

• Laws that make it legal. •

• More emphasis on pain control & consideration for the patient’s perception of their own dignity

• More individuals with living wills, medical advocates, and other documents prior to falling ill.

• Greater awareness towards which procedures are effective and which simply prolong suffering & pain.

We believe that legalizing PAS, after a more adequate definition of requirements and diagnosis criteria has been formulated, can greatly prevent prolonged pain, suffering, and loss of dignity experienced by some terminally ill patients.

Which Statement is not true about the Death with Dignity Act of Oregon?

A. You must be a resident of OregonB. You must have a terminal illness with less than

a year to liveC. You must be legally/medically competentD. Two physicians must have confirmed your

diagnosis

Which is not one of the legal alternatives to Physician Assisted Suicide?

A. EuthanasiaB. Withdrawal of TreatmentC. Terminal SedationD. Advanced Directives

True or False: Surgery, Abortion, and Physician Assisted Suicide / Euthanasia are referred to in the Original Hippocratic Oath. In taking this oath, healthcare professionals swore to not perform these practices. The Hippocratic Oath has since been revised and no longer mentions the three of these things.

True or False: Oregon is the only state in the United States where PAS is legal.

True or False: In PAS, a physician actively administers the lethal medication to end the patient’s life.

American Medical Association. (n.d.). American College of Physicians - Care of patients near the end of life. Retrieved from http://www.ama-assn.org/ama/

pub/physician-resources/medical-ethics/ about-ethics-group/ethics-resource-center/educational-resources/ federation-repository-ethics-

documents-online/american-college-physicians/ acp-end-of-life-care.page#organ

CBS News. (2009, November 22). The cost of dying. Retrieved from http://www.cbsnews.com/ 8301-18560_162-5711689.html

Guido, G. W. (2009). Legal & ethical issues in nursing (5th ed.). Upper Saddle River, NJ: Pearson.

Hendin, H., Foley, K., & White, M. (1998). Physician-assisted suicide: Reflections on Oregon’s first case. Issues in Law & Medicine, 14(3), 243-269.

Hosseini, H. M. (2012). Ethics, the illegality of physician assisted suicide in the United States and the role and ordeal of Dr. Jack Kevorkian before his death.

Review of European Studies, 4(5). http://dx.doi.org/10.5539/res.v4n5p203

Lachman, V. D. (2010). Physician-assisted suicide: Compassionate liberation or murder? MEDSURG Nursing, 19(2).

McIntyre, A. (2004). Doctrine of double effect. Retrieved from Stanford Encyclopedia of Philosphy website: http://plato.stanford.edu/entries/double-effect/

MedicineNet. (2012, September 20). Definition of physician-assisted suicide. Retrieved from MedicineNet website: http://www.medterms.com/script/

main/art.asp?articlekey=32841

Olsen, M. L., Swetz, K. M., & Mueller, P. S. (2010). Ethical decision making with end-of-life care: Palliative sedation and withholding or withdrawing life-

sustaining treatments. Mayo Clinic Proceedings, 85(10), 949-954. http://dx.doi.org/10.4065/mcp.2010.0201

Oregon Public Health Division. (2012). Oregon's death with dignity act -- 2012. Retrieved from http://public.health.oregon.gov/

ProviderPartnerResources/Evaluationresearch/deathwithdignityact/ Pages/index.aspx

Oxford University Press. (2013). Physician, n. In OED online. Retrieved from http://www.oed.com.ezproxy.lib.usf.edu/view/Entry/ 143129?

redirectedFrom=physician+assisted+suicide#eid30461454

ProCon.org. (2012). History of euthanasia and physician-assisted suicide. Retrieved from http://euthanasia.procon.org/view.resource.php?

resourceID=000130

Texas Hospital Association. (n.d.). What are my options for advanced directives? Retrieved from http://www.tha.org/generalpublic/advancedirectives/

whataremyoptionsfor09c0/

Tyson, P. (2001). The hippocratic oath today. Retrieved from http://www.pbs.org/wgbh/nova/body/ hippocratic-oath-today.html

Strohm, M. (n.d.). Physician-assisted suicide: Is it murder or compassion for a doctor to help kill a patient? ABC Action News. Retrieved from http://

www.abcactionnews.com/dpp/marketplace/law_tv/physician-assisted-suicide-is-it-murder-or-compassion-for-a-doctor-to-help-kill-a-patient

U.S. Department of Health and Human Services. (2011, January). Use of advanced directives in long-term care populations (Issue Brief No. 54). Retrieved

from Centers for Disease Control and Prevention website: http://www.cdc.gov/nchs/data/databriefs/db54.pdf

United States Census Bureau. (2010). Age and sex composition in the United States: 2010 censusbrief. Retrieved from http://www.census.gov/population/

age/

Webb, M. (Presenter). (2013). Ethics and morality. Lecture presented at Blackboard, University of South Florida, Tampa, FL.