San Francisco, CA (ASRN.ORG)--  Nurses in today’s world face ethical dilemmas that are more challenging, perplexing, and treacherous than ever before.  These dilemmas are complicated by advancements in medical technology that serve to prolong life as well as philosophical and legal debates over patient autonomy, quality of life, and the definition of death.  No other issue raises more ethical, or practical, questions about the role of the nurse in treating patients than physician-assisted suicide.

 “Physician-assisted suicide” is the provision to a patient by a medical health professional of the means of ending his or her own life.  The ethical issues raised by the concept of physician- assisted suicide include patient autonomy, quality of life, and what it means to act in the patient’s best interests.  The health professional’s degree of participation in the suicide may vary.  The physician may give a patient a prescription for a lethal dose of medication that the patient can take when the patient chooses, or the physician may personally administer the lethal dose at the patient’s request.  Each of these actions would qualify as “physician-assisted suicide.”  A nurse may be involved in assisted suicide by providing or administering the means of death in his or her capacity as a health care professional, by assisting a physician in doing so, or by tacitly approving the actions of another health care professional by failing to stop or report a physician-assisted suicide of which he or she is aware.  It is also important to define what physician-assisted suicide is not.  There is a difference between acting to end life and administering a treatment for another reason—such as to reduce pain—that may have as an unrelated, but foreseeable, consequence the hastening of a terminally ill patient’s death. 

It is also important to think about what we mean by “patient autonomy” and what limits can and should be placed upon it?  Does “patient autonomy” include a “right to die”?

It is well-accepted that a patient has the right to reject medical treatment even when the patient’s treating physician or nurse believes the treatment is in his or her best interest. In such a case, withholding treatment at the patient’s request is not considered “physician-assisted” suicide but rather a gesture of respect towards the dignity and free-will of the patient.  However, according to most medical bodies and ethics boards, the duty to provide care to a patient does not encompass a duty to comply with a patient’s request to be put to death, no matter how hopeless the patient’s condition or how intense the patient’s pain. 

In order to honor a patient’s autonomy, nurses and other medical health professionals must be sure that a patient’s choices are informed (i.e., that the patient understands the consequences of his or decision) and not the product of pressure or coercion.  Unfortunately, it may not always be clear whether a patient’s decision is actually well-informed and freely made.  For example, some patients may request withdrawal of treatment or assisted suicide because they believe themselves to be a financial or emotional burden on their caretakers and thus feel a “duty” to die.  In addition, there is the possibility that a patient who is ill or in pain will be depressed or suffer from some other mental disorder.  Although the patient is technically competent to make his or her own decisions, it is important to consider to what extent those decisions are affected by treated mood disorders or other mental illnesses.  Thus, “autonomy” can be compromised by many factors, not all of which can be immediately detected or accurately judged by a treating medical professional.

Another important consideration is “quality of life.”  At what point does life cease to have “quality” and who should decide how much “quality” a particular patient’s life has?  A related and valid question is whether the patient is always capable of judging the “quality” of his or her life, and, if the patient is incapable of doing so, who should make that judgment?  Considerations of quality of life are closely linked to a determination of what is in a patient’s best interests.  The challenge is to define what a patient’s best interests are and, again, identify who should be allowed to determine what those best interests are and whether they are met by withdrawing or administering a particular treatment.  Some proponents of physician-assisted suicide argue that those who oppose it are placing their own abstract ethical concerns above a practical consideration of the patient’s best interests.  These proponents argue that it is not in the best interests of a pain-wracked terminally ill patient to suffer needlessly when his or her life is almost over anyway.  From this perspective, the failure to end that suffering, even if the only way of doing so is the end the patient’s life, is an abdication of the health professional’s duty to do what is best for the patient’s well-being.  For such a patient, death is better than a continued existence of intense, unbearable suffering.  However, such an argument presumes that medical professionals, who are trained to discern what is best for a patient’s health, will be able to determine what is best for the patient overall.  This point of view, though well-intentioned, threatens to verge on paternalism, where the physician believes so much in his knowledge of what is best that he or she ignores the patient’s right to self-determination.  Thus, there is an inherent tension between respecting a patient’s autonomy and acting in his or her best interests.

Additional complications arise when a patient is incapacitated and a surrogate is making decisions on his or her behalf.  In that case, deciding what a patient wants or what is in his or her best interests becomes a matter of guesswork for which a physician or nurse is not trained or qualified.

Throughout the United States, it remains illegal under most circumstances for a medical professional, whether a physician or nurse, to assist in the suicide of a patient, even if that patient has a terminal illness, is suffering pain, and specifically requests the assistance.  There are limited exceptions: under Oregon’s Death with Dignity Act, a competent adult who is terminally ill with less than six months to live may make a written request to his doctor for a lethal dose of medication.  The request must be initiated by the patient, not suggested by a physician, and healthcare providers are not required to comply with the request.  As of November 2008, Washington State has a similar law.  However, a nurse who participates in an assisted suicide can face severe legal consequences, including prosecution for murder.  The debate over assisted suicide has focused so much attention on the decisions healthcare providers make in their treatment of the terminally ill that some courts have found no distinction between palliative care that hastens death and action taken for the purpose of actively ending a patient’s life.  Thus, nurses and other medical professionals may, in some cases, face adverse legal consequences when they act in accordance with their ethical obligation to ease the suffering of the terminally ill.

The Code of Ethics for Nurses provides some guidance for nurses who are confronted with end-of-life issues and requests for assisted suicide. Nurses, as well as physicians, have a duty to alleviate suffering and to provide “supportive care” to the terminally ill.  Nurses treat more than the patient’s physical ailments, but also seek to provide psychological comfort and support to the patient and his or her family.  Moreover, “a fundamental principle that underlies all nursing practice is respect for the inherent worth, dignity, and human rights of every individual.”  Thus, nurses have a duty to respect patient autonomy, and to do so with consideration for the patient’s “lifestyle, value system and religious beliefs.”  Nurses should play an active role in helping terminally ill patients prepare for death and to “minimize unwarranted or unwanted treatment and patient suffering” by counseling them with respect to decisions about such as DNR orders, experimental treatments, and pain management.  However, it is within a nurse’s ethical prerogative to administer palliative care that may incidentally hasten death, he or she is forbidden under the Code of Ethics from “act[ing] with the sole intent of ending a patient’s life even though such action may be motivated by compassion, respect for patient autonomy and quality of life considerations”

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