This paper reviews the ethical challenges of assisted suicide In the context of its relationship with the field of nursing. While nurses as a whole are not significantly involved in discussions regarding assisted suicide, its legalization and the formation of laws that relate to it impact nurses in a multitude of ways: legal, professional, and ethical.
First, it is important to define assisted suicide, physician assisted suicide, and euthanasia, as these concepts have important differences, and each may imply a different relationship to nursing. Alone, assisted suicide refers to the act of knowledgeably assisting a person to end their life, or encouraging them to initiate the act. Physician assisted suicide specifically refers to cases in which the person ending their life is assisted by a physician, either by the physician ending the life, or by the physician providing a patient with the means to end his or her own life (Evans, 2015). Euthanasia is loosely defined as ending someone’s life when they are in a great deal of pain and it is assumed necessary to relieve them of it. This method includes both active and passive euthanasia, the former includes acts such as actively administering a lethal injection, while the latter refers to the opposite – withholding treatment as in the willful neglect of (or not providing) operations necessary to sustain life (Mccrae and Bloomfield, 2013). Calling the act euthanasia denotes the assumption that the life is ended by someone other than a physician or the patient (Harris, 2014). For the sake of simplicity, this paper will use the term ‘assisted suicide’ loosely to include the aforementioned acts, except when it is specifically stated otherwise.
Assisted suicide is currently a highly controversial practice for several reasons. One reason for the controversy is that the chances of surviving what used to be fatal diseases are now significantly increased due to advances in technology and medicine. When there is hope that life could be preserved, both patients and medical professionals may feel obligated to make attempts at it, rather than “giving up” and choosing to end a life artificially (Evans, 2015). Another reason for the controversy directly relates to the validity of the decision to end a person’s life. Not only must a person hold moral responsibility to make this decision if the patient is unable to, but even if the patient does authorize it, there are additional validity risks. For example, there have been cases in the past where the patient’s family had been found to influence him or her to die for their personal benefit. An important part of assisted suicide is keeping the best interest of the patient in the forefront. It can be argued that when a patient makes a conscious decision to abandon their own benefit counteracts that (Griffith, 2014). Due to the vulnerable situation a patient is in, commonly leading to their reliance on a nurse for health care assistance, a nurse’s role in healthcare is extremely important to consider when a practice as complex as assisted suicide is considered .
In countries that have legalised assisted suicide, nurses have statistically been proven to play a large role. In fact, nurses make up 37%, or the majority of healthcare providers (how is that a majority?) who are first consulted and engaged when patients consider options for assisted suicide. To add to the already morally complex process, nurses spend extensive time with these patients, and often are tasked with managing the medical aspects of assisted suicide, while higher up staff, such as doctors, hold the power to make the official and final decisions. It may be argued that doctors make the binary decision to end or not to end the life, while nurses must deal with the moral, ethical, and professional dilemmas associated with their actions when the decision is carried through (Evans, 2015).
As Americans are living longer, the geriatric population will continue to increase and the importance of discussing end-of-life options will only increase as well (Harris, 2014). Dementia is already an enormous problem in the developed world. The United Kingdom for example reports, over 800,000 senior citizens suffering from it. It is important to quote those numbers in the United States; look at CDC consensus report). The numbers are expected to increase, and the concern is that the cost to support all those who are inflicted will become increasingly significant in the decision to keep the elderly who suffer from dementia alive (Mccrae and Bloomfield, 2013). The “CNA’s Code of Ethics for Registered Nurses states that when patients are terminally ill or dying, nurses ‘foster comfort, alleviate suffering, advocate for adequate relief of discomfort and pain, and support a dignified and peaceful death’” (Canadian Nurses Protective Society, 2015, p. 2). Due to personal beliefs, a nurse’s interpretation of the above may or may not allow for morally valid intentional ending of a life, thus causing serious controversy at the personal level.
As of now, to address the growing debate over assisted suicide, studies are beginning to shed light on the controversy from the nurses viewpoints. Palliative care nurses, for example, have been found to be the only subgroup of nurses that did not, in a majority vote, support assisted suicide. A distinguishing factor of palliative nursing is the sheer amount of time the nurse spends with patients. Considering relatively similar nurse educational backgrounds, it may be argued that their standpoint stems from emotional one rather than from a rational considerations, and heavily results from emotional attachment to patients which are formed over extended interactions (Evans, 2015). A nurse’s role should be to do what is best for the patient. Therefore, it may be necessary to put less weight on the normal, but strong emotional bias in the ethical the consideration palliative nurses make in their analysis. Further, they are at a minority in terms of nurse subgroups, so statistically their opinions should not make a large impact. Extrapolating from this study though, we can see how caregivers with even less patient contact such as doctors, would make more logical decisions on assisted suicide. Arguably, this may not be good as their decisions may lack compassion, something that non-palliative nurse may be able to offer in substantial but not excessive quantities. Taking compassionate care into account, patients may benefit from elevated decision-making privileges given to non-palliative nurses, rather than allowing all major assisted suicide-relate decisions to be made by doctors.
Assisted suicide is also an ethical dilemma for nurses to due their religious beliefs. More significant than the effect of spending extended periods of time with patients is a nurse’s personal religious beliefs. Many religions explicitly outlaw assisted suicide, and seeing how 42% of nurses opposing it expressed religious concerns, we can statistically see the large impact of religion on health care now and if/when assisted suicide become more widely accepted (Evans, 2015). By that time, healthcare facilities should have develops policies and such to allow nurses to do their jobs without ultimately ignoring their important personal beliefs. (Canadian Nurses Protective Society, 2015)
The legal aspects of assisted suicide are fairly ambiguous and vary greatly from state to state and country to country. In Oregon for example, assisted suicide is legal but patients requesting it must meet many requirements to be eligible, and must ultimately end their own lives rather than have a medical professional end it for them (Harris, 2014). The situation under which the act was performed must also greatly be taken into consideration.
“A woman who bought a lethal drug on the internet and mixed it into a form that could be taken by her parents who had entered a suicide pact was not prosecuted as the CPS decided that it would not be in the public interest to do so. The woman had acted out of compassion in response to a direct request from her parents (Marsden, 2014). Those who forced the person into killing themselves or sought to profit from their death still face prosecution (Director of Public Prosecutions, 2010)” (Griffith, 2014, p. 3).
This is a case where the situation would take precedent, and the woman, while technically having broken a law, would not be prosecuted. In many cases, family members are given some legal leeway, but for the most part, nurses are judged harshly under the law for assisting a patient in their death (Griffith, 2014). Occasionally, nurses who perform assisted suicide when it is not legal may not be prosecuted. In the UK though, the Nursing and Midwifery Council may still hold nurses accountable and they risk losing their licences (Griffith, 2014).
Part of what makes assisted suicide illegal is controversy over what is best for the patient. If the patient is suffering a lot, the immediate thought may be to take steps to end their suffering. An argument for assisted suicide is that it follows that logic (Fernandes, 2015). Another perspective on the ethics of assisted suicide is maintaining patient autonomy, in other words allowing patients the freedom to do what they want in regards to their lives. It can be considered an act of compassion to allow a person suffering greatly to relieve themselves (Fernandes, 2015). Making self-administration a requirement of assisted suicide also supports patient autonomy, and a valid option (Harris, 2014). A worry in the consideration of assisted suicide is the potential for abuse in the malicious influence of a person on another and the abuse of assisted suicide on an unconscious person. Those near death may not be entirely emotionally stable or logically sound, and people seeking to gain from their deaths may take advantage of assisted suicide as an option (Harris, 2014). This is not only an ethical concern, but a major legal issue. Short of requiring self-administration of lethal agents, is may be difficult to remove the risk of harmful influence (Fernandes, 2015). Canada has taken steps to ensure patients willingly support their assisted suicide, but even their guidelines remain fairly vague (Canadian Nurses Protective Society, 2015). Simply giving patients the option to die may place unneeded pressure on them to make that choice (Trueland, 2014).
It will be extremely important to have competent nurses available to patients potentially making such decisions, as with so much patient exposure, they can expect to receive many questions about assisted suicide (Canadian Nurses Protective Society, 2015). There is also a very valid concern about people’s changing impressions of nurses, as nursing jobs including assisted suicide may give the impression that nurses are there to hasten death (Fernandes, 2015). Additionally, one must wonder what responsibilities nurses will be given in the future. Nurse practitioners for example hold extremely important roles, and there is no doubt of the potential for them to eventually play a part in assessing patients will to live (Canadian Nurses Protective Society, 2015). Professional aspects aside, nurses are people too, and there is no doubt that dealing with dying patients, both in the process and in their last moments, will create an emotional burden (Fernandes, 2015). Nursing groups where medical staff can hold discussions may be an important part of professional stress relief if nurses face increased roles in assisted suicide. Early education, such as increased discussion of assisted suicide in undergraduate programs, will be very important (Trueland, 2014).
In summary, assisted suicide is an extremely controversial subject that currently impacts nurses and will do so even more as time passes. There are issues such as validating a patient’s will to live and preventing people from taking advantage of vulnerable patients. Additionally both patients’ families and nurses are at risk when performing assisted suicide in many places, and may risk losing jobs if not going to jail. We see that certain nurses find assisted suicide more agreeable, and those tend to be the least religious nurses and the ones who spend less time caring for patients in their final days. While the legal aspects of assisted suicide must certainly be taken care of to allow for a safe, efficient, and trustworthy medical system, nurses who must deal with the consequences of these changes must be educated properly. This includes additions to the undergraduate curriculum, and groups within the workplace to take care of any issues, emotional or professional, that nurses may encounter.
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