Legalization of Physician Assisted Suicide, Research Paper Example

Abstract

In the past two decades, discussions over the ethical nature of physician assisted suicide have become increasingly prevalent. In spite of the increasing quality of legislation that promotes these practices, many individuals believe that legalizing physician assisted suicide will contribute to the prevalence of non-voluntary deaths. The purpose of this study is to ascertain whether legalizing physician assisted euthanasia will contribute to the continuation or reduction of human rights. Specifically, the project aims to determine whether the legalization of physician assisted suicide will lead to acceptance of non-voluntary euthanasia. It is hypothesized that there will not be a detectable relationship between the increasing incidence of physician assisted suicide practices and non-voluntary euthanasia. A literature review was conducted to assess existing legislation that legalizes physician assisted suicide in the state of Washington, the Netherlands, and Belgium. In all three locations, regulatory standards have been put in place to ensure that patients are able to consent to euthanasia and that they are certain of their decision. As laws continue to be added to regulate these procedures, the human rights and safety of patients will continue to be protected. It is therefore necessary to determine how these nations could improve the quality of their euthanasia standards to further demonstrate the utility and ethical nature of this legislation. The development of effective laws regulating physician assisted suicide may plausibly contribute to safe and effective euthanasia practices in other parts of the world. An increase in the legality of physician suicide will ensure that the human rights of terminally ill patients will continue to be protected.

Chapter I: Introduction

The question as to whether an individual has the right to his or her own life has been a topic under debate for centuries. However, in the modern medical setting, ethical questions surrounding physician assisted suicide have become an essential debate. There is much evidence for the benefit of this process, in spite of existing legislation that counters the ethical nature of this act. Many patients argue that providing patients the right to engage in physician assisted suicide should be considered a basic human right. Those who have endured pain and suffering over long periods of time recognize that prolonged treatment is often associated with a poor quality of life in addition to exorbitant hospital expenses. Individuals that argue against physician assisted suicide often maintain the belief that life is precious and according to religious values, it would not be reasonable to take control over life and death decisions. In addition, critics claim that physician assisted suicide will lead to acceptance of non-voluntary active euthanasia. However, physician assisted suicide practices have been adopted by several states in the United States of America, in addition to a number of countries including Belgium and the Netherlands.

Background of the Study

Physician assisted suicide is a process by which doctors are responsible for providing their patients with the physical means necessary to end their own lives (Snyder & Sulmasy, 2001). This form of suicide is a supervised and controlled method that is typically implemented to prevent terminally ill patients from experiencing high levels of pain and living a poor quality of life. In all forms of legalized euthanasia, physician assisted suicide must be requested by the patient. Furthermore, individuals that wish to undergo physician assisted suicide must undergo psychological evaluations and consent to this procedure both verbally and in writing on several different occasions to ensure the certainty of this decision (Dunn et al., 1998). Even though rigid regulations are put in place in the localities that permit euthanasia, many governments criminalize suicide attempts and there are legal penalties for suicide attempts, in spite of the reasons provided (Washburn, 1967).

Problem Statement

Doctors, special interests groups, and members of the general public continue to quarrel as to whether it is ethical to legalize physician assisted suicide. Historically, many societies have prohibited acts of suicide on any basis because these acts directly contradict the religious statutes on which many of these countries and localities were established. However, in the modern setting, it is necessary to re-examine the impacts of physician assisted suicide on society. Many proponents of physician assisted suicide argue that enabling legislation to allow physician assisted suicide will lead to stringent requirements for participation in this process and protect the rights of the patients. Therefore, it is essential to determine whether the legalization of physician assisted suicide will lead to acceptance of non-voluntary euthanasia. Critics of the legalization of physician assisted suicide claim that promoting passage of laws that support this act will actively reduce the right of patients across the world. However, it is necessary to examine whether existing evidence promotes the understanding that legalizing physician assisted euthanasia will contribute to the continuation or reduction of human rights.

Purpose and Objectives of the Study

The purpose of this study is to ascertain whether legalizing physician assisted euthanasia will contribute to the continuation or reduction of human rights. Specifically, the project aims to determine whether the legalization of physician assisted suicide will lead to acceptance of non-voluntary euthanasia. To do so, several ethical considerations pertaining to physician assisted suicide will be analyzed. First, existing laws that promote physician assisted suicide will be assessed as they relate to the protection of human rights in addition to their flaws in protecting human rights. Next, existing laws that prevent the legalization of suicide in any manner will be similarly examined. The literature that supports physician assisted suicide will then be assessed to determine the popular opinion of physicians in support of the movement. Last, physician statements and research that conclude that physician assisted suicide actively counteracts human rights will be discussed. All literature will be analyzed in a manner that ascertains whether physician assisted suicide could be reasonably used to promote acceptance of non-voluntary euthanasia or similar unethical acts.

Rationale of the Study

While many special interests groups and citizens regularly voice their opinions about the legalization of physician assisted suicide, input is not commonly received from physicians into the creation of laws that would guide these practices. Although the opinions of patients are a highly important component of choices pertaining to physician assisted suicide, conversations between physicians and patients have not been highly reported on the topic. Therefore, it is necessary to culminate governmental and physician opinion in a manner that fully assesses whether physician assisted suicide is a protector or detractor of human rights. Individuals on both sides of this argument are very passionate about their personal beliefs on this topic, but their statements are typically based on pre-existing bias and lack the inclusion of fact. It is therefore essential to determine the medical and ethical facts that dictate the medical practice of physician assisted suicide as it is applied across the world and consider whether these laws are sufficient to prevent the acceptance of non-voluntary euthanasia. In addition, it is necessary to determine whether currently existing laws across the world that criminalize suicide are sufficient in protecting against non-voluntary euthanasia. Overall, there are many ethical and political concerns that are applicable to gaining a full understanding of achieving ethical patient care, and it is imperative to address the legalization of physician assisted suicide as a consequence. Many proponents of physician assisted suicide claim that widespread legalization of the procedure will contribute to the further development of regulatory procedures that will positively contribute to the protections and rights that patients receive. However, it is essential to determine whether existing legislation is capable of promoting these rights and whether modifications of these laws should be made to ensure that the quality of patient care will not be compromised as a consequence of these laws.

Definitions of Terms

Assisted suicide: Assisted suicide occurs when an individual provides information, guidance, or physical aid in some manner to an individual that wishes to take his or her own life with the knowledge that this aid will be utilized for this purpose. “Physician assisted suicide” occurs when a doctor provides this form of aid to a patient.

Euthanasia: Euthanasia is the act of intentional killing either with or without the permission of the impacted human being for his or her intended benefit, either voluntarily or involuntarily.

Euthanasia by Action: Euthanasia by action occurs when an individual intentionally causes another individual’s death by performing a physical and direct action, such as applying a lethal injection to the individual.

Euthanasia by Omission: Euthanasia by omission occurs when an individual intentionally causes another individual’s death by not providing them with the basic means necessary to defend their lives. This could include withdrawing medical care, food, and/or water.

Involuntary Euthanasia: Involuntary euthanasia occurs when the person who is to be put to death has not offered consent, offered no request, and has actively expressed his or her wish to the contrary.

Non-Voluntary Euthanasia: Non-voluntary euthanasia occurs when the person who is to be put to death has not offered consent for this procedure and offered no request.

Voluntary Euthanasia: Voluntary euthanasia occurs win the individual who is to be put to death has specifically requested to be killed, and thus has issued a request for the procedure and has provided consent.

Limitations of the Study

Discussions over the right to die typically contain biased data because individuals often feel strongly about their want to promote this right or to protect life. Therefore, some bias will be intrinsically present in the data that is being utilized to gain an understanding of the relationship between physician assisted suicide legislation and the incidence of non-voluntary euthanasia. Sources will be used in a manner that balances both sides of the argument. In addition, since a majority of physician assisted suicide laws have been created in the past 15 years, there is not a sufficient reporting of the impacts that this legislation has on voluntary and non-voluntary physician assisted suicide statistics. It is therefore important to consider that this situation must be analyzed in light of the presence of complete data. However, the findings of this study could be utilized as preliminary research to gain an understanding of research needs as they pertain to this topic.

Theoretical Framework

The legalization of euthanasia is typically discussed in reference to ethics. Therefore, it is essential to discuss a variety of ethical principles that are used to rationalize physician assisted suicide. Thus, it is essential to discuss physician assisted suicide as it pertains to deontological ethics. According to philosophers Immanuel Kant’s interpretation of deontology, actions are ethical due to the motives of the individual, as opposed to the consequences of the action (Kant, 1785). It is therefore beneficial to consider the ethical nature of euthanasia in these terms. Many individuals in the field of bioethics consider physician assisted suicide to be an ethical action according to these terms (Fins & Bacchetta, 2015). According to Kant’s interpretation of deontological ethics, the act of suicide is not unethical, but the desire to want to help patients escape pain is. Therefore, even though suicide is viewed as an unethical act in many cases, assisted suicide does not fall under this definition because it is powered by the ethical understanding that it is beneficial to help others.

It is also important to understand physician assisted suicide in the context of moral absolutism, which states that the positive consequences of an action may make an ill-intended action the right thing to do (Pojman, 1999). As a consequence of this belief, people tend to act upon their individualistic values with the assumption that the outcome of their actions will contribute to a positive outcome. Opponents of physician assisted suicide are therefore concerned that physicians may act upon these intrinsic values in a manner that contradicts the wishes of the patient. Many religious groups and special interests groups voice this particular concern. As a result, non-voluntary euthanasia would become more common. It is therefore necessary to explore the ethical decision making process that doctor’s follow when deciding to agree to a euthanasia request from a patient. Furthermore, determining whether physicians will act upon their intrinsic belief than an individual would benefit from a lack of existence would provide an essential understanding of this situation as well.

Research Hypotheses

It is expected that the legalization of physician assisted euthanasia will contribute to the continuation of human rights. Although few regions and countries have approved laws that promote this practice, they dictate stringent requirements that must be met for physicians to perform physician assisted suicide. Therefore, it is unlikely that involuntary or non-voluntary euthanasia will occur. Under these laws, the patient must request euthanasia and ascertain this desire over a period of time. This enables the physician to be certain of the patient’s intent. Furthermore, there are many regulations that prohibit the physician from being able to engage in a breach of the patient’s intent as it pertains to their livelihood. While physicians are permitted to make decisions that would protect the ability of the patient to live a high quality life, they are not permitted to make choices for the patient that would result in the opposite impact. Therefore, physician assisted suicide legislation will not be designed to permit the physician to implement his or her own decisions pertaining to the life of the patient. In addition, the ethical values of the physician will become necessarily irrelevant to protect the wishes of the patient.

Chapter II: Literature Review

The Impact of Existing Legislation Promoting Physician Assisted Suicide

The state of Washington allows terminally ill patients to request permission to engage in physician assisted suicide. However, there are many stringent regulations surrounding these practices. In order to gain a greater understanding of physician assisted suicide in the state as it pertains to the physician-patient relationship, a research team conducted a study to determine how many physician assisted suicide requests were issued in addition to how many were responded to. To do so, questionnaires were issued to more than 1400 physicians to determine their involvement in physician assisted suicide practices. It was found that 12% of respondents were issued explicit requests from patients to undergo physician assisted suicide and 4% received non-explicit requests (Back et al., 1996). Individuals that were most likely to submit such requests were terminally ill patients who were suffering from AIDS, neurological disease, and cancer. Of all patients that requested physician assisted suicide, the request was granted for approximately half. Based on this evidence, it is apparent that not all individuals who request physician assisted suicide will have their requests granted. Furthermore, patients request physician assisted suicide for diverse reasons.

In the Netherlands, physician assisted suicide practices were not historically legal, but physicians respond to requests for voluntary euthanasia with relative openness. In order to gain an understanding of the frequency with which these practices are performed, researchers sought to analyze end of life practices in the region by determining physician assisted suicide events that occurred between the years 1990 and 1995. Using controlled physician interview, the researchers found that a majority of requests for euthanasia were made by patients during the later stages of their disease and that requests for voluntary euthanasia increased over time. However, assisted suicide only accounted for 0.4% of all deaths analyzed in the study. In addition, in 1990, 0.8% of deaths occurred without explicit consent from the patient and 0.7% of deaths occurred without explicit consent in 1995 (van der Maas et al., 1996). Therefore, it is apparent that the application of physician assisted suicide without the provision of consent is low in the Netherlands. Furthermore, the amount of euthanasia with non-explicit consent has decreased over time.

To gain an understanding of the prevalence of physician assisted suicide under legislation in Belgium, researchers issued a survey to approximately 7000 physicians who issued a representative sample of death certificates between June and November of 2007 (Chambaere et al., 2010). Based on the issued responses, it was found that patients who provided their physicians with an explicit request for euthanasia represented 2.0% of the issued death certificates, while 1.8% of the issued death certificates reflected non-explicit requests. In the cases in which non-explicit requests for euthanasia were claimed, there was a high incidence of patients that did not have predictable disease trajectories. Therefore, in these cases, it is plausible that patients provided consent in a not explicit manner.

Overall, there are not many palliative options for end of life care that promotes a high quality of life. Therefore, many terminally ill patients experiencing high levels of pain tend to enter a state of depression and have feelings of hopelessness that cannot be subdued by existing medical treatments. As a result, studies have found that terminal sedation and voluntarily stopping eating and drinking would allow health care professionals to address a wide range of patient suffering (Quill et al., 1997). An ethical analysis of terminal care and physician assisted suicide has revealed that it would be reasonable to implement legislation to address this level of human suffering. Allowing end of life protections to be entered into the law could reasonably address concerns that many patients have regarding their end of life rights. Knowing that the individual, not the law or physician, has the ability to make end of life decisions has the ability to contribute to reduced stress for patients that are experiencing high levels of pain and low quality of life as terminally ill patients.

Based on the existing literature, it is apparent that some physician assisted suicide cases do not result as a consequence of explicit consent. This is an apparent flaw in the established voluntary euthanasia legislation and creates a need for further legislation to be issues to ensure that patient rights are protected. However, in cases in which explicit consent for euthanasia was not given, it is important to understand that there was implicit evidence that allowed the physician to understand the wishes of the patient. Even without the provision of documentation, there is no evidence present in the aforementioned cases that indicates that non-voluntary euthanasia was conducted. Instead, physicians were required to assimilate evidence to contribute to the end of life care for their patients.

Laws Prohibiting Physician Assisted Suicide

According to the state laws of many governments in the United States, it is not legal to engage in or assist with the act of suicide. One of the most stringent laws is XLIV 765.309 issued by the state of Florida in 2015. The purpose of this legislation is to renew the understanding that suicide is not legal and cannot be performed, even in medical settings. The statute specifically claims:

“(1) Nothing in this chapter shall be construed to condone, authorize, or approve mercy killing or euthanasia, or to permit any affirmative or deliberate act or omission to end life other than to permit the natural process of dying.

(2) The withholding or withdrawal of life-prolonging procedures from a patient in accordance with any provision of this chapter does not, for any purpose, constitute a suicide” (XLIV 765.309, 2015).

This law was specifically created in reaction to legislation that had been created in states like Washington and Oregon to allow physician assisted suicide under certain measures. Other states have responded to this legislation in the same manner, such as California (California Penal Code Section 369a-402c, n.d.). Under these codes, it is illegal to assist suicide attempts in any manner.

In 1997, the United States Supreme Court had the opportunity to assess whether terminally ill individuals should be provided with a constitutionally protected right to engage in physician assisted suicide. In Vacco v. Quill, the Supreme Court upheld the state’s right to decide whether or not physician assisted suicide should be permitted and therefore ascertained that “the right to die with assistance is not a fundamental right” (Vacco v. Quill, 117 S. Ct. 2293, 1997). An analysis of the case, however, reveals that there may have been faulty reasoning on the behalf of the court. Specifically, some court cases have argued that the right to die is an extension of the patient’s right to privacy. In addition, under the stance that the maintenance of life is essential, in cases in which death is not avoidable, medical care could reasonably be considered unnecessary invasion of the body (Feinberg, 1998). However, it is the responsibility of the state to incorporate these understandings into their lawmaking under the decision that has been made by the Supreme Court.

While there appears to be a major discussion pertaining to physician assisted suicide in the United States, few other countries that have not permitted its implementation have examined this argument. For example, in Finland and Germany, there is no penalty has been documented with regards to assisted suicide (Birnbacher & Edgar, 2008). In the United States, Maine and Montana have flexible laws prohibiting mercy killing (Blocher, 1999). In Maine, the state legislature is against any form of discrimination for voluntary and physician-assisted mercy killing. In Montana, Judge Dorothy McCarter demonstrated that some patients can be granted the right to a mercy killing after experiencing a terminal illness. In nations in which laws do not exist that explicitly confirm or deny the ability for physician’s to engage in physician assisted suicide do not appear to be taking actions to promote patient rights on this matter, although they are engaged in ethical debate. A majority of the research studies available pertaining to the ethical nature of physician assisted suicide in addition to the availability of medical statistics for this issue exist for publications issued by the United States, the Netherlands, and Belgium.

Chapter III: Methodology

Description of the Subjects

This systematic review incorporates opinions and data from physicians located in the state of Washington, the Netherlands, and Belgium. All physicians were actively involved in the application of physician assisted suicide or have provided comments that protest their desire to engage in an act that they believe to be ethical. A majority of the physician data incorporated in the study has been derived from patient death certificate data and survey information. In cases that require informed consent, documentation was originally provided to the physicians whose data will be used. The retrospective nature of this analysis enables exemption from the acquisition of informed consent documentation.

Description of the Research Instruments

This study is a systematic review that analyzes a culmination of legislation and physician opinion. Thus, a literature review and discussion is used to examine the ethical practice of physician assisted suicide as it pertains to the protection of patient rights. Legislation is analyzed in a manner that determines whether non-voluntary euthanasia is plausible or likely. This assessment will be discussed in terms of the existing quantitative data available on the subject. Recommendations based on the analysis will be made.

Procedures

An analysis of the literature was performed to determine whether existing physician assisted suicide legislation can opportunistically promote non-voluntary euthanasia. To do so, existing laws that describe physician assisted suicide were analyzed on the basis of the role of the physician, existing safeguards, and the ability of the legislation to promote the patient’s end of life care. Specifically, 2001 the Termination of Life on Request and Assisted Suicide (Review Procedures) Act issued by the Netherlands, the 2008 “Death with Dignity Act” implemented by the state of Washington, and a series of recent legislative acts signed into law by Belgium were examined. These laws were analyzed as they relate to the protection of human rights in addition to their flaws in protecting human rights.

The literature was then assessed to determine the popular opinion of physicians in support of physician assisted suicide in addition to reasons that justify their claims. To do so, the Google Scholar and PubMed tools were utilized. A search including the terms “physician assisted suicide”, “ethics”, Washington state”, “Belgium”, and “Netherlands was conducted. Journals articles that were written to defend the validity of physician assisted suicide were selected. All articles utilizing physician commentary were published after the year 2001 for searches that pertained to doctors in the Netherlands, after the year 2008 for searches that pertained to doctors in Washington state, and after the year 2002 for searches that pertained to doctors in Belgium to ensure that opinions on the legislation were reflective of events that followed the legalization of physician assisted suicide in the respective countries. All articles incorporating a quantitative understanding of physician assisted suicide were published after 1990. Quantitative and qualitative examples from the literature to defend these opinions were provided.

Last, physician statements and research that conclude that physician assisted suicide actively counteracts human rights will be discussed. The Google Scholar and PubMed tools were utilized. A search including the terms “physician assisted suicide”, “ethics”, Washington state”, “Belgium”, and “Netherlands was conducted. Journals articles that were written to reject the validity of physician assisted suicide were selected. Articles were selected according to the same year limitations as those set for discussions to support physician assisted suicide. Quantitative and qualitative examples from the literature will be examined to defend these opinions. Literary evidence was then synthesized in a manner that effectively articulates whether physician assisted suicide could be reasonably used to promote acceptance of non-voluntary euthanasia or similar unethical acts.

Chapter IV: Results

The Death with Dignity Act and Physician Opinion in the State of Washington

The state of Washington implemented the “Death with Dignity Act” in 2008 which permitted patients the ability to apply for the ability to receive physician assisted suicide. The document includes a series of safeguards, including clearly stated attending physician responsibilities, counseling referral to determine the mental stability of the patient, provision of the right to rescind the request, adhering to a waiting period, and the provision of written and oral requests (The Washington Death with Dignity Act, 2008). One aspect of the legislation claims:

“A person shall not receive a prescription for medication to end his or her life in a humane and dignified manner unless he or she has made an informed decision. Immediately before writing a prescription for a medication under this chapter, the attending physician shall verify that the qualified patient is making an informed decision” (The Washington Death with Dignity Act, 2008).

This legislation is written to ensure that the physician follows specified requirements while implementing physician assisted suicide. According to this documentation, the patient must be willing to experience a rigorous list of checks to ensure that their desire to undergo physician assisted suicide is confirmed. Due to the stringent regulations imposed by the physicians in the state of Washington, all requests for physician assisted suicide must be explicit. Section 10 of the “Death with Dignity Act” explains that consider must be oral and written. Written requests therefore constitute as explicit requests. Section 22 provides a specific form for request that must be filled out by patients. In this request, they are also asked to document whether or not they wish to inform their family about this decision and whether this notification would be relevant. Furthermore, two witnesses must be present. These safeguards ensure that the patient was not persuaded by the physician to undergo euthanasia and that doing so it due to the will of the patient. A waiting period that ensues after the request is issued is made to ensure that the patient still wishes to engage in physician assisted suicide. Section 11 of the act, “Waiting Periods” states that 15 days must pass between the initial oral request for euthanasia and the writing of the prescription for medically assisted suicide. Furthermore, forty-eight hours must pass between the provision of the written request and the provision of the prescription. There have been no reports of physicians failing to comply with these regulation and the requirements are provided in a clear manner that prevent against potential misunderstandings.

Doctors are currently in disagreement as to whether the legislation issued in the state of Washington is sufficient to defend the rights of patients who request physician assisted suicide. Drs. Lawrence Hartmann and Arthur Meyerson ascertain the need for an ongoing conversation between physicians as to whether the psychological consultation requirement is sufficient to ensure that patients are able to activate their right for physician assisted suicide (2011). However, laws should not be made to criminalize physician assisted suicide because this does not help resolve the ethical problem at hand. They claim:

“Laws simply criminalizing physician-assisted suicide do not help clear such ground. Rather, the reverse. They do affect practice, powerfully if always imperfectly, but they also foster passionate premature closure rather than reasonable discussion, acknowledgment of complexity, learning, and evolution of varieties of decent, balanced, and caring solutions (Hartmann & Meyerson, 2011).

Thus, Hartmann and Meyerson conclude that potential boundaries to the effective implementation of physician assisted suicide legislation is directly related to the inability of physicians to implement legislation according to their own ethics. However, it is important for all physicians to act on the wishes of their patients within the context of existing laws. Therefore, some physicians believe that it is more advantageous to discuss how existing legislation could be revised in a more beneficial manner instead of continuing to engage in arguments stating that the legislation should not exist.

The Termination of Life on Request and Assisted Suicide and Holland

Following the acquisition of an enhanced understanding of euthanasia practices as they pertain to medicine, Holland passed a law that would approve physician assisted suicide under the implementation of certain regulations in 2001. Stringent requirements were put forth to ensure the protection of the patient and specific clauses were inserted to specify physician conduct:

“In order to comply with the due care criteria referred to in article 293, paragraph 2, of the Criminal Code, the attending physician must:

a. be satisfied that the patient has made a voluntary and carefully considered request;

b. be satisfied that the patient’s suffering was unbearable, and that there was no prospect of improvement;

c. have informed the patient about his situation and his prospects; 2 AVT00/WS61419A

d. have come to the conclusion, together with the patient, that there is no reasonable alternative in the light of the patient’s situation;

e. have consulted at least one other, independent physician, who must have seen the patient and given a written opinion on the due care criteria referred to in a. to d. above; and

f. have terminated the patient’s life or provided assistance with suicide with due medical care and attention” (Termination of Life on Request and Assisted Suicide (Review Procedures) Act, 2001).

Therefore, it is apparent that clear requirements have put in place to ensure that the physician will protect the rights of patients. To do so, physicians must carefully consider whether there are alternatives to physician assisted suicide and to provide these recommendations to the patient. In addition, similar to the state of Washington legislation, at least two physicians must agree that the euthanasia request is reasonable. Therefore, there are many checks and balances in place to ensure that the rights of the patient is being protected and that the physician is acting in accordance to ethical practice. Overall, it appears that this legislation was drafted in response to concerns that both governmental officials and health care professionals had with regards to physician assisted suicide practices that existed in the country prior to the drafting of relevant legislature. There was a small extent of implicit requests for physician assisted suicide that were met prior to 2001. Thus, the “Termination of Life on Request and Assisted Suicide (Review Procedures) Act” was created in part to address these concerns.

An assessment of the impact of voluntary euthanasia legislation has contributed to a series of mixed opinions. In some cases, professionals believe that these practices have led to an increase in non-voluntary death and that euthanasia counteracts the roles and responsibilities of the physician. Prior to the implementation of Termination of Life on Request and Assisted Suicide (Review Procedures) Act”, there was a prevalence of approximately 2% of implicit euthanasia, which some professionals argue could be seen as involuntary. Although these patients may have not had the ability to provide consent for euthanasia, some would argue that this indicates that the euthanasia should not have been taken place. The legislation implemented by the state of Washington would acted to ensure that without explicit consent, euthanasia should not take place. However, this wording is not present in the legislation implemented by the Netherlands. A critic of physician assisted legislation therefore explains:

“In 1989, while teaching law and medical ethics at the University of Cambridge, Professor John Keown began to investigate PAS and euthanasia in the Netherlands. He found that key Dutch guidelines, such as requiring an explicit request from the patient, have long been widely violated with virtual impunity. He pointed out that the first of several official surveys conducted by the Dutch found that in 1990, “the total number of life-shortening acts and omissions where the doctor’s primary intention … was to kill, and which are therefore indubitably euthanasiast, is 10,558.” Shockingly, the majority of these cases were nonvoluntary” (Anderson, 2015)”.

The discrepancies that have existed with regards to non-voluntary euthanasia have been to an extent, addressed though the implementation of the Act. Previous studies indicated that implicit consent was issued by a small percentage of the population and this number continued to decrease due to implementation of best practices prior to the creation of this legislation. However, a similar assessment of non-voluntary euthanasia prevalence has not been conducted in the years following the implementation of the act. Therefore, it is plausible that the legislation prevents non-voluntary euthanasia or the numbers for this data are somewhat negligible. In spite of the lack of new data, opponents of physician assisted suicide continue to claim that there is a high number of deaths related to not clearly stated requests for this procedure. There is neither evidence for or against this claim, and it is therefore unsupported by the existing literature.

Physician Assisted Suicide and Belgium

Belgium has among the least restrictive euthanasia laws of the countries that currently permit physician assisted suicide. In 2002, the first legislation permitting medically assisted suicide was passed. The Belgian Act on Euthanasia was passed in order to define this practice and to document the individuals that are permitted to consent for participation. The rights provided to the patient pertain directly to informed consent provided them by the physician, thereby allowing the individual to make an informed decision regarding their health. The provisions that physicians must follow on this basis therefore include that the patient must be informed about his or her life expectancy, the physician must be certain of the patient’s condition and the request for physician assisted suicide must be discussed over several occasions, an additional physician must be consulted for a second opinion, the request must be discussed with a nursing team that has regular contact with the patient, the request should be discussed with relatives if applicable, and the patient must be granted the opportunity to discuss the requests with all relevant individuals (Belgian Act on Euthanasia, 2002). Last, this documentation expresses that in cases in which an individual becomes no longer able to document their will, they are able to develop an advanced directive, regardless of age, that will allow physicians to understand the nature of their request. As of 2014, this legislation was amended to permit euthanasia by lethal injection for children. Although parents must agree with their child’s decision to end their lives, there is no longer an age restriction in place for physician assisted suicide.

Even though much of the world is opposed to the concept of child euthanasia, many physicians in Belgium believe that the legislation is appropriate because it ensures the provision of human rights for all individuals. In a recent news report, a physician interviewed on the subject claimed:

“Children are not tiny humans that we can boss around,” said van den Werff Ten Bosch, a pediatric oncologist who works at Brussels University Hospital and has spoken out in favor of the proposed law. “Children with terminal diseases like cancer mature much faster than other children. They think a lot about their life and death and how they’d like their death to be. And sometimes they’re more courageous than their parents,” she said (Braw, 2013).

Overall, Belgium is the one country that has attempted to expand the right of individuals to physician assisted suicide rather than restrict it. Some citizens and individuals from other nations are concerned that this right will be misused, but many Belgians defend their right to die very seriously. Therefore, it is unlikely that changes will be made to this legislation in a backwards direction; instead, Belgians intend to expand the right to death to ensure that the human rights of its citizens are protected. Ensuring that parents must agree with their child’s decision to undergo a physician assisted suicide helps to implement regulatory measures that protect the rights of the child. It is possible that there will be cases in which parents will withdraw this right from their children, but according to the cultural standards that provided for the development of this legislation, it appears that a majority of Belgians would promote their child’s decision to end their lives if they were terminally ill and in pain.

Chapter V: Discussion, Conclusions, Recommendations

Discussion

There is little evidence present that indicates that the legalization of physician assisted suicide will contribute to the increase in incidence of non-voluntary euthanasia. Many individuals that criticize this legislation do so in spite of a lack of evidence to support their cause. Several studies focusing on the incidence on non-voluntary euthanasia have been conducted in the Netherlands, and in Belgium (van der Maas et al., 1996; (Chambaere et al., 2010). However, these studies were conducted prior to the implementation of the most recent laws introduced in these areas. When the first analysis of non-voluntary euthanasia was conducted in the Netherlands, there were no laws in place to regulate these practices and physician assisted suicide was technically considered illegal. In addition, the analysis conducted by Chambaere et al. was conducted prior to Belguim’s amendment to its physician assisted suicide laws. Even though the laws were made to be more inclusive of members of the population, there is no evidence that indicates that this altered legislation will trigger an association with increased incidence of non-voluntary euthanasia.

While there are only a small number of localities that have allowed the implementation of physician assisted suicide according to legal standards, a majority of legal codes are similar. This is effective because they all ensure that certain requirements are made both by the physician and the patient to ensure that the patient is making the correct decision in deciding to undergo physician assisted suicide. The laws that guide these practices in the state of Washington, the Netherlands, and Belgium state that the patients must be informed of their disease status, the patients must discuss their options with their physicians and/or friends and family to come to a final decision, and more than one physician must believe that the physician assisted suicide is both wanted and warranted. Although the specific protocol that physicians must follow differ according to these locations, all measures put in place are done to ensure that euthanasia practices will be voluntary. Prior to the implementation of these laws, implicit consent was permitted in some instances, but these laws have been rewritten to put additional checks and balances in place to ensure that explicit consent will be given prior to the procedure.

The United States is an interesting example of a country that permits physician assisted suicide because only several states permit the use of this method. The Supreme Court decided that it is the responsibility for individual states to determine whether or not they will permit physician assisted suicide (Vacco v. Quill, 117 S. Ct. 2293, 1997). Therefore, it is important for physicians, patients, and human rights activists to make an effective case for physician assisted suicide in these areas. Even though the “death with dignity” movement is often promoted in the name of compassion and mercy, many individuals believe that it does not constitute true care. Many individuals believe that it is the responsibility of physicians to protect the lives of their patients and by promoting physician assisted suicide, they are actively working against their oath as doctors in addition to the patient’s best interest.

Drawing upon his experience as a pastor and bioethicist, Blocher agrees with this stance, stating that no form of suicide is ethical (Blocher, 1999). Many groups are against euthanasia in the United States, including the Patients’ Rights Council, Choice is an Illusion, the Terri Schiavo Life and Hope Network, the People with Disabilities Opposing Legalized Assisted Suicide, People with Disabilities in Illinois. The Patient’s Rights Council acts to oppose the legalization of euthanasia by providing the public with education programs. Many other organizations have followed suit. This movement has support in several other nations as well, including ethicists, scholars, and religious leaders (Keown, 2005). As demonstrated, religion is a major contributor to a lack of belief in the principles of physician assisted suicide. These individuals believe that since life was created by God, it could only be ended by God. However, physicians and individuals that understand the level of pain that terminally ill patients are experiencing believe that in spite of the value of life, some patients cannot be saved or provided with effective palliative care. Therefore, it is reasonable to respect their wishes and help them end their lives.

Overall, the argument concerning physician assisted suicide has many sides. All individuals are interested in determining how to best promote quality patient care and respecting life. However, the mechanisms that are followed to accomplish these goals differ significantly on a case by case basis. In many cases, it is important for opponents of physician assisted suicide to understand that this practice is put in place to help individuals that wish to end their own lives. The existing legislation ensures that this is done according to the will of the patient and these cases do not result in non-voluntary euthanasia due to the many safeguards that are in place. It is important to consider that the right to die is an important human right and each individual should be able to make this decision for themselves, with the guidance of their doctors, family, and friends. Ultimately, it is inhumane to refuse the right for an individual to die on the basis of non-existing data. The discussion over the right to die will continue to be a challenging understanding due to the lack of statistical information that is available regarding its practices. However, once this information is gained, it would be reasonable to promote these understandings in a manner that could contribute to the support of human rights for terminally ill patients.

Conclusions

The literature does not indicate that there is a justification that permitted physician assisted suicide contributes to non-voluntary euthanasia. Overall, the implementation of laws that legalize the practice have positively contributed to the implementation of regulatory procedures. Critics of physician suicide cannot reasonably justify their claims using the evidence. This is in part because a significant amount of evidence is not present to justify either sides of this argument. However, because many patients around the world continue to request physician assisted suicide to end their pain, it is apparent that this is a high in demand practice among terminally ill patients. In order to defend the rights of these individuals, it is therefore important to ensure that laws are implemented to ensure their fair treatment by physicians and that they have fair access to their right to die. The state of Washington and the Netherlands currently promote these practices in a restrictive manner, although patients are regularly able to access physician assisted suicide. Belgium, on the other hand, has implemented less stringent requirements for physician assisted suicide practices. While less regulation ensures a greater degree of freedom, it also opens the door for abuse by physicians. It is therefore necessary for governments to implement balanced laws that promote the rights of patients while protecting the quality of care they will receive.

Recommendations

The lack of evidence available that describes the prevalence or incidence of non-voluntary suicides indicates a need for hospitals that support the implementation of physician assisted suicide to report clearer data for public understanding. Studies that attempt to reveal this statistic instead discuss implicit consent, which cannot necessarily be understood to be the same as enabling non-voluntary euthanasia. Based on the different legislation that exists in the United States, the Netherlands, and Belgium, it would be beneficial to define non-voluntary euthanasia differently according to the specific laws that guide euthanasia practices within a particular country. Due to the stringent oral and written requests that the state of Washington requires for physician assisted suicide, it would therefore be plausible to define non-voluntary euthanasia in this situation as euthanasia that does not include the provision of written consent. In this manner, it would be reasonable to determine, statistically, the percentage of physicians within the state that comply with the “Death with Dignity Act”. Since this law is comprehensive, agreement with its statutes would indicate that there should be no incidences of non-voluntary euthanasia. If no non-voluntary euthanasia cases are detected, then it is reasonable to ascertain that the rights of patients within this state are being sufficiently protected.

In order to ensure that patients receive a high quality of care in Belgium, it would be beneficial to implement a procedure similar to the one implemented in the state of Washington. Obtaining a series of written and oral consents for physician assisted suicide would more greatly confirm the patient’s desire to undergo this process. Furthermore, since Belgium does not have an age requirement for physician assisted suicide, it would benefit by creating education programs for children to help them make this decision. One of the primary concerns that critics against physician assisted suicide for children have is that they are unable to understand the implications of the process. In addition, they do not truly understand the state of their own illness or potential for the illness to be treated or cured due to a general lack of understanding of science. Therefore, programs should be created to help sick children determine whether physician assisted suicide is the right choice for them. Since they have the ability to make this choice with the consent of their parents, it is important for them to be a component of the informed consent process as well, which in this case would require acquisition of knowledge about their medical condition.

Because the legalization of physician assisted suicide has been highly effective in countries like the Netherlands, it would be beneficial for other countries to permit these practices as well. Prior to the implementation of legislation to permit voluntary euthanasia, many physicians across this territory were engaging in physician assisted suicide practices openly, but illegally. This demonstrates that a majority of the population was in favor of the legality of this technique, but were concerned about safety measures that would guide this process. Allowing an already practiced method to become legal added additional oversight that would protect the well-being of patients. Therefore, it is important for other nations to implement this type of legislation as well. Many patients who wish to end their own lives due to medical reasons will find a way to accomplish suicide whether or not they receive help from their physician. Thus, it is in the best interests of the physicians to help their patients end their lives so they can do so in a dignified and pain free manner. Allowing physician assisted suicide in countries in which these practices are currently prohitibited will be beneficial because it is important to respect the end of life wishes of terminally ill patients.

Even though physician assisted suicide is a decision that must be made by individual states in the United States, it is valuable for states that have already implemented physician assisted suicide legislation to release data pertaining to their practices to help other states understand why similar legislation should be passed in all states. Since the debate over physician assisted suicide is primarily an ethical debate, it is important to gain a greater understanding of this topic in terms of quantitative and qualitative values. Therefore, this argument would benefit from having interviews with patients regarding their decisions and publishing the findings. Knowledge of the incidence of voluntary euthanasia among those that request it, the rate of non-voluntary euthanasia, and the relationship between the types of illness had and the end of life decision made would provide a useful contribution to the ethical and medical understanding of these practices. Ultimately, it is important to comprehend the meaning of this data in the context of legislation and medical practices to help doctors and government officials make better decisions about end of life values. It is important for these two groups of professionals to collaborate and form a solution that will confer advantage to patients both within the country and across the world. This data will help develop an effective discussion of human rights and ethics as they pertain to physician assisted suicide. In time, this understanding will direct health care practices in a manner that positively contributes to the welfare of all people.

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