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Dying with DignityCaroline L. EckardDrOIDCOM225

DefinitionsDeath with dignity: (1) an end-of-life option that allows certain eligible individuals to legally request and obtain medications from their physician to end their life in a peaceful, humane, and dignified manner; (2) state legislation codifying such an end-of-life option; (3) a family of organizations promoting the end-of-life option around the United States (FAQs).Physician Assisted Death: a term often used interchangeably with physician-assisted suicide (PAS), which involves a doctor "knowingly and intentionally providing a person with the knowledge or means or both required to commit suicide, including counseling about lethal doses of drugs, prescribing such lethal doses or supplying the drugs (CMA Policy).Euthanasia: knowingly and intentionally performing an act that is explicitly intended to end another person's life and that includes the following elements: the subject has an incurable illness; the agent knows about the person's condition; commits the act with the primary intention of ending the life of that person; and the act is undertaken with empathy and compassion and without personal gain (CMA Policy).Three types of Euthanasia are identified; the divisions are premised on whether the subject has and expresses a desire to end their life:Voluntary euthanasia is limited to situations where the subject is a competent, informed person who has voluntarily asked for his or her life to be ended. Non-voluntary euthanasia means the person has not developed or expressed his or her preference regarding aid in dying or is incapacitated and is unable to make or exercise an informed choice. In-voluntary euthanasia means the person made an informed choice and expressed his or her refusal for aid in dying.

PAS/PAD vs Euthanasia

involve the use of lethal medications to deliberately end a patient's lifethe patient must self-administer the medications; the "aid-in-dying" refers to a physician providing the medications, but the patient decides whether and when to ingest the lethal medicationwhen a third party administers medication or acts directly to end the patients lifePhysician Aid in Dying/Physician Assisted SuicideEuthanasia(Braddock III & Tonelli 2013)

Other Practices that are not PAS or PADSome other practices that should be distinguished from physician aid-in-dying include:Withholding/withdrawing life-sustaining treatments: When a competent adult patient makes an informed decision to refuse life-sustaining treatment, their wishes are generally respected. The right of a competent adult patient to refuse life-sustaining treatments is supported by law.Pain medication that may hasten death: Often a terminally ill, suffering patient may require dosages of pain medication that have side effects that may hasten death, such as impairing respiration. Using the ethical principle of double effect as the foundational argument, it is generally held by most professional societies, and supported in court decisions, that this action is justifiable. Since the primary goal and intention of administering these medications is to relieve suffering, the secondary outcome of potentially hastening death is recognized as an expected and acceptable side-effect in a terminally ill patient.Palliative sedation: This term refers to the practice of sedating a terminally ill patient to the point of unconsciousness, due to intractable pain and suffering that has been refractory to traditional medical management. Such patients are imminently dying, usually hours or days from death. Often other life-sustaining interventions continue to be withheld (CPR, respirator, antibiotics, artificial nutrition and hydration, etc.) while the patient is sedated. Palliative sedation may occur for a short period (respite from intractable pain) or the patient may be sedated until s/he dies. In the rare instances when pain and suffering is refractory to treatment even with expert clinical management by pain and palliative care professionals, palliative sedation may legally be employed.

Where is PAS/PAD legal?

By NickCT - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=39316187

Briefly legal in 2014 but overturned in 2015Legal as of: 1997

Legal as of: November 2016Legal as of: May 2013Legal as of: November 2008Legal as of: 2009 Baxter v. MontanaLegal as of June 9, 2016(As of March 2015)Bill passed in October 2015Law passed in November 1994

States where there is no specific statute making assisted suicide illegalWashington D.C.Nevada (The act may or may not be covered by common law.)North Carolina (The act may or may not be covered by common law.)Utah (Utah does not recognize common law and has no specific statute for assisted suicide.)West VirginiaWyoming (Wyoming does not recognize common law and has no specific statute for assisted suicide.)(ProCon.org 2015)

Who Qualifies for PAS/PAD?Must be a resident within one of the six statesMust be 18 years or olderMust have six months or less till expected death due to a terminal illnessMust have two oral (or least 15 days apart) and one written request to a physicianMust be capable of making and communicating health care decisions for him/herself and has made the request voluntarily(ProCon.org 2015)

Most Common Arguments Against Physician Aid-in-Dying:Sanctity of lifePassive vs. Active distinctionPotential for abuseProfessional integrityFallibility of the profession

Argument #1: Sanctity of Human LifeReligious and secular traditions upholding the sanctity of human life have historically prohibited suicide or assistance in dying. PAD is morally wrong because it is viewed as diminishing the sanctity of life. (Braddock III & Tonelli 2013)We are made in Gods image (Genesis 1:2627) and therefore human life has an inherently sacred attribute that should be protected and respected at all times. While God gave humanity the authority to kill and eat other forms of life (Genesis 9:3), the murdering of other human beings is expressly forbidden, with the penalty being death (Genesis 9:6).(Old Testament vs New Testament)

Counter Argument to the Sanctity of Human LifeNot everyone has the same God or even believes in God(s), it is unfair to take away a choice because some people disagreeIf the penalty for bloodshed is death - isnt that just more bloodshed?With the definition of bloodshed meaning: (1) destruction of life, as in war or murder; slaughter; or (2) the shedding of blood by injury, wound, etc (bloodshed).If you take the second definition: There is no blood involved in PAD, the patient merely takes a few pills and falls asleep to die.If you take the first definition: According to the United States Law, murder is the killing of another human being under conditions specifically covered in law. In the U.S., special statutory definitions include: murder committed with malice aforethought, characterized by deliberation or premeditation or occurring during the commission of another serious crime, as robbery or arson (first-degree murder) and murder by intent but without deliberation or premeditation (second-degree murder) (murder). Due to the fact that PAD is done without malicious intent and is done not by the physician but at the will of the patient to end their life merely with the aid of a physician, it should not be attributed to murder.Furthermore, some physicians aid their patients in dying without even knowing it, usually prescriptions are given in monthly increments meaning you most likely will have 30 pills in one fill of the medication, if one were to take all 30 pills, they would most likely die or become extremely ill.

Argument #2: Passive vs. Active DistinctionThere is an important difference between passively "letting die" and actively "killing." Treatment refusal or withholding treatment equates to letting die (passive) and is justifiable, whereas PAD equates to killing (active) and is not justifiable (Braddock III & Tonelli 2013).

Counter Argument #2: Passive vs. Active DistinctionBoth killing (active) and withholding treatment (passive) have the same result: the patient dies, the difference being that the person either dies quickly or slowly. Furthermore, since the physician only supplies the patient with the script to ascertain the drugs, and does not administer them directly or lay a hand on the patient, it could be considered passive (accepting or allowing what happens or what others do, without active response or resistance).Usually when one has a terminal illness, they are in extreme pain, sometimes the drugs do not work any more or theyre incapacitated or otherwise not all there. In the event of being in extreme pain and knowing you wont recover, would you rather have a quick and painless death or prolong your suffering to get to the same end result?

Argument #3: Potential for AbuseVulnerable populations, lacking access to quality care and support, may be pushed into assisted death. Furthermore, assisted death may become a cost-containment strategy. Burdened family members and health care providers may encourage loved ones to opt for assisted death and the protections in legislation can never catch all instances of such coercion or exploitation. To protect against these abuses, PAD should remain illegal.(Braddock III & Tonelli 2013)

Counter Argument #3: Potential for AbuseWith all the restrictions in place for being allowed to participate in PAD, it is unlikely that one would be able to go through all avenues and requirements without arousing suspicion, and since the patient must communicate to the physician that he/she wishes to end their life, the only way one could possibly use this as a means to rid themselves of debt would be to either blackmail the patient into giving their consent or use a psychological tactic to convince the patient to give their consent (i.e. hypn