The debate about assisted suicide has come back into the news with the recent arrests of four members of the Final Exit Network, a Georgia-based group accused of assisted suicide in the death of a Georgia man in 2008. The group also faces charges of assisted suicide in Arizona, stemming from a 2007 case that may have involved a patient who wasn't terminally ill and may have had impaired judgment and questionable mental health at the time.1
The aging U.S. population and healthcare reform means that the debate about assisted suicide and natural death will only intensify. As nurses, we need to be well-informed in order to contribute clarity and information to this debate.
Untangling the terminology
Among the terms being used in the debate are assisted suicide, euthanasia, aid in dying, and the right to die. Assisted suicide, as understood nationally and as defined in Oregon's Death with Dignity Act, is the act of providing prescription medication to a terminally ill patient at his request for the purpose of effecting a peaceful death. The patient requesting aid in dying must have full capacity to make medical decisions, make the request himself, and administer the medication himself.2 The medication prescribed, usually a sedative/hypnotic, causes deep sleep, leading to eventual cessation of respiration.
Suicide, differing from assisted suicide, is the taking of one's own life without the assistance of another person.
Oregon's law, which technically is a physician-assisted suicide law, has many safeguards in place to ensure adherence to the intent of the law:
* The person must make several requests for assisted suicide, with at least 15 days between the first and last request.
* Two physicians must determine that the person is competent.
* The person must be provided with information about hospice.
In 2008, according to the state's Web site, 88 prescriptions for lethal medications were written under the provisions of Oregon's law, and 60 patients ended their lives.3
A similar law was approved in the state of Washington and took effect March 5, 2009.4 Montana voters also approved an assisted suicide law last year, but the court ruling legalizing the practice is under appeal. Assisted suicide is illegal in most states.
Euthanasia, as you know, comes from the Greek eu meaning well and thanatos meaning death, and translates as "dying well" or a "good death." Most people would describe a good death as one that's peaceful, painless, lucid, and provides the opportunity for the expression of love and family presence.
In ethical parlance, the term euthanasia is divided between active euthanasia and passive euthanasia. Active euthanasia denotes instances when someone takes direct action (for example, a lethal injection) to bring about a patient's death. Passive euthanasia denotes refusal to intervene to prevent a patient's death.
Because of the concern that passive euthanasia involves long-term suffering, the greatest question the public and nurses face is whether forgoing intensive therapy to allow a natural death is preferred over other ways of dying.
Compassion or aid?
Persons often seek aid in dying when their lives are fraught with pain and other physical symptoms, depression, and loss of dignity. In those circumstances, they may turn to a group such as the Final Exit Network.
According to its Web site, Final Exit Network provides only counseling, training, and support. Trained members of the network respond to requests from person seeking a way to end their self-proclaimed painful lives. Final Exit Network says that it only helps competent individuals who wish to know how to end their own lives, and lists inclusion and exclusion criteria on its Web site.5
Members of the network follow directions from the 1991 book by Derek Humphry, Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying to counsel persons who wish to commit suicide. These guides often are present at the time of the suicide, but according to the network, merely provide a compassionate presence and don't assist the patient. Because assisted suicide is a felony in Georgia, members of Final Exit could face jail time if convicted.
Where nursing stands
As a nurse, you need to know the professional stance on assisted suicide and the underlying reasons why the debate continues.
The American Nurses Association's (ANA's) Code of Ethics for Nurses calls for providing supportive care to dying patients, and intervening to enable the patient to live with as much physical, emotional, social, and spiritual well-being as possible.6 However, an ANA position statement on assisted suicide states that nurses shouldn't participate in assisted suicide, but should always work toward comprehensive care of the ill and dying.7 Nurses in Oregon, and now Washington, don't assist with suicide, but care for patients who elect assisted suicide in the same way they care for all patients, with dignity and compassion.
An interesting byproduct of the Oregon law has been an increase in use of hospice and greater attention and expectations of patients about symptom control and improved pain management.8,9
Assisted suicide remains a controversial, emotional, and moral issue. By understanding the arguments on all sides, you can be an informed professional voice in the debate.
1. Rubin P. Death wish. Phoenix New Times News. August 22, 2007. http://www.phoenixnewtimes.com/2007-08-23/news/death-wish. [Context Link]
2. State of Oregon. Oregon Death with Dignity Act. http://oregon.gov/DHS/ph/pas/ors.shtml. [Context Link]
3. State of Oregon. 2008 Summary of Oregon's Death with Dignity Act. http://www.oregon.gov/DHS/ph/pas/docs/year11.pdf. [Context Link]
4. State of Washington. Washington Death with Dignity Act. http://wei.secstate.wa.gov/osos/en/Documents/I1000-Text%20for%20web.pdf. [Context Link]
5. Final Exit Network. http://www.finalexitnetwork.org. [Context Link]
6. American Nurses Association. Code of Ethics for Nurses. Washington, DC: American Nurses Publishing; 2001. [Context Link]
7. American Nurses Association. Ethics and human rights position statement: assisted suicide. Silver Spring, Md; American Nurses Association: 1994. http://www.nursingworld.org/MainMenuCategories/HealthcareandPolicyIssues/ANAPosi. [Context Link]
8. Robeznieks A. Survey shows heightened focus on pain at death. Am Med News. 2004;47(32):14. [Context Link]
9. Tilden VP, Tolle SW, Drach LL, Perrin NA. Out-of-hospital death: advance care planning, decedent symptoms, and caregiver burden. J Am Geriatr Soc. 2004;52(4):532. [Context Link]