End of Life Issues: Part One

A Time to Give Birth, and a Time to Die (Eccl. 3:2)

by William Cutrer, M.D., and Sandra Glahn, Th.M.

During the fall of 2000, PBS sponsored a six-hour series that took a highly favorable view of physician-assisted suicide (PAS). Included in the human drama were a woman in Oregon who could legally commit suicide, though she got too sick to swallow the prescribed medications and died naturally soon thereafter. Another patient, a man in Louisiana with Lou Gehrig’s Disease, could not legally take part in PAS, but he was a veterinarian. That gave him access to the medications, but he too, by the time he was ready to take his life, was too sick to take the drugs. He died shortly thereafter.

Do these people have a right to take their own lives? Do they have a right to ask physicians to help them? How do we reason ethically? How can we best honor God with our lives and deaths? This sort of question has become more common, probably due in part to shifting demographics:

More than half the people in history who have reached age sixty-five are alive today.

Seventy thousand Americans are one hundred years old or older. That number is projected to reach more than 834,000 by 2050, according to the U.S. Census Bureau.

The National Hospice Foundation found that half of Americans want their families to carry out their final wishes, but 75% haven’t explained what their desires are.

Our population is aging and living longer, so we are seeing some changes in the emphasis on end of life issues. In 1993 for the first time one state (Oregon) passed legislation that enabled terminally ill patients or family members to receive as many painkilling drugs as needed to relieve illness-related suffering. The bill stopped short of legalizing PAS, but that same year, Oregon Right to Die was founded to back a PAS initiative. By the end of the following year, Oregonians had approved Measure 16, making the Death With Dignity Act the nation’s first law permitting PAS. (For a complete listing of state and Supreme Court rulings go to www.religioustolerance.org.)

In our next few columns we will consider some of the difficult issues involved when a patient is suffering with a terminal illness. But in order to engage in the discussion, we must first define some key terms, recognizing that these may vary slightly depending on what sources you read:

Withdrawal of Treatment – The decision to stop prolonging death. This involves continuing to provide care, but withholding or withdrawing curative therapies and aggressive efforts to cure disease or sustain life.

Euthanasia – The act of ending the life of a suffering patient; taken from a similar Greek word meaning “easy or good death.”

Active Euthanasia – Intentional administration of medications or other interventions to cause the patient’s death.

Indirect Euthanasia – sometimes referred to as inadvertant death and not euthanasia, because the death results from a “dual effect.” Administering narcotics or other pharmaceuticals to relieve pain, shortness of breath, nausea, or other symptoms in a terminal patient with the unintended or incidental consequence of causing death.

Voluntary Euthanasia – Done at the patient’s persistent request.

Involuntary Euthanasia – The patient has refused euthanasia, but is killed.

Nonvoluntary Euthanasia – Result of a therapeutic decision to terminate the life of the patient, such as when a patient in a coma has not expressed wishes, but the patient’s life is terminated as a result of a family or physician decision.

Physician Assisted Suicide (PAS) – Providing medications or other interventions with the understanding that the patient intends to use them to commit suicide.

So what’s the key difference between euthanasia and PAS? During euthanasia, when death itself occurs, it’s carried out by the doctor or his agents; in physician-assisted suicide, the patient fulfills the final step of terminating his/her own life. Dr. Jack Kevorkian, the outspoken advocate for euthanasia and PAS, describes the difference between the two in his own words: “It’s like giving someone a loaded gun. The patient pulls the trigger, not the doctor. If the doctor sets up the needle and syringe but lets the patient pull the plunger, that’s assisted suicide. If the doctor pushed the plunger, it would be euthanasia.”

Attitudes about euthanasia in general vary significantly, depending on whether the euthanasia is voluntary or involuntary. Views on PAS are more clearly defined. A survey of Americans about their attitudes toward PAS reveals the following:

1/3 support it under variety of circumstances
1/3 oppose it under any circumstances
1/3 support it in selected cases but oppose it under most circumstances

In this series, we will consider some end-of-life scenarios through our principles of ethics: Beneficence, Nonmaleficence, Autonomy, and Justice (refer to first column for definitions)

We will also explore other key related considerations:

Sanctity of Life
Confidentiality
Medical Futility
Resource allocation

Often when we think of Proverbs 31, we think of the noble wife. But earlier in that chapter we find some verses that give us some guidance in the end of life debate: Give beer to those who are perishing, wine to those who are in anguish; Speak up for those who cannot speak for themselves…(Pro 31:6-7).

So what are the ethical considerations in helping the suffering patient? How far is too far? What can be done to provide comfort care to alleviate suffering? Join us next time as we consider these and other key considerations.