End-of-life issues in healthcare are a highly controversial matter from several standpoints. From the ethical perspective, such interventions as physician-assisted suicide (PAS) or withdrawal of life-supporting care may be considered a direct violation of healthcare ethics. From a moral perspective, participating in PAS or withdrawing the necessary life-supporting care can put an immense psychological toll on physicians. In the case of Mr. Martinez, a 75-year-old patient who rejected cardiopulmonary resuscitation (CPR), the physicians faced a difficult choice between disobeying the patient to save him or respecting his choice despite the negative outcome. Given these considerations, it can be argued that an open discussion around end-life and care withdrawal issues is needed to determine ethical solutions that would be acceptable for patients, physicians, and the public.
The moral controversy behind such interventions as PAS and care withdrawal is twofold. Firstly, these practices create significant moral qualms for physicians, as they feel morally wrong to let a patient die. The impact was found to be more severe in cases of euthanasia, an extreme version of PAS, where a physician directly ends a patient’s life. For instance, a survey in the Netherlands showed that out of 159 physicians who had performed euthanasia, 52% experienced psychological discomfort, and 43% had to seek emotional support (Kelly et al., 2020). A survey of 1,000 U.S. physicians by Hetzler III et al. (2019) revealed that only 13% of respondents would be comfortable performing PAS if that procedure was legal. In this regard, one can hardly agree with Dr. Timothy Quill’s argument, who stated that there is no moral difference between removing life-sustaining treatment and hastening a patient’s death (Navasky & O’Connor, 2012). Medical professionals sense the moral difference between standard practice and harmful interventions. In this regard, it would be morally justified from the physician’s perspective to transfer Mt. Martinez to intensive care in order to save him.
In addition, an application of PAS and life support-limiting interventions can be perceived as a slippery moral slope. According to Munson (2014), PAS critics claim that legalization would open a path for abuse and malpractice. In particular, PAS opponents argue that instead of helping people die with dignity, PAS would be cynically used to drive the poor and elderly into ending their lives (Munson, 2014). However, it can be argued that legalization under strictly specified and scrutinized conditions would prevent abuse and malpractice. For instance, Dr. Quill advocated for a system where a legalized PAS should be used only as a last resort for patients with confirmed terminal illnesses (Navasky & O’Connor, 2012). It should be noted that Mr. Martinez’s case would not fall under the end-of-life issue category since the patient was not terminally ill. As such, the physicians would avoid the slippery slope altogether by moving Mr. Martinez to intensive care and helping him survive.
Regarding the patient’s perspective, PAS and similar interventions in their current state create significant ethical contradictions between the principles of patient autonomy, decisional authority, and physicians’ ethical obligations. On the one hand, a physician takes an oath not to harm the patient knowingly (Munson, 2014). On the other hand, a patient exhibits autonomy manifested in the right to control their body (Gedge et al., 2007). When a patient or their family asks a physician to perform potentially harmful actions, they put them in a challenging ethical situation. A refusal violates the patient’s autonomy and demonstrates that a physician puts their perceptions of benefit and value above the patient’s concerns. An acceptance violates nonmaleficence’s principle, as the patient may die because of the physician’s actions. In Mr. Martinez’s case, he and his wife exercised patient autonomy and deliberately rejected the safer treatment with CPR to achieve a self-perceived improvement in quality of life.
This scenario demonstrates that end-of-life issues might not necessarily be related to PAS in order to present a serious ethical problem. According to Emanuel et al. (1991), 71% of outpatients refused life-sustaining treatment in hypothetic scenarios. As such, patients may use their autonomy to prevent being treated in life-threatening conditions, forcing a physician to either let the patient die or abuse their authority. In Mr. Martinez’s case, the physicians were left in front of a question with two wrong answers. Interestingly, knowing that physicians cannot make an objectively right choice makes it easier to save the patient despite their perception of benefit. If anything, saving a patient allows physicians to maintain a positive moral outlook since they fulfill their professional duty by preventing death.
To conclude, an open discussion is needed to alleviate the moral and ethical controversy around the life-end issues. From the moral perspective, a sense of wrongdoing may be mitigated if such interventions as PAS were legalized and openly discussed between medical professionals, patients, and their families. Despite Dr. Quill’s claims of little difference between PAS and life-sustaining treatment removal, the current legal context puts a heavy moral burden on physicians. In such circumstances, physicians should try their best to save the patients in order to resolve potential moral conflicts.
However, Dr. Quill made a reasonable point regarding the PAS exclusivity for patients with verified terminal illnesses. If the legal context around controversial interventions were changed, physicians would be enabled to discuss the problematic questions with patients and their families. Clear patient-physician communication guidelines would be set to prevent unethical conduct. Consequently, physicians and patients would receive an opportunity to develop an ethical solution, satisfactory for both parties. In Mr. Martinez’s case, a proper discussion would have allowed the physicians to explain the CPR’s life-saving impact to him and his wife, preventing the need to choose from two objectively wrong alternatives.
References
Emanuel, L. L, Barry, M. J., Stoeckle, J. D., Ettelson, L. M., & Emanuel, E. J. (1991). Advance directives for medical care: A case for greater use. The New England Journal of Medicine, 324(13), 889–895.
Gedge, E., Giacomini, M., & Cook, D. (2007). Withholding and withdrawing life support in critical care settings: Ethical issues concerning consent. Journal of Medical Ethics, 33(4), 215.
Hetzler III, P. T., Nie, J., Zhou, A., & Dugdale, L. S. (2019). Focus: Death: A report of physicians’ beliefs about physician-assisted suicide: A national study. The Yale Journal of Biology and Medicine, 92(4), 575-585.
Kelly, B., Handley, T., Kissane, D., Vamos, M., & Attia, J. (2020). “An indelible mark” the response to participation in euthanasia and physician-assisted suicide among doctors: A review of research findings. Palliative & Supportive Care, 18(1), 82-88.
Munson, R. (2014). Intervention and reflection: Basic issues in bioethics (concise ed.). Wadsworth.
Navasky, M., & O’Connor, K. (2012). The suicide plan [Film]. Frontline.