When it comes to end-of-life treatment, patients currently have a few different options available to them. One option, refusal of treatment, is when a decisionally capable patient is put in the driver’s seat with respect to medical treatment under the doctrine of informed consent. Another option is pain management, where palliative medicine is administered to entirely eliminate, or reduce pain to a level that the patient finds tolerable. There is also terminal sedation, which is the practice of maintaining a patient in a state of deep and continuous unconsciousness until the point of death.
A fourth option, if the patient is in a jurisdiction that has legalized it, is physician-assisted death. In the following shortened excerpt from Physician-Assisted Death:What Everyone Needs to Know, L.W. Sumner helps us understand exactly what physician-assisted death (PAD) is.
What is physician-assisted death?
The end-of-life treatment options we have surveyed so far—refusal of life-sustaining treatment, aggressive pain management, and terminal sedation—are all relatively uncontroversial from an ethical standpoint (with the exception of some issues we have noted along the way). They are also legal in most jurisdictions, including the United States. However, our main topic is another end-of-life option that is neither ethically uncontroversial nor legal (except in a few places). So we need to be sure we understand exactly what physician-assisted death (PAD) is.
As we have seen, there are many ways in which physicians (and other health care providers) may assist their patients through the dying process. Furthermore, as we have also seen, at least some of these ways may have the effect of hastening the patient’s death. However, PAD refers exclusively to one particular way in which a doctor may help to hasten a patient’s death: by providing the patient with medication (typically a barbiturate) at a dose level that is intended to cause death and that does in fact cause death. There are two ways in which this may occur. In physician-assisted suicide the doctor prescribes the medication for the patient, who then self- administers it orally. In physician-administered euthanasia the doctor administers the medication to the patient intravenously or by means of an injection. The difference between these two forms of PAD is strictly one of agency: who ends up actually administering the medication to the patient. In either case the administration of the medication is the immediate, or proximate, cause of the patient’s death.
As the phrase suggests, PAD (in either form) is something done by a physician: it is physician-assisted death. So, while it is possible for others (family, friends, etc.) to assist someone’s death, even by providing or administering a lethal dose of medication, we are confining ourselves here to cases in which this is done by a doctor (or by another health care provider, such as a nurse, under the direction of a doctor). Unlike patient refusal of life-sustaining treatment, PAD involves administering treatment rather than withholding or withdrawing it. To put it differently, it is something that patients must request, not something they must refuse. In terms of a common (though misleading) distinction, PAD is therefore necessarily “active” (since it requires the administration of a lethal medication) rather than “passive.” The phrase “active euthanasia” is therefore redundant, and “passive euthanasia” is a contradiction.
“Unlike patient refusal of life-sustaining treatment, PAD involves administering treatment rather than withholding or withdrawing it.”
The best way to bring out the further features of PAD is to compare it to the other end-of-life treatment measures considered earlier. There are two important similarities among all of these measures. First, they all have at least the potential to hasten the patient’s death. This is obviously true for PAD, in which the administration of the medication is the cause of death. But it is also true for refusal of life-sustaining treatment (on the assumption that the treatment refused would have extended the patient’s life for however short a period) and for terminal sedation (at least on the assumption that the patient refuses artificial feeding and hydration while sedated) and may potentially be true for pain management (though, as we saw earlier, this is a matter of some controversy).
The second similarity is that all of these treatment options can be either voluntary or nonvoluntary. A treatment option is voluntary when it is requested (or, in the case of discontinuation of treatment, refused) by a patient who is decisionally capable at the time at which the treatment is to be administered. But they can be nonvoluntary as well: in the case of a currently decisionally incapable patient life-sustaining treatment can be refused, or higher doses of opioids or sedatives can be requested, by substitute decision makers. The same can be true for PAD in the case of a patient currently incapacitated by conditions such as severe dementia or irreversible unconsciousness.
Voluntary end-of-life measures that have the effect of hastening death are easier to defend than nonvoluntary ones since in these cases the factor of patient autonomy is fully in play: the patient himself or herself is making an informed request (or refusal) at the time at which treatment will be initiated (or discontinued). The situation becomes much more complicated when the patient is not currently capable of making such a request and even more complicated for patients who have never had this capacity.
There are equally important differences between PAD and the other end-of-life measures. One of these has to do with cause of death. In the case of PAD it is clear that the administration of the lethal medication is the immediate, or proximate, cause of death. This might also be said to be true for pain management or terminal sedation, if they do sometimes have the effect of shortening life. But in the case of treatment refusal it is at least arguable that the cause of death is the patient’s illness (though this is less arguable when the treatment refused is artificial ventilation or nutrition and hydration). The other difference is a matter of intention. When a patient refuses further treatment, it may often be misleading, or just downright wrong, to say that he or she is thereby intending to hasten death (though the same exceptions might apply). We have also seen that high doses of opioids or sedatives are normally administered in order to minimize or eliminate patient suffering; if they ever also hasten the patient’s death, then this is regarded as a further unintended effect. However, in the case of PAD the intent of the administration of the medication is precisely to cause death—or, to put it another way, to end the patient’s suffering by bringing about death.
So PAD appears to differ from other end-of-life treatment options in terms of both causation and intention. It is these differences that are often thought to define an ethical “bright line” dividing PAD from these other, less controversial measures.
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