As a rule, the idea of dying is perceived by society negatively and painfully, which leads to the fact that this issue is hushed up and does not receive proper attention and discussion. However, in the last years or months of life, most patients retain their sanity and all mental qualities before the onset of the disease. The issue of dignified and maximally painless dying is crucial, especially considering the possible consequences for the mental balance of patients and their loved ones. The most common aspects of hospice nursing are pain alleviation, attention to the cultural and religious diversity of patients and their relatives, informing patients about their conditions, and the right to medically assisted suicide. This paper aims to discuss the topics of death with dignity, the right to die, and the benefits of hospice nursing.
Assisted Suicide as a Social Practice
Assisted suicide or death with dignity is a recognized practice in some countries, including nine US states. The practice of assisted suicide is strictly regulated by the laws of these states and has clearly defined implementation procedures. Interestingly, this practice should consider many implicit factors when accepting applications for assisted suicide, given that it is about people’s lives. For example, it is not uncommon for older people to experience suffering because of the disrespectful and aggressive attitude of relatives who take care of them. In such a case, a request for euthanasia can be a veiled call for help.
Therefore, the implementation of the practice of assisted suicide can have different sociological and philosophical perspectives. It is noteworthy that in 1951, for the first time in scientific circles, they began to talk about the role of patients who decided to end their lives with the help of assisted suicide (Schipke, 2021). In particular, Talcott Parsons suggested identifying their role in the theoretical understanding of the subjective experience of dying and the process of dying. Later, in the 1960s, the role of patients who go through the dying process was redefined. Hospices and palliative medicine emerged, giving rise to a new role for the ‘chronic patient.’ This definition was innovative since it became an intermediary between the sick and dying patient.
Remarkably, philosophical concepts addressing the issue of euthanasia include a functionalist perspective, a conflict perspective, and a philosophical theory of transhumanism. From the functionalist perspective, actions should be assessed based on the consequences and potential for good results (Richardson, 2002). In addition, the functionalist approach considers medically assisted suicide from the position of the society’s choice, which creates and enables such practice, not as an individual dilemma.
It would be logical to assume that if such a practice was created by society, it considered the moral aspects. However, the idea of medically assisted suicide first appeared during the Third Reich and was applied to the captured people who could not work for health reasons (Barsness et al., 2020). Later the idea was adopted in the medical field and began to be seen as an opportunity for dying people who had no chance of recovery. In this context, it is logical that the functionalist approach suggests treating patients with no hope of recovery as an unjustifiably high-cost economic burden, which is related to the initial euthanasia concept.
Therefore, the functionalist perspective justifies medically assisted suicide as an economically beneficial solution for society, since the money saved on treatment can be used to help those patients who have a chance of recovery. In other words, this perspective is based on the cost-benefit criterion. It also supports the idea that assisted suicide can be implemented for the patient’s good in case of incurable diseases to eliminate the pain.
Then, the conflict perspective critiques the idea that the right to commit assisted suicide is a human right to die with dignity. It discovers the related issues like free will and free decision and factors that may push a person to the decision (Dolgin, 2020). Another important objection presented by the conflict perspective is that the right to assisted suicide without the related corrections can be used by all adult people, which means that there should be rules requiring that assisted suicide could be implemented only for terminally ill patients. Moreover, the patients should be advised regarding other ulterior options, particularly, in dubious situations.
According to the theory of trans-humanism, euthanasia can be viewed in a philosophical framework and in the context of life extension technologies. Immortalism, as a branch of trans-humanism, presupposes the emergence of a perfect society focused on minimizing suffering and striving for pleasure. This approach also uses the ideas of negative utilitarianism and neo-hedonism. Scientists are also considering the potential of developing specific bio-politics of death and dying in a society (Bugajska, 2021). It is believed that the tendencies of neo-hedonism and negative utilitarianism only exacerbate the dilemma of the legalization of assisted suicide due to medical conditions such as incurable diseases.
In other words, this reveals the paradox of trans-humanism, in the context of humanity’s approach to viewing death through the prism of autonomy and personal freedom. The justification of euthanasia is often discussed in medical circles, from the standpoint of it being a just or unjust practice to end human suffering. In this vein, attitudes towards euthanasia have evolved in the medical and scientific community. It is believed that transhumanism, as the most widespread modern social philosophy, has the prerequisites for solving the end-of-life dilemma.
The Hippocratic Principles are another position from which the scientific world evaluates the practice of euthanasia. In particular, the postulates of mercy, no-harm, and fairness provide a framework and guidance for the physicians’ behavior. The later idea of autonomy, which came about in the 18th century, complements these principles, completing the picture. As a result, the described ideas influence decision-making in modern clinical practice, including when approving or rejecting the idea of the legality of euthanasia. Interestingly, the principles of Hippocrates underpinned medical practice until the late nineteenth century, until they were dominated by currents arising from the economic and social pressures of the time, undermining the pursuit of justice and equality (Sulivan et al., 2021). In particular, the pseudoscientific movement of eugenics completely overturned all existing principles and even perverted them to their complete opposite, which began to create difficulties subsequently for adapting the idea of euthanasia to medical practice and its basic postulates.
Types of Euthanasia
The understanding of the justification or inadmissibility of euthanasia is also viewed from the standpoint of understanding the term itself. Today this term is considered as assisted death of patients who suffer from incurable diseases. There are several forms of euthanasia, which differ from each other and are used in different circumstances. According to Kontomanolis et al. (2018), active euthanasia is used as a direct intervention for a dying patient who is relieved of suffering by injecting drugs. In countries where this procedure is allowed, the decision can be made by the patient himself, as well as his relatives, friends, or doctors.
Then, passive euthanasia is the practice of stopping treatment resulting in the death of the patient. For example, doctors can turn off devices to support breathing and heartbeat, or stop blood transfusions or oxygen supplies. Assisted suicide is a medical practice where a patient with an end-stage degenerative disease that has resulted in a complete loss of cognition, but is mentally stable, and asks for help with premature death before he meets the final consequences of the disease (Kontomanolis et al., 2018). In such a situation doctors can also inject the patient with a deadly drug.
Eugenic euthanasia was seen as removing the burden from society as it was applied to members of society who, for some reason, could not work. For example, it could be people with physical or mental illnesses, or people with special needs, which made them unsuitable in terms of the benefits they brought to society (Kontomanolis et al., 2018). Today, abortion is also considered a form of eugenic euthanasia, sometimes this practice was applied to children with developmental defects and incurable diseases. Finally, voluntary euthanasia and living will is an opportunity for a patient being cared for at the end of life to choose euthanasia by writing a written statement. Noteworthy, the tendency to diversify the euthanasia forms is an argument that proves its wider popularity as a medical practice, even though a banned one. It can also be assumed that euthanasia is usually perceived as an ambiguous practice, which requires further discussion and consideration before being implemented in medical institutions.
Interestingly, physician-assisted suicide (PAS) is another synonym or type of euthanasia. Barsness et al. (2020) note that the potential risks of legalizing PAS are mainly discussed in the scientific community. In addition, it is widely accepted that quality palliative care reduces the patient’s tendency to require PAS. According to scientists, PAS is now legal in nine states in the US including the District of Columbia, Washington, Vermont, Oregon, Maine, Hawaii, Colorado, Montana, and California (Barsness et al., 2020). In the rest of the United States, euthanasia is illegal and is considered complicity in murder or manslaughter, with appropriate penalties.
Given that PAS is applied to people who experience fatal, unbearable suffering that cannot be eliminated, pain relieved, or cured, in some countries, such as the Netherlands, it is considered a humane practice. However, given the ambiguity of the concept of incurability in the context of the constant progress and evolution of medicine, the appointment of euthanasia can be a fatal mistake, especially concerning mentally ill people, or in the case of unexplored diseases, or diseases for which active scientific work is being carried out (Barsness et al., 2020). On the one hand, patients have free will and can utilize it to end their lives, and according to the principle of autonomy, doctors and society must respect this right. On the other hand, people who commit suicide due to mental anguish also show free will, but society does not contribute to their aspirations, and assistance in suicide is considered a crime in most societies.
It is also important to consider that euthanasia is often used in situations where the patient is unable to express his free will. For example, if a patient is in a coma, relatives can make this decision for him, guided by ethical considerations that may be wrong. Equally important, doctors can disconnect the patient from the equipment for economic or practical reasons, which also goes against generally accepted moral norms.
It is noteworthy that euthanasia is prohibited for persons under the age of 18 and is illegal if the patient does not have an incurable disease that threatens death in the next six months. Professional communities have expressed differing opinions about euthanasia, including PAS, considering this practice mainly from a moral point of view. Considering euthanasia from the point of view of expediency is no longer common in the medical community, as well as in the scientific community, after debunking the myths associated with eugenics. Not enough attention has been paid to the problem of euthanasia in peer-reviewed journals recently.
At the same time, when attention is paid to this topic, it is viewed through the prism of such keywords as suicide, medicine, and treatment, and there were no emotionally positive or negative connotations in the messages. This means that the practice of euthanasia is still perceived on a par with the practice of suicide, however, it is not condemned by society, since it is legalized in some countries and justified from the position of Hippocrates’ postulates, such as compassion and the desire to save a person from suffering.
As noted above, in nine states, euthanasia is legal when assisted by a doctor. These are the states of California, Colorado, the District of Columbia, Hawaii, Maine, Montana, Oregon, Vermont, and Washington. The following laws govern the procedure for granting the opportunity of death with dignity: Cal. Pen. Code § 401 and “End of Life Option Act,” Colo. Rev. Stat. § 18-3-104 (1) (b) and “Colorado End-of-Life Options Act,” Common law in District of Columbia and “Death with Dignity Act of 2016.”
Other legislative documents are Haw. Rev. Stat. § 707-702 (1) (b), Me. Rev. Stat. Title 17A, § 204 and “Maine Death with Dignity Act,” Mont. Code § 45-5-105, Mont. Code § 45-5-102 thru 104 and “The Rights of the Terminally Ill Act.” These are also Or. Rev. Stat. § 163.125 (1) (b), §§ 127.800 – 127.995 and “Oregon Death with Dignity Act,” Vermont Common law and “Patient Choices at End of Life” regulation, Wa. Rev. Code § 9A.36.060 Initiative 1000, approved 10/4/08 and “Washington Death with Dignity Act.”
Therefore, in every state where euthanasia is allowed, there is a prescribed procedure for its implementation. The main requirement for the lawful implementation of euthanasia in most cases is a doctor’s conclusion that the patient is at the terminal stage of an incurable disease and is in excruciating pain. As a rule, the patient’s demand for euthanasia is not a sufficient condition for assisted suicide. This decision is correct, as it is not uncommon for patients to request euthanasia when they require other assistance, such as treatment for mental illness, financial support, or hospitalization. If the patient has no other alternatives, the doctor decides to approve the requirement.
However, in such a situation, it seems important to note that the physician who decides on the provision of assisted suicide should evaluate not only existing, but also potential alternatives, and inform the patient about them. For example, if a patient is in the terminal stage of cancer, he should be aware of research on new drugs or surgical treatments for the disease. Even if the patient’s chances are extremely low, the physician should communicate such changes to the patient and their family, friends, or other caregivers or supporters.
Procedure and Peculiarities: Oregon Law
Oregon’s Death with Dignity Act, passed in November 1994, allows doctors to prescribe lethal drugs for terminally ill Oregon residents. It is necessary to consider this law in more detail since it regulates the procedure of assisted suicide and allows you to focus on controversial points that require corrections or additions. In particular, there is historical evidence of why patients requested euthanasia in 1998-2000 (“Oregon’s assisted suicide law,” 2020). In total, 70 deadly drugs were provided, and the patients who took them had diseases such as cancer, amyotrophic lateral sclerosis, chronic obstructive pulmonary disease, and others.
Noteworthy, the reasons why patients required the procedure of assisted suicide included “fear of being a burden, fear of losing autonomy, fear of losing control over bodily functions, inadequate pain control, fear of reducing the ability to do enjoyable activities” (“Oregon’s assisted suicide law,” 2020, par. 5). Other reasons for this request were financial implications, combined concerns about the burden, autonomy, activity, and bodily functions, and other combinations of burden, autonomy, activity, and bodily functions.
The presented list of reasons gives a vivid idea of why people seek to end their lives, and what can be the most frightening source of pain for them. It is important to understand that most of these reasons are surmountable difficulties, and physicians should focus primarily on saving patients’ lives. In other words, doctors should not allow patients to take a deadly drug, or justify the need to take such a drug for the reasons listed. As is customary in most state laws, the only reason doctors may prescribe euthanasia is when a patient is in constant physical pain that cannot be relieved with pain medication and is in the terminal stages of an illness that cannot be cured.
Corrections and Solutions
Given the common reasons people seek euthanasia, clinicians should consider how to overcome these causes. In particular, one needs to make sure that the patient is adequately supported and does not feel a burden, maintains sufficient autonomy, has control over bodily functions, and receives sufficient pain relievers to control pain. The physician deciding on euthanasia should ask if the patient is still able to do enjoyable activities. At the same time, factors need to be considered as to how severe the psychological burden on the patient is financially, and how adequately he can cope with the combined concerns of burden, autonomy, activity, bodily functions, and other combinations of these factors. Moreover, state laws should oblige doctors and nurses to make preliminary assessments of the patient’s life circumstances and treatment.
Thus, the death with dignity and various aspects of the patient’s right to assisted suicide was discussed. The main considerations regarding the right of the doctors to make the decisions to prescript the lethal medications are related to their sensitivity and interest in patients’ circumstances of life. Therefore, the requirement to show such interest should be introduced into the existing acts and regulations. The doctors and nurses should pay attention if patients receive adequate treatment and support to alleviate pain and meet the needs related to their conditions. At the same time, the ethical considerations regarding the right of the patients to die depending on the philosophical and religious positions of patients, their relatives, and the ideas prevalent in the given society.
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Kontomanolis, E. N., Kenanidou, E., Kalagasidou, S., Papamanolis, V., & Fasoulakis, Z. N. (2018). The conflict between euthanasia and human dignity: A different glance. The Ulutas Medical Journal, 4(4), 184-193.
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