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Physician-Assisted Suicide: A Violation of Ethics and the Hippocratic Oath

by Ashley Gillan '13

Euthanasia has been a continuous source of controversy in the United States in the 20th century. Euthanasia and physician-assisted suicide are often used interchangeably, but they have very different legal meanings. Euthanasia, also called “mercy killing” in the past, refers to the intentional, knowingly and directly taking an action for the purpose of causing the death of another person (Marker 59). It is committed when someone other than the person who dies performs the last act, without which death would not occur. It is also considered homicide in every state. Physician-assisted suicide (PAS), on the other hand, refers to when a person intentionally and knowingly provides the means of death to another person so that the person can use it to commit suicide (Marker 59). Assisted suicide takes place when a person who dies takes the last act, without which death would not occur.

Before a physician can begin his or her practice, they must take the Hippocratic Oath. The Hippocratic Oath lays out the guidelines that the physician must follow in order to maintain their professional standing. Curiously enough, the oath specifically speaks out against such acts as euthanasia and abortion. The question arises, then, how physicians avoid such restrictions, and whether or not it is ethically correct to do so. Although there is no doubt that a patient should have the right to refuse medical treatment, it is against a doctor's Hippocratic Oath to administer lethal drugs to a terminally ill person or otherwise take on any intentional role in ending a patient's life, even if it is by request of the patient. Therefore, euthanasia as well as physician-assisted suicide should remain illegal across the United States.

The Hippocratic Oath is believed to have been written around the 4th century B.C (North). The exact author is unknown, but the popular belief is that it was written by Hippocrates, the Greek philosopher for which the oath was named (North). He was born in the island of Cos between 470 and 460 B.C and died circa 370 B.C. (The Hippocratic Oath). However, the oath appears to be more strongly influenced by followers of Pythagoras than Hippocrates (North). The oath, or at least a version of it, has remained in practice to the present day. The original version states:

I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give a woman a pessary to produce abortion. With purity and holiness I will pass my life and practice my Art. I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females or males, of freemen and slaves (National Kidney and Transplant Division of Urology 1999).

The modern version of the Oath says virtually the same thing, but in more modern language:

I will follow that method of treatment which according to my ability and judgment, I consider for the benefit of my patient and abstain from whatever is harmful or mischievous. I will neither prescribe nor administer a lethal dose of medicine to any patient even if asked nor counsel any such thing nor perform the utmost respect for every human life from fertilization to natural death and reject abortion that deliberately takes a unique human life (National Kidney and Transplant Division of Urology 1999).

An interesting concept is that both the original and modern versions restrict practices that “take a unique human life” such as abortion and euthanasia. The question arises then, how do physicians who practice PAS get around the restriction laid out in the Hippocratic Oath? They do it because, although the version previously mentions is the modern translation of the original version, it is not the only version taken by physicians. In fact, contrary to popular belief, the Hippocratic Oath is not required by most modern medical schools (North). There are numerous versions of the oath that are less strict and omit such restrictions as euthanasia and abortion due to discrepancies among different translations. In essence, physicians are finding loopholes in the system. The oath was implemented as a way to provide guidelines for doctors to follow. It also provides a checks-and-balances system so that no doctor can have the power to exploit their patients. Without it, there is nothing to keep any doctor from using their power as a way to abuse the vulnerability of their patients or to further their careers.

As previously mentioned, euthanasia has been a major source of controversy throughout the 20th century. Prior to 1990, the attitude concerning euthanasia and PAS was, “it could never happen here.” However, the case of Dr. Kevorkian in 1990 changed the attitude and brought the issue closer to home. In 1990 Dr. Jack Kevorkian gained national prominence when he designed a device that enabled people who wanted to die to self-administer toxic chemicals, after initial assistance from a physician (Darr 31).

Later that same year Janet Adkins, a 54-year-old Alzheimer's patient enlisted Dr. Kevorkian's help in aiding her to commit suicide before she became so impaired that she could no longer make a “rational decision.” Her mental state was questioned because of her diagnosis (Darr 31). In his early assisted suicides, Kevorkian played an active role by starting a saline drip before the patient initiated the flow of toxic chemicals. Later, after his medical license was revoked, he used carbon monoxide that was breathed through a mask and in which the patient initiated the flow of gas. He also began videotaping conversations with these patients documenting their states of mind as well as their desire to die (Darr 31).

Although hastily passed legislation in Michigan outlawed assisted suicide, it did not stop Dr. Kevorkian. He was finally convicted of second-degree murder in 1998 based substantially on a tape of him administering a lethal injection to a Lou Gehrig's disease patient (Darr 32). Of the 69 people known to have been killed by him, only about 25 percent had been diagnosed as terminally ill (Darr 32). The rest had been diagnosed with degenerative diseases or their mental state was unknown, which raises significant ethical issues. He was released from prison on June 1, 2007 after serving eight years of his 10-25 year sentence based on the promise that he wouldn't assist in more suicides (Darr 32).

The Terri Schiavo case is comparable to Jack Kevorkian's case because it shows the difference between PAS and the right to refuse medical treatment. Terri Schiavo went into cardiac arrest in 1990 after adopting an "iced tea diet" in which, due to an eating disorder, she drank 10 to 15 glasses of iced tea each day (Terri Schiavo). This resulted in a disastrous potassium deficiency that caused irreversible brain damage and caused her to remain in a permanent vegetative state for the last 15 years of her life (Terri Schiavo).  Neurological tests indicated that her cerebral cortex was principally liquid. Both Schiavo's doctors and her court-appointed doctors expressed the opinion that there existed no hope of rehabilitation. Her husband, Michael Schiavo, stated that it was his wife's wish that she not be kept alive through unnatural, mechanical means (Terri Schiavo). Michael Schiavo wanted life support suspended by removing her feeding tube, after which Terri would slowly die of malnutrition and dehydration.

The Schiavo case was heard in Florida courts more than 20 times. Every time, the court ruled that the decision was her husband's to make, upholding the sanctity of marriage long respected by legal precedent (Terri Schiavo). Schiavo's parents, Bob and Mary Schindler, refused to accept this verdict, feeling in their hearts that their daughter would somehow recover. Schiavo's feeding tube was finally removed on March 18, 2005, and her heart stopped beating 13 days later (Terri Schiavo). The autopsy conducted after her death established that her brain damage was even worse than experts had said while she was alive. Schiavo's brain weighed about half what a healthy human brain weighs, damage that left her unable to think, feel, see or interact in any way with her environment (Terri Schiavo). There was no chance she could have recovered.

The Schiavo case exemplifies the difference between providing the means needed to make suicide possible, and simply refusing medical treatment. Terri did not want to end her life, but there was nothing the doctors could do to aid in her recovery. Doctors tried everything to bring Terri back, but still were unable to. It was at this point, when it was realized that a recovery was no longer possible, Terri's husband Michael asked that she be taken off of life support. This is the main difference between Terri Schiavo and Jack Kevorkian. Terri Schiavo had no hope of recovering from her vegetative state and, without the help of the artificial life support (i.e. her feeding tube), she would not have been able to maintain the functions necessary for life.

Dr. Kevorkian's patients, on the other hand, were quite capable of maintaining life by their own bodily processes. They did not need feeding tubes or breathing machines to keep their bodies functioning. Their bodies were able to do this under their own accord. Kevorkian's patients still had a life ahead of them. It may have been cut short by disease, but there was still a possibility for life. After all, only about a quarter of the patients he aided in dying had been diagnosed with a terminal illness. Kevorkian's patients were still able to function in a way that Terri would never again be able to.

As of now, there are only three states in which PAS is legal: Oregon, Montana and Washington (O'Reilly). According to Oregon law, lethal prescriptions are supposed to be limited to patients who have a life expectancy of six months or less (Darr 34). The patient must also be at least 18 years old, an Oregon resident, and mentally sound enough to make a rational decision (Darr 34).  During the first two years that PAS was legal, reports indicated that two people who had been prescribed the deadly overdose were still alive more than six months later (Marker 65). One patient was still alive 17 months after the lethal drugs were prescribed (Marker 65). The Department of Human Services (DHS) does not investigate how physicians determine their patient's life expectancies, a decision that relies solely on the “reasonable medical judgment” of the practicing physician. There is no way to determine if doctors are violating the guidelines set in place by the law since the same doctors who may be violating the guidelines set in place by the DHS would have to report themselves (Marker 65). The second Oregon report states, “Noncompliance is difficult to assess because of the possible repercussions for noncompliant physicians reporting data to the division” (Marker 65).

Oregon reports are notoriously inaccurate due to the dependence upon physicians to report PAS cases to DHS (Marker 63). There were 208 reported deaths in the first seven years (Marker 63); however the actual number of deaths is unknown. The Department of Human Services has to rely on the word of doctors who prescribe lethal drugs. Due to major flaws in the state's reporting system, there is no way to know for sure how many or under what circumstances patients have died from PAS (marker 63). Practicing physicians may or may not report all PAS cases to the division. Because the Death with Dignity law contains no penalties for doctors who do not report prescribing lethal doses for the purpose of suicide (Marker 63), some doctors may not see any incentive to report all cases. This lack of regulating what is reported can lead to a huge distortion of data that can affect the accuracy of these reports.

The Oregon reports also claim that there have been ten instances of vomiting, but no other reported complications associated with PAS (Marker 63). However, during the seventh year, physicians who prescribed lethal drugs for assisted suicide were present at fewer that 16 percent of reported deaths; therefore, the information provided by doctors may come from secondhand accounts of those present at the deaths (Marker 63). The fact that official reports do not reflect what is actually happening is emphasized when news accounts of complications, none of which were reflected in the official reports. Overdoses of barbiturates are known to cause vomiting as a person begins to lose consciousness. The patient then inhales and chokes on the vomit. In other cases, panic, feelings of terror, and assaultive behavior can occur from the drug-induced confusion (Marker 63).

There are several cases of complications associated with PAS. In 1999, the Oregonian described the death of Patrick Matheny who received his lethal prescription from the Oregon Health and Science University. He had difficulty when he tried to take the drugs four months later and his brother-in-law, Joe Hayes, had to help Matheny die. According to Hayes, “It doesn't go smoothly for everyone. For Pat it was a huge problem. It would not have worked without help” (Marker 63).

The following year the Oregonian and other Portland-area news outlets carried accounts of another case in which complications arose during PAS. While speaking at Portland Community College, pro-assisted suicide attorney described a botched assisted suicide. “The man was at home. There was no doctor there. After he took it [the lethal dose], he began to have some physical symptoms. The symptoms were hard for his wife to handle. Well, she called 911. The guy ended up being taken by 911 to a local Portland hospital. Revived. In the middle of it. And taken to a local nursing facility” (Marker 63).

In 2005, David Prueitt took a prescribed lethal dose in the presence of family and members of Compassion and Choices (C & C). After being unconscious for 65 hours, he awoke. It was only after his family told the media about the botched suicide attempt that C & C publically acknowledged the case. As a response, DHS issued a release saying it “has no authority to investigate individual Death with Dignity cases” (Marker 63).

Another reason for the skepticism about Oregon's official claims that complications are limited to vomiting is the experience in the Netherlands where PAS complications and problems are not uncommon. One article in the New England Journal of Medicine described a Dutch study that found that, because of problems or complications, doctors in the Netherlands felt the need to intervene (by giving a lethal injection) in 18 percent of cases (Marker 64). This causes Dr. Sherwin Nuland of Yale University to question the credibility of Oregon's lack of reported complications. He noted that the Dutch have had years of practice to learn ways to overcome complications, yet complications are still reported. He wrote, “The Dutch findings seem more credible [than the Oregon Reports]” (Marker 64).

Finally, according to the guidelines set forth in the Oregon Death with Dignity Act, PAS patients must be of sound mind and judgment in order to be prescribed the legal dose. However, there is at least one account of a person with dementia dying of a lethal overdose prescribed under the law. Eighty-five-year-old Kate Cheney died of assisted suicide under Oregon's law even though she reportedly was suffering from early dementia. Her own physician declined to provide the lethal prescription. She then went to two separate psychologists who both concluded that she was not mentally sound enough to make the decision of PAS. The first psychologist claimed that she was not eligible for PAS because she was not explicitly seeking it, her daughter seemed to be coaching her to seek PAS, and Cheney could not remember the name of her doctor or details of a hospital stay that month. The second psychologist said that Cheney was competent but possible under the influence of her daughter who was “somewhat coercive.” Finally a managed care ethicist who was overseeing her case determined that she was qualified for assisted suicide and the drugs were prescribed (Marker 64).

After all of this, PAS should not be legalized in any more states. There are many complications with PAS, and too many discrepancies in the Oregon Reports. Because of this, the federal government should become involved and make physician-assisted suicide illegal country-wide. Although Oregon has put requirements in place that limits PAS patients to state residents, if a person is desperate enough they can find a way around that by moving to the state or fabricating a residency. If physician-assisted suicide was to be made illegal across the United States, it would completely eliminate the possibility of a person going to another state in order to gain aid in committing suicide. If they wanted to kill themselves, they would have to go to a completely different country, which severely limits the number of people who would be able to do it.

Not only are there many complications and discrepancies involved with PAS, but physicians are still taking part in another person's death. They have counseled the patient and prescribed the lethal drugs needed to end the life. No human being should have the right or the power to end another person's life. Each individual human life is just as important as the next; that is why there are documents such as the United States Constitution and the Universal Declaration of Human Rights that declare equality for all men and women. Euthanasia is illegal because it involves the physician actually committing the final act that ends the patient's life, such as administering a lethal injection. However, in PAS the physician is still providing the means needed to end a life and ultimately the cause of another person's death. They are still causing a death, and that is why PAS should also be made illegal.

PAS is not only controversial among average citizens, but also among physicians themselves. Many studies have been done on physicians' attitudes towards this subject. When physicians were asked whether or not PAS should be legalized, one study, conducted by Dickenson et al. in 1997, yielded a result of 48 percent for the legalization of PAS and 52 percent against (G. E. Dickenson et al. 46). A second study, conducted by Duberstein et al. in 1995 yielded a result of 31 percent for and 69 percent against when asked the same question (G. E. Dickenson et al. 46). When asked whether or not the physicians approved of PAS numerous studies yielded similar results. In one study, conducted by Bachman et al. in 1996, 17 percent of physicians agreed with PAS while 83 percent were against it (G. E. Dickenson et al. 47). Finally, when asked if physicians would actually participate in PAS a majority of physicians said they would not. In a study conducted by Dickenson et al. in 1997, 33 percent of physicians said that they would participate in PAS whereas 67 percent said that they would not participate (G. E Dickenson et al. 48).

Of course there are still many supporters of PAS in the United States. There is Compassion and Caring, a nonprofit organization that devotes itself to creative legal and legislative initiatives to secure comprehensive and compassionate options at the end of life. According to the C & C website, “We set national standards for end-of-life care and assert constitutional protection for aid in dying. Our team of litigators and legislative experts fights bills that would force patients to endure futile, invasive treatment; sets enforceability standards for advance directives; mandates pain and palliative care training for physicians; monitors legislative and policy initiatives; and ultimately shapes best-practice standards for end-of-life care” (About Compassion and Caring).

Another pro-PAS argument is the patient's “right to die” which claims a patient should be able to choose how and when they die (Euthanasia). There is also the claim that patients should be able to control the amount of pain  and suffering that they undergo at the end of their life. It also states that it is a physician's duty to minimize the pain experienced by the patient by either providing medications to manage it or the means for the patient to end their suffering completely, if that PAS is requested. PAS supporters argue that it is more unethical for a physician to prolong the suffering of a patient then it is for the physician to prescribe a lethal prescription if the patient wishes to end their life (Euthanasia).

The Hippocratic Oath is meant provide safeguards to protect patients from being exploited by physicians. Without the oath, there is nothing to keep a doctor from committing acts that may not be in the best interest of the patient. While there are instances where withholding medical treatment or removing a person from life-support may be the best course of action, such as in the Terri Schiavo case, it is simply not ethically correct for a physician to provide the means needed for a patient to end their life. The Dr. Kevorkian case illustrates this nicely. The people he attempted to help may not have been in the correct mental state to make the decisions that they did. Even if their mental state was unquestionable, it is still a doctor's duty to preserve life, not to take it away.

The biggest problem with PAS lies in the inability to effectively monitor and report all cases. The data that has been collected so far is skewed due to the amount of PAS cases that go unreported each year. Physician-assisted suicide can also be dangerous and result in complications that harm, rather than help, the patient. PAS simply does more harm than good, and therefore is not in the best interest of the patient. Since it is a physician's duty to always have their patients' best interests at heart, physician-assisted suicide is unethical and needs to be made illegal nation-wide.


Work Cited

Compassion and Choices: Learn About The Movement. Compassion and Choices. Web. 8 Dec. 2009.

This website explains the mission of Compassion and Choices. It gives a brief history of the PAS movement and explains why PAS is a cause worth fighting for. The website also provides its users with pro-PAS articles, the number to a counselor in which they can speak to about PAS-related issues, and a way to donate to the cause.

Darr, Kurt. “Assistance in Dying: Part II. Assisted Suicide in the United States.” Hospital Topics 88.2 (2007): 31-36. Academic Search Premier. EBSCO. Web. 9 Nov. 2009.

Darr's article discusses the legality of assisted suicide in the United States and its status as of 2007, when the article was written. To support his claims, Darr uses different case studies as well as focuses on Oregon, the only US state where assistance in dying is legal. He discusses the case of Dr. Jack Kevorkian, better known as “Doctor Death” and also of Elizabeth Bouvia, a 26 year old cerebral palsy patient who wished for a California hospital to aid her in death by starvation.

Dickinson, George E., et al. "US physicians' attitudes concerning euthanasia and physician-assisted death: A systematic literature review." Mortality 10.1 (2005): 43-52. Academic Search Premier. EBSCO. Web. 11 Nov. 2009.

This article is a literature review that demonstrates physicians' attitudes towards PAS and Euthanasia. It also provides statistics from numerous studies in order to support its claim.

Euthanasia. ProCon.Org, 9 Dec. 2009. Web. 9 Dec. 2009.

This website provides the arguments both for and against euthanasia and physician-assisted suicide. It defines key terms, explains the moral problems, the law and public policy, and health care implications.

Marker, Rita L. "EUTHANASIA AND ASSISTED SUICIDE TODAY." Society 43.4 (2006): 59-67. Academic Search Premier. EBSCO. Web. 19 Nov. 2009.

This article discusses physician-assisted suicide and euthanasia through the 20th and 21st centuries.  It defines both euthanasia and physician-assisted suicide and clarifies the differences between the two terms. The article then describes the movements towards the legalization of physician-assisted suicide in the different states, and how these movements are modeled off of the Oregon Death with Dignity Act. It focuses on the discrepancies in the Oregon Reports and how these reports may not be as credible as the Department of Human Services make them out to be.

North, Michael. "North | Hippocrates | The Oath." North- The Hippocratic Oath. U.S. National Library of Medicine, 1 June 2009. Web. 08 Dec. 2009.

This website gives a brief history of the Hippocratic Oath, the believed author, and who might have actually inspired the philosophy behind the oath. It supplements and reinforces the information provided by the National Kidney and Transplant Division of Urology website.

O'Reilly, Kevin B. "Montana judge rejects stay of physician-assisted suicide ruling." American Medical News. American Medical Association, 29 Jan. 2009. Web. 08 Dec. 2009.

This website describes the legislation on PAS that has recently been passed in both Montana and Washington. It also lists the states in which PAS is legal.

"The Hippocratic Oath." Oath and Law of Hippocrates. National Kidney and Transplant Division of Urology. Web. 10 Nov. 2009.

This website simply states both the original version of the Hippocratic Oath and the Modern version of the Oath that is most commonly used today. It also gives a brief background of both the Oath and Hippocrates, the author.

"Terri Schiavo." NNDB: Tracking the entire world. Soylent Communications. Web. 12 Nov. 2009.

This website gives a brief overview of the Terri Schiavo case. It explains who exactly she was, what her diagnosis was, and an explanation of her case and the controversy that surrounded it between the years 1990, when she entered the vegetative state, and 2005, when she was taken off of life support and passed away.