The case is that of a 35 year old white, single, female who was found on her bed stuporous and moaning by her father and mother with whom she lives. There was a note in the room written by her explaining that she had carefully considered her life and what was happening to her and that she wanted to die. There was evidence in the bathroom that she had most likely taken three bottles of different pills including barbiturates. The family immediately called the paramedics and the patient was taken to the nearby hospital emergency room. The physician was presented with the note and the bottles and since the patient was not fully unconscious began to insert a nasogastric tube to aspirate the contents of the stomach. As he was attempting to get the tube down, the patient became briefly more responsive and cried out that she didn’t want the tube, she didn’t want any treatment and that she wanted to be left alone and allowed to die. She moaned that she had left a note which said she wanted to die and she meant it. The family arrived in the next few minutes and informed the physician that she had not seemed depressed to them and she had never seen a psychiatrist but the medications were prescribed by her general physician. When told about what she had requested of the physician, the family urged that the doctor continue treatment.
What should he do next? The physician realized that if she had consumed the pills in the bottles she would most likely not survive without medical treatment and yet it seemed clear that she did not want any treatment.
The issue is whether the doctor must follow the request of the patient and stop treatment and allow her to die.
Please address the following questions:
1.) Does the principle of patient autonomy apply here?
2.) Can the physician perform a treatment against the consent of the patient?
3.) What is the responsibility of the ER physician in this matter?
4.) Must the physician be required to participate in completing an attempted suicide?
Euthanasia and Physician-Assisted Dying
Dr. W Abushahba
Euthanasia come from a Greek antiquity meaning “good death.”
A death free of pain and anxiety brought about by the use of medication
deliberately putting an end to someone’s life in order to spare the individual’s suffering
What is Euthanasia?
Clip-Eye to Eye: Opposing Views
“Active Euthanasia”- taking specific steps to cause the patient’s death
“Passive Euthanasia”- usually defined as withdrawing medical treatment with the deliberate intention of causing the patient’s death; doctors not killing anyone, but not saving them
Difference? For active, something is done to end the patient’s life. For example, injecting a patient with a lethal substance is a type of Active Euthanasia. In passive, something is not done that would have preserved the patient’s life. A type of Passive Euthanasia would be “Pulling the plug.”
Types: Active vs Passive
Voluntary active euthanasia is when doctors intentionally inject lethal medication or other interventions to cause the patient’s death at the patient’s request and full consent.
Involuntary active euthanasia is intentionally administering medications or other interventions to cause patient’s death when patient was competent but without the patient’s explicit request and/or fully informed consent
Voluntary vs Involuntary
The major argument in favor of Euthanasia is that the person is suffering great pain
They argue that no person should live with the constant fear of dying or the pain associated with a terminal illness
This goes for both physical and mental pain
Right to Commit Suicide
In terms of Euthanasia, the right to commit suicide is associated with persons assisting the suicide
It is a quick solution to a dreadful problem
If they give consent, why is it wrong to assist in suicide?
Reasons for Euthanasia
Arguments For Euthanasia
Provides relief to patients with extreme pain
Provides a way of relief when a person’s quality of life is low
Frees up medical funds to help other people
It is another case of freedom of choice
Arguments Against Euthanasia
Devalues human life
Physicians and other medical care providers should not be involved in directly causing death
“I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion”
In 1939, the Nazis created a program to secretly but systematically kill mentally and physically disabled people, including Germans, who were housed in institutions. The code name for this program was Aktion T-4.
Controlled euthanasia for terminally ill, handicapped & psychiatric patients
Handicapped, disabled children (early 1939)
Mentally ill, retarded adults (October 1939)
Criminally insane, epileptics, polio victims, schizophrenics, senile, paralyzed All valueless individuals: Jews, non-Germans
This led to millions being killed
The Nazi’s Slippery Slope into Euthanasia
The Netherlands became the first European country to legalize euthanasia in 2001, permitting it in the case of terminally ill patients who have no hope of recovery, suffer unbearable pain and ask to die.
Belgium has legalized euthanasia under strict conditions
France has passed a right-to-do law that empowers the terminally ill to refuse life-extending treatments but does not legalize euthanasia.
Switzerland allows passive assistance to terminally ill people who have expressed a wish to die, and the practice is common
The Oregon Experience
Oregon legalized physician-assisted suicide in 1997
Physician-assisted suicide: When a physician provides medications or other means to a patient with the understanding that the patient intends to use them to commit suicide
Since 1997 the rule in Oregon has been:
Doctors must agree that patients have less than 6 months to live and are mentally competent to make the decision.
The doctors can only prescribe the dosage not administer it.
ROMAN CATHOLIC : The use of euthanasia consists in putting an end to the lives of handicapped sick or dying persons. It is moral unacceptable.
ISLAMIC: Suicide and euthanasia are explicitly forbidden
“Do not kill (or destroy) yourselves, for verily Allah has been to you most Merciful” (Qur’an 4:29).
“…The message of Judaism is that one must struggle until the last breath of life. Until the last moment, one has to live and rejoice and give thanks to the Creator …” Dr. Rachamim Melamed-Cohen, Jewsweek, March, 2002
Only 1 out of 5 of his patients were
Some patients were not ill, only depressed
Proposes doing experiments on people being killed to learn more about death.
He created “suicide centers” in Michigan, but later convicted by the owner.
Clip-Kevorkian’s 60 Minutes Interview
Assisted with one of his patients with death who was suffering from leukemia
In contrast to Dr. Kevorkian, he knew his patient and treated for a long time.
He wrote about her death in a medical journal and was prosecuted by the local district attorney for murder.
Dr. Anna Pou
On duty at Memorial Hospital when Hurricane Katrina struck on Aug 29, 2005
July 17 , 2006 Arrested under a judges warrant for four counts of second degree murder in connection of deaths with Life Care Patients
July 24, 2007 A grand jury refused to indict her and was cleared of all charges for second degree murder
Memorial Medical Center
Flooded in the Aftermath of Hurricane Katrina in 2005.
All electrical and plumbing functions failed due to flooding in basement
Temperatures Climbed to 110 degrees without water post Hurricane
2006 Hospital renamed to Oshner Baptist Medical Center
Horror at Memorial
Toilets overflowed, spilling feces and filth down the hallways, and there was no running water and scant communication between floors. Backup generators took over for a while, but by early Wednesday morning, the electrical grids in the basement that kept the generators going, also failed. The total blackout meant computers fell silent, cell phones could not be recharged and patients’ life-support systems were useless.
Triage and DNR
A nurse wrote “1,” “2” or “3” on a sheet of paper with a Marks-A-Lot pen and taped it to the clothing over a patient’s chest
DNR or Do Not Resuscitate were generally given to patients in category 3.
Interview with Sheri Fink
Interview with Sheri Fink Regarding What happened in Katrina
Pro-Want to allow her to die
Con-Against allowing her to die
In the News: The Story of Grace Sung Eun Lee
Change of Heart?
Request to Die
Dr. Walid Abushahba
When a person requests to end their life in a painless matter.
Jean –Paul Sartre “Not to choose is always still a choice”
Christianity views on voluntary death
“Life is a gift from God and only God can take it back”
It deprives the community of talented people
It deprives children of their parents
It is unnatural
Goes against the instinct of self-preservation
Argued that voluntary death is NOT a sin
“It’s a kind of blasphemy to imagine that any creative being can (by taking his own life) disturb the order of the world.”
“Any suicide is insignificant to the workings of the universe and it is blasphemy to think otherwise.”
He believed that if the motive of suicide is self-interest (escaping pain) then that is not a moral justification.
“Suicide is immoral because people should always be treated as ends in themselves, never as mere means.”
John Stuart Mill
As long as others are not harmed, we can do whatever we want with our own lives and bodies.
Do we agree with this statement?
A WOMAN WITH CEREBRAL PALSY AND PARALYSIS
NO MOTOR FUNCTION IN ANY OF HER LIMBS OR SKELETAL MUSCLES
THROUGH ASSISTANCE SHE ACHIEVED HER B.S. IN SOCIAL WORK
MARRIED FOR 1 YEAR
ATTEMPTED TO HAVE A CHILD WITH NO SUCCESS
LOST THE COURT BATTLE TO HELP END HER LIFE
Elizabeth’s Plan To Die
IN 1983 SHE CHECKED HERSELF INTO RIVERSIDE GENERAL HOSPITAL IN CALIFORNIA CLAIMING SHE WAS SUICIDAL
ANNOUNCED HER PLANS TO STARVE HERSELF TO DEATH AND STARTED TO REFUSE SOLID FOODS FROM THE NURSES
WHEN THE HOSPITAL REFUSED TO RESPECT HER WISHES SHE CONTACTED THE MEDIA AND SOUGHT LEGAL REPRESENTATION
“LIFE AS A DISABLED PERSON WAS A FATE WORSE THAN DEATH”
SHE WAS TIRED OF BEING A BURDEN AND HAVING TO DEPEND ON OTHER PEOPLE TO FUNCTION IN LIFE
BELIEVED SHE WOULD NEVER FIND A MEANINGFUL JOB
SHE FELT IT WAS HER RIGHT TO CHOOSE
“If I really could, I would go out there and kill myself. But I can’t. I physically can’t…I see death as letting go of all burdens. It is being able to be free of my physical disabilities and mental struggle to live.” –Elizabeth Bouvia
After her victory in court, Elizabeth did not kill herself
When some caring people offered to help her die, she changed her mind
Getting control over her life gave her a reason to live
However in 1996 she still needed a morphine drip to control her pain and was having conflicting feelings about being alive
In 2008 in the Los Angeles Times mentioned that Elizabeth Bouvia was still alive
Larry McAfee case
Due to a motorcycle accident, he became almost completely paralyzed at the age of 29.
Snapped his head
Crushed two top vertebrae
Left with use of only his eyes, mouth and head
Could not breathe on his own-needed a ventilator
Larry McAfee case
1989 McAfee filed suit in federal court to exercise his right to dies
He did not want his ventilator disconnected but had designed a puff-sip switch for his IV line
Blowing and sucking in a specific pattern would enable him to turn on an electric switch that would activate the flow of lethal drugs into him
Judge Edward Johnson ruled in McAfee’s favor
RATIONALITY & COMPETENCE
KEN HARRISON WAS A ARTIST THAT MADE SCULPTURES
INVOLVED IN A CAR ACCIDENT, HE BECAME PARALYZED FROM THE NECK DOWN
ALL HE IS ABLE TO DO IS TALK
EVENTUALLY HE BECOMES FRUSTRATED AND DEPRESSED WITH HIS DISABILITY AND DECIDES HE WANTS TO DIE
Why is it harder to commit suicide?
Some people may want to die painlessly and aesthetically.
Want to be sure that they accomplish their intentions.
If disabled, it’s impossible to kill yourself without someone else’s help.
In 1987, Robert McFarlene tried to kill himself & took 30-45 tablets of 10mg Valium.
The attempt to kill himself didn’t work, due to an insufficient quantity. Instead causing him to be brain-but-not-bodily dead.
Most people suicidal attempts don’t work.
Even Physicians don’t know how to assist a suicide.
In 1985, Physician Robert Rosier didn’t know how much morphine to give his terminally ill wife to help her die.
Poisoning: If failed; Lasting effects can include internal organ damage
Slitting wrist in a warm tub: Must be made deep and in right place
Drug / Alcohol Overdose: If failed, can lead to severe to permanent organ failure .
Gun Shot: One of the most often achieved forms of suicide is by gun shot. Generally a head shot is 99 percent effective.
The list goes on….
“Today’s meaning of prejudice comes close to this. Without examining a person on his or her own merit, we have already adopted a negative attitude that implies a judgment. A prejudice is a mixture of beliefs and feelings that predisposes people to respond negatively to members of a particular group.”
A prejudice system destroys the independence of disabled people rather than nurturing it.
What makes a disabled person want to die is the cumulative effect of centuries of prejudice against people who are physically disabled.