Physician Assisted Suicide
At some point ones expanding of free will infringes on another’s. At what point is the free will of the mass abridged by the few? Do we have to codify everything in law?
Content
Inconsistencies with Libertarianism: A view through Healthcare Policy March 15, 2008
Healthcare Ethics
2
Oregon in November 1994 passed a law allowing physician assisted suicide. In Lee v. Oregon, the law was ruled unconstitutional, while the Ninth Circuit Court in 1997 overturned the previous ruling. An attempt in November of that year was made to repeal the law by vote but it failed and subsequently Oregon now allows physician assisted suicide (Snyder, 2006). Proponents of regulated suicide and those in favor of extending palliative care view patient’s autonomy, financial resources, and societal stress, the personal care of a patient and the long-term effects of suicide as major factors in their stance of the issue. National Health Care policy and our public health system has been a wedge of complication in this issue splitting the two sides quite effectively. What is of concern is the logic behind the assisted suicide debate and advocacy groups in general. Progressive rights can and do outstrip the ethics that support them over time. The benefits of our healthcare system have been scattered between the upper class, middle-class, and the poor, through a mixture of public and private insurance. The goal of healthcare by large is to protect and enhance the well being of those who can least effect or afford to do so themselves (Bluhm & Heineman, 2007). In essence, this is a form of utilitarianism with the good of society outweighing the lack of treatment due to cost. However, utilitarianism in this respect is a double-edged sword because the premise of cost effectiveness can be used to weaken healthcare and is prominent in advocates arguments wishing to promote adequate pain management, palliative care, and an expansion of Hospice services. Providing healthcare services or any time funded- re-allocation of resources from the few to the many has been a methodology wrought with intricacy of regulation and formula. There is the implication as Randall B. Ripley and Grace. A Franklin found that
Healthcare Ethics
3
intense, powerful opposition from the few with resources will become highly organized and will disproportionally move policy toward favoring their benefit against the masses (Bluhm & Heineman, 2007). In essence, this can be summarized as the masses blunt pressure of need vs. the minorities vaulting of the spear of protection. Due to the nature of healthcare, cost conflicts, and most large policy implementations, change in America in any one direction has been incremental. Only in a severe moments or windows of time have health care policy direction movements been large, such as during the New Deal and a second time during the Great Society (Bluhm & Heineman, 2007). Those advocating assistance in suicide remark that the overarching view of depression in suicide cases proves too much and is too broad a sweep to be useful as a litmus test for deciding against laws regulating assisted suicide (Harber, 2000). Of the majority of those who are depressed there is some who can decide the costs of living against the benefits of dying from a terminal illness (Harber, 2000). Those who are severely suffering from an illness without the ability to recover do understand the capacity of life and that of death. Both the view that killing oneself devolves natural law or Kantian law; one of contradiction of itself is not in itself convincing (Harber, 2000). What remains is the high cost of living with severe, debilitating pain and death (Harber, 2000). Corollary can be used between U.S smoking policy and U.S assisted suicide policy. The impetus for this is because both can involve U.S Healthcare policy, personal autonomy and wealth distribution and transfer. Distribution and transfer of healthcare dollars or insurance coverage has been fragmented at the national level (Bluhm & Heineman, 2007). Deliberate modifications to re-fashion what is normal in both instances
Healthcare Ethics
4
have been undertaken. Activists in both groups, assisted suicide and anti-smoking have targeted efforts at the state level through tort law and the use of the ballot (Bluhm & Heineman, 2007). Individual autonomy or the right to chose ones own actions and destiny is paired with humanitarian ethos (Mappes & Zembaty, 2007). In both the antismoking debate and in Euthanasia or PSA, PAD suicide, respect for individual choice should be provided and granted if no other individual is negatively effected (Mappes & Zembaty, 2007). This in both is a form of deontological ethics. Seeking governmental assistance is a significant method of activist as well as those who proclaim the opposite of a legislative/Judicial “slippery slope” (Bluhm & Heineman, 2007). Reaction from congress from anti-smoking activists was mixed wherein more success was achieved through the states, which is what pro-assisted suicide advocates have also experienced. In both cases they were much more successful at moving policy in favor of their agendas (Mappes & Zembaty, 2007) (Bluhm & Heineman, 2007). To illuminate or reduce smoking advocates shifted from the “right to chose” to “equal rights” or personal autonomy for victims such as the young and non-smokers. According to Dan W. Brock denying oneself life sustaining treatment and allowing euthanasia to be applied to oneself should be permissible equally on the grounds of selfdetermination or autonomy (Mappes & Zembaty, 2007). These positions of autonomy and juxtaposed, one in the case of removing a right of autonomy and one giving a right of autonomy. To the writer if autonomy is a fundamental deontological law then one of these rights is in error fur autonomy cannot be according to both advocacy groups. Utilitarianism might find a second flaw with euthanasia based on statistical data.
Healthcare Ethics
5
Risk is in itself an expansive component of the debate in all health related issues, both in the anti-smoking debate and in the suicide debate. There are risks in smoking, in breathing second-hand smoke, in driving, in all things associated with life and in how we die, not only in end of life decision making. According to advocates for physician assisted suicide no new risks are introduced with the new polices that would not be already present in the current policies (Mayo & Gunderson, 2006). Informed consent is already an integral part of all medical decisions involving one self as well as including, medical power of attorney, wills, living wills and DNR’s. The explosive growth of technologies from 1960 until currently that prolong life has made the value of life as unique turn toward aggression and medical vitalism that is paternalistic, causing as much or more harm that should be (Mayo & Gunderson, 2006). According to Mayo utilitarianism is used as a risk-based fork for those against PAD or PAS away from the true issue of medical vitalism (Mayo & Gunderson, 2006). Utilitarianism proposed by Jeremey Bentham is measured by a calculus of pleasures and pains and not by intentions. This calculus for a social good to actually be socially good must add up to a net sum of pleasure over pain or the good of the many vs. the good of the few (Bluhm & Heineman, 2007). One major flaw in this calculus is that of the value of a pleasure or a value of a pain (Mappes & Zembaty, 2007). Statistically though for euthanasia, policy, and assisted suicide data tracking can be used to follow the path of this policy and some possible impetus for health care insurers with references to the smoking debate. Declining health is a factor in up to 25% of all suicides with 50% of them in people over 50 and expanding to 70% in people older
Healthcare Ethics
6
than 60 years of age (Roleff, 1998). Statistically in 95% of all suicides, a diagnosable psychiatric illness is present within just a few months of death (Hendin, 1997). Statistically the converse slant of anti-assisted suicide, euthanasia can be determined. With the Dutch/Netherlands system of euthanasia upwards of 75% of assisted suicide requests from doctors are declined by them due to issue beneath the request such that counseling or symptom control are adequate (Watts & Howell, 1992). In 1990 some 66% of those who responded to a Gallup poll in the US regarding assisted suicide for those who were terminally ill a moral right (Watts & Howell, 1992). This figure had increased from 45% during 1975 (Watts & Howell, 1992). Finally in the Netherlands, where assisted suicide has been fully implemented for some time, only 2% of all deaths are those due to euthanasia (Watts & Howell, 1992). In 1990, 1250 cases of explicit intentional doctor assisted suicide occurred but by 1995 the total was 1900 (Hendin, 1997), upwards of 80% of these suicides had no death requests for termination. With Oregon, a study done by Louis L. Miller 1996 revealed 51% support the Oregon Death with Dignity Act with 13% greater support since 1994. Again, the study was repeated in 2001 with Hospice nurses 16% more supportive of ODDA then in 1994 with an increase of 24% for social workers as supportive of ODDA as well. This expanding attitude has the potential to undermine hospice care in the near future.
Healthcare Ethics
7
(Miller, 2004) Economically it can run upwards of 40,000 dollars to provide palliative care to a dying patient but only 40 dollars to assist a suicide of the same patient (Smith, 2005). Kaiser/Permanente issued an email statement to its northwest division doctors, upwards of 800, urging them to use PAS methods of Physician Assisted Suicide as a cost saving technique (Smith, 2005). The savings nationally from PAS intervention would be in the hundred of Billons of Dollars and would drive assisted suicide by profit (Smith, 2005). In 1998, the Oregon State Health Commission provided funding within its plan structure for PAS reimbursement for those who were poor and were under the State run plan. Finally, it can be noted that only 5% of all of Oregon’s suicide cases in total within 7 years had obtained psychiatric counseling (Smith, 2005). Under the utilitarianism, filler pleasure would be maximized as viewed in cost savings by HMO’s, PPO’s, and state funded health plans, while statistically safeguards are not adequately present. In human life utilitarianism palliative care and not expense savings agents would maximize pleasures in favor of poor under privileged dying patients. Considering those to gain the most monetarily are those administering PAS, this
Healthcare Ethics
8
would create a conflict of interest. Again, assisted suicide and Euthanasia do not meet the mark of utilitarianism, not from a patient standpoint Libertarians under the auspices of the definition of the libertarian’s ethic: 1. Believe in free will that is not to be abridged by the state. 2. The individual interest should not be abridged for the mass. In the anti-smoking’s ban in NY and that of the Oregon PAS law both actually produced greater layers of policy and personal rights reduction. This is not to say a containment of second hand smoke is not without good warrant. In October of 2003 fines were implemented to those bars, taverns, and restaurants that do not comply with the statewide clean-indoor act ban on smoking (Bluhm & Heineman, 2007). According to the Empires State Restaurant and Tavern Association they argue that the policing and compliance of the law is left to the restaurants and bars. If it is enforced, it is enforced by the local county health department (Bluhm & Heineman, 2007). With the Oregon PAS and the Dutch model, review committees had to be complied, a second doctor consultation, oral requests, written requests, support for other alternatives, possible counseling, and fixing a time of death (Mappes & Zembaty, 2007). At some point ones expanding of free will infringes on another’s. At what point is the free will of the mass abridged by the few? We have cases where one person’s rights infringe upon another’s. We have issues where logic can fight logic and statistics can fight statistics. Because we are as a society ever more struggling with fewer resources, we have splintered into focus groups, interest groups and lobbying groups. In the case of smoking, a right to smoke was taken away, albeit due to health hazards. The smoking debate is only an illustration to illuminate PAS, PAD and Euthanasia. In personal autonomy to decide, death rights attempted to be given.
Healthcare Ethics
9
Consistency is found in America’s special interest groups to have rather than to give. We want to be free of smoke and we want the right to decide what to do with our bodies, but what of someone other than me or us, perhaps, you or them? Do all decisions need to be codified, to be written in law? As for euthanasia perhaps we can keep the decisions informal, a poorly kept secret between the person and his or her doctor (Harber, 2000). When did the value or an oral commitment fall?
Healthcare Ethics 10 Bibliography
Bluhm, W. T., & Heineman, R. A. (2007). Ethics and Public Policy: Method and Cases. Upper Saddle River, NJ: Pearson Education Inc. Harber, J. G. (2000). Physicians Should Grant Requests for Assistance in Suicide: Greenhaven Press. Hendin, H. (1997). Physician-assisted suicide: a look at the Netherlads. (Dutch acceptance of euthanasia). Current(398), 25-26. Mappes, T. A., & Zembaty, J. S. (2007). Social Ethics: Morality and Social Policy (7th ed.). New York: McGraw-Hill. Mayo, D. J., & Gunderson, M. (2006). Legalizing Voluntary Euthanasia Would Not Harm the Disabled. Opposing Viewpoints Resource Center. Miller, L. L. (2004). Proportion of Oregon physicians, nurses, and social workers in support of and opposition to the Oregon Death with Dignity Act, 1999 and 2001: Palliative Medicine. Roleff, T. L. (1998). Effective Pain Management Can Prevent Assisted Suicide. Journal. Retrieved from http://find.galegroup.com.library.esc.edu Smith, W. J. (2005). Assisted Suicide Would Be Mandated for Economic Reasons. San Diego: Greenhaven Press. Snyder, C. (2006). Oregon's Assisted Suicide Experience: Safeguards Do Not Work (Publication. Retrieved 3/10/2008, from Gale Cengage Learning: http://find.galegroup.com.library.esc.edu
Healthcare Ethics 11 Watts, D. T., & Howell, T. (1992). Assisted Suicide is Not Voluntary Active. Journal of the American Geriatrics Society, 40(October), 1043-1046.
Healthcare Ethics
2
Oregon in November 1994 passed a law allowing physician assisted suicide. In Lee v. Oregon, the law was ruled unconstitutional, while the Ninth Circuit Court in 1997 overturned the previous ruling. An attempt in November of that year was made to repeal the law by vote but it failed and subsequently Oregon now allows physician assisted suicide (Snyder, 2006). Proponents of regulated suicide and those in favor of extending palliative care view patient’s autonomy, financial resources, and societal stress, the personal care of a patient and the long-term effects of suicide as major factors in their stance of the issue. National Health Care policy and our public health system has been a wedge of complication in this issue splitting the two sides quite effectively. What is of concern is the logic behind the assisted suicide debate and advocacy groups in general. Progressive rights can and do outstrip the ethics that support them over time. The benefits of our healthcare system have been scattered between the upper class, middle-class, and the poor, through a mixture of public and private insurance. The goal of healthcare by large is to protect and enhance the well being of those who can least effect or afford to do so themselves (Bluhm & Heineman, 2007). In essence, this is a form of utilitarianism with the good of society outweighing the lack of treatment due to cost. However, utilitarianism in this respect is a double-edged sword because the premise of cost effectiveness can be used to weaken healthcare and is prominent in advocates arguments wishing to promote adequate pain management, palliative care, and an expansion of Hospice services. Providing healthcare services or any time funded- re-allocation of resources from the few to the many has been a methodology wrought with intricacy of regulation and formula. There is the implication as Randall B. Ripley and Grace. A Franklin found that
Healthcare Ethics
3
intense, powerful opposition from the few with resources will become highly organized and will disproportionally move policy toward favoring their benefit against the masses (Bluhm & Heineman, 2007). In essence, this can be summarized as the masses blunt pressure of need vs. the minorities vaulting of the spear of protection. Due to the nature of healthcare, cost conflicts, and most large policy implementations, change in America in any one direction has been incremental. Only in a severe moments or windows of time have health care policy direction movements been large, such as during the New Deal and a second time during the Great Society (Bluhm & Heineman, 2007). Those advocating assistance in suicide remark that the overarching view of depression in suicide cases proves too much and is too broad a sweep to be useful as a litmus test for deciding against laws regulating assisted suicide (Harber, 2000). Of the majority of those who are depressed there is some who can decide the costs of living against the benefits of dying from a terminal illness (Harber, 2000). Those who are severely suffering from an illness without the ability to recover do understand the capacity of life and that of death. Both the view that killing oneself devolves natural law or Kantian law; one of contradiction of itself is not in itself convincing (Harber, 2000). What remains is the high cost of living with severe, debilitating pain and death (Harber, 2000). Corollary can be used between U.S smoking policy and U.S assisted suicide policy. The impetus for this is because both can involve U.S Healthcare policy, personal autonomy and wealth distribution and transfer. Distribution and transfer of healthcare dollars or insurance coverage has been fragmented at the national level (Bluhm & Heineman, 2007). Deliberate modifications to re-fashion what is normal in both instances
Healthcare Ethics
4
have been undertaken. Activists in both groups, assisted suicide and anti-smoking have targeted efforts at the state level through tort law and the use of the ballot (Bluhm & Heineman, 2007). Individual autonomy or the right to chose ones own actions and destiny is paired with humanitarian ethos (Mappes & Zembaty, 2007). In both the antismoking debate and in Euthanasia or PSA, PAD suicide, respect for individual choice should be provided and granted if no other individual is negatively effected (Mappes & Zembaty, 2007). This in both is a form of deontological ethics. Seeking governmental assistance is a significant method of activist as well as those who proclaim the opposite of a legislative/Judicial “slippery slope” (Bluhm & Heineman, 2007). Reaction from congress from anti-smoking activists was mixed wherein more success was achieved through the states, which is what pro-assisted suicide advocates have also experienced. In both cases they were much more successful at moving policy in favor of their agendas (Mappes & Zembaty, 2007) (Bluhm & Heineman, 2007). To illuminate or reduce smoking advocates shifted from the “right to chose” to “equal rights” or personal autonomy for victims such as the young and non-smokers. According to Dan W. Brock denying oneself life sustaining treatment and allowing euthanasia to be applied to oneself should be permissible equally on the grounds of selfdetermination or autonomy (Mappes & Zembaty, 2007). These positions of autonomy and juxtaposed, one in the case of removing a right of autonomy and one giving a right of autonomy. To the writer if autonomy is a fundamental deontological law then one of these rights is in error fur autonomy cannot be according to both advocacy groups. Utilitarianism might find a second flaw with euthanasia based on statistical data.
Healthcare Ethics
5
Risk is in itself an expansive component of the debate in all health related issues, both in the anti-smoking debate and in the suicide debate. There are risks in smoking, in breathing second-hand smoke, in driving, in all things associated with life and in how we die, not only in end of life decision making. According to advocates for physician assisted suicide no new risks are introduced with the new polices that would not be already present in the current policies (Mayo & Gunderson, 2006). Informed consent is already an integral part of all medical decisions involving one self as well as including, medical power of attorney, wills, living wills and DNR’s. The explosive growth of technologies from 1960 until currently that prolong life has made the value of life as unique turn toward aggression and medical vitalism that is paternalistic, causing as much or more harm that should be (Mayo & Gunderson, 2006). According to Mayo utilitarianism is used as a risk-based fork for those against PAD or PAS away from the true issue of medical vitalism (Mayo & Gunderson, 2006). Utilitarianism proposed by Jeremey Bentham is measured by a calculus of pleasures and pains and not by intentions. This calculus for a social good to actually be socially good must add up to a net sum of pleasure over pain or the good of the many vs. the good of the few (Bluhm & Heineman, 2007). One major flaw in this calculus is that of the value of a pleasure or a value of a pain (Mappes & Zembaty, 2007). Statistically though for euthanasia, policy, and assisted suicide data tracking can be used to follow the path of this policy and some possible impetus for health care insurers with references to the smoking debate. Declining health is a factor in up to 25% of all suicides with 50% of them in people over 50 and expanding to 70% in people older
Healthcare Ethics
6
than 60 years of age (Roleff, 1998). Statistically in 95% of all suicides, a diagnosable psychiatric illness is present within just a few months of death (Hendin, 1997). Statistically the converse slant of anti-assisted suicide, euthanasia can be determined. With the Dutch/Netherlands system of euthanasia upwards of 75% of assisted suicide requests from doctors are declined by them due to issue beneath the request such that counseling or symptom control are adequate (Watts & Howell, 1992). In 1990 some 66% of those who responded to a Gallup poll in the US regarding assisted suicide for those who were terminally ill a moral right (Watts & Howell, 1992). This figure had increased from 45% during 1975 (Watts & Howell, 1992). Finally in the Netherlands, where assisted suicide has been fully implemented for some time, only 2% of all deaths are those due to euthanasia (Watts & Howell, 1992). In 1990, 1250 cases of explicit intentional doctor assisted suicide occurred but by 1995 the total was 1900 (Hendin, 1997), upwards of 80% of these suicides had no death requests for termination. With Oregon, a study done by Louis L. Miller 1996 revealed 51% support the Oregon Death with Dignity Act with 13% greater support since 1994. Again, the study was repeated in 2001 with Hospice nurses 16% more supportive of ODDA then in 1994 with an increase of 24% for social workers as supportive of ODDA as well. This expanding attitude has the potential to undermine hospice care in the near future.
Healthcare Ethics
7
(Miller, 2004) Economically it can run upwards of 40,000 dollars to provide palliative care to a dying patient but only 40 dollars to assist a suicide of the same patient (Smith, 2005). Kaiser/Permanente issued an email statement to its northwest division doctors, upwards of 800, urging them to use PAS methods of Physician Assisted Suicide as a cost saving technique (Smith, 2005). The savings nationally from PAS intervention would be in the hundred of Billons of Dollars and would drive assisted suicide by profit (Smith, 2005). In 1998, the Oregon State Health Commission provided funding within its plan structure for PAS reimbursement for those who were poor and were under the State run plan. Finally, it can be noted that only 5% of all of Oregon’s suicide cases in total within 7 years had obtained psychiatric counseling (Smith, 2005). Under the utilitarianism, filler pleasure would be maximized as viewed in cost savings by HMO’s, PPO’s, and state funded health plans, while statistically safeguards are not adequately present. In human life utilitarianism palliative care and not expense savings agents would maximize pleasures in favor of poor under privileged dying patients. Considering those to gain the most monetarily are those administering PAS, this
Healthcare Ethics
8
would create a conflict of interest. Again, assisted suicide and Euthanasia do not meet the mark of utilitarianism, not from a patient standpoint Libertarians under the auspices of the definition of the libertarian’s ethic: 1. Believe in free will that is not to be abridged by the state. 2. The individual interest should not be abridged for the mass. In the anti-smoking’s ban in NY and that of the Oregon PAS law both actually produced greater layers of policy and personal rights reduction. This is not to say a containment of second hand smoke is not without good warrant. In October of 2003 fines were implemented to those bars, taverns, and restaurants that do not comply with the statewide clean-indoor act ban on smoking (Bluhm & Heineman, 2007). According to the Empires State Restaurant and Tavern Association they argue that the policing and compliance of the law is left to the restaurants and bars. If it is enforced, it is enforced by the local county health department (Bluhm & Heineman, 2007). With the Oregon PAS and the Dutch model, review committees had to be complied, a second doctor consultation, oral requests, written requests, support for other alternatives, possible counseling, and fixing a time of death (Mappes & Zembaty, 2007). At some point ones expanding of free will infringes on another’s. At what point is the free will of the mass abridged by the few? We have cases where one person’s rights infringe upon another’s. We have issues where logic can fight logic and statistics can fight statistics. Because we are as a society ever more struggling with fewer resources, we have splintered into focus groups, interest groups and lobbying groups. In the case of smoking, a right to smoke was taken away, albeit due to health hazards. The smoking debate is only an illustration to illuminate PAS, PAD and Euthanasia. In personal autonomy to decide, death rights attempted to be given.
Healthcare Ethics
9
Consistency is found in America’s special interest groups to have rather than to give. We want to be free of smoke and we want the right to decide what to do with our bodies, but what of someone other than me or us, perhaps, you or them? Do all decisions need to be codified, to be written in law? As for euthanasia perhaps we can keep the decisions informal, a poorly kept secret between the person and his or her doctor (Harber, 2000). When did the value or an oral commitment fall?
Healthcare Ethics 10 Bibliography
Bluhm, W. T., & Heineman, R. A. (2007). Ethics and Public Policy: Method and Cases. Upper Saddle River, NJ: Pearson Education Inc. Harber, J. G. (2000). Physicians Should Grant Requests for Assistance in Suicide: Greenhaven Press. Hendin, H. (1997). Physician-assisted suicide: a look at the Netherlads. (Dutch acceptance of euthanasia). Current(398), 25-26. Mappes, T. A., & Zembaty, J. S. (2007). Social Ethics: Morality and Social Policy (7th ed.). New York: McGraw-Hill. Mayo, D. J., & Gunderson, M. (2006). Legalizing Voluntary Euthanasia Would Not Harm the Disabled. Opposing Viewpoints Resource Center. Miller, L. L. (2004). Proportion of Oregon physicians, nurses, and social workers in support of and opposition to the Oregon Death with Dignity Act, 1999 and 2001: Palliative Medicine. Roleff, T. L. (1998). Effective Pain Management Can Prevent Assisted Suicide. Journal. Retrieved from http://find.galegroup.com.library.esc.edu Smith, W. J. (2005). Assisted Suicide Would Be Mandated for Economic Reasons. San Diego: Greenhaven Press. Snyder, C. (2006). Oregon's Assisted Suicide Experience: Safeguards Do Not Work (Publication. Retrieved 3/10/2008, from Gale Cengage Learning: http://find.galegroup.com.library.esc.edu
Healthcare Ethics 11 Watts, D. T., & Howell, T. (1992). Assisted Suicide is Not Voluntary Active. Journal of the American Geriatrics Society, 40(October), 1043-1046.
