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Trust and Physician-assisted suicide
TRUST AND PHYSICIAN-ASSISTED SUICIDE by Joan Liaschenko,
RN, PhD
In the first week of January, the U.S. Supreme Court began hearing arguments in the matter of assisted suicide. The prohibition against physician-assisted suicide (PAS) in Oregon, New York, and Washington is being challenged. As might be expected, the reasoning on both sides of the issue is deeply passionate; advocates and detractors cut across religion, philosophy, legal positions, and everyday experience. In my view, some arguments on both sides are less compelling than others. One theory I find peculiar and particularly troubling is the argument that allowing PAS would breach (or destroy) the trust the patient has placed in the health care provider-a major argument used by organized nursing. Perhaps I find it difficult to understand fully because I have yet to find this argument described in any detail by nursing authors. Certainly trust is of singular importance to human life because, as many philosophers have noted, its absence would make life impossible. Trust is related to action; we trust or do not trust people to do something. Trust is an attitude of optimism about the goodwill and competence of another that leads us to think we can count on the other person for something.’ The competence, however, is limited to some domain. For example, it would be strange, not to mention incorrect, if patients were to trust us with the electrical wiring of their houses. In general, patients trust health care providers to be concerned about their well-being and to be technically competent in the domain of health-related matters. No disagreement exists between those in favor of PAS and those opposed in terms of what constitutes the goal or aim of the health
94 HOME
CARE PROVIDER
professions: to do good by the patient and avoid harm. The difference comes in the meaning of these terms. Two views seem to exist among those who oppose PAS on the grounds of betrayal of trust. Some who make the betrayal-of-trust argument seem to assume death is the greatest harm that can befall anyone, and therefore health care providers must do everything in their power to forestall death. The other line of reasoning, the one most common to the official position of nursing, does not contend that death is the greatest harm. But this position does seem to maintain, however, that the only death acceptable is one in keeping with nursing’s (and others’) definition of a “good” death. Such a death takes a “natural” course even while the best palliative care available is used. Most of the time many of us would agree that health care providers should do everything in their power to help a patient avoid death. But within the context of contemporary therapeutics, everything can be very troubling. Everything made sense when one could do almost nothing. For most of human history, little could be offered to alter the outcome of disease in the sick individual. Florence Nightingale’s theory of healing was to put the body in the best possible condition for nature to heal. But this was really al1 there was. Essentially what medicine had to offer was the power
APRIL 1997, VOL. 2 NO. 2
‘
A QUESTION
OF ETHICS
of the relationship between physician and patient. Historically, this fact was a major reason that nursing
someone involved in the “death and dying movement” in the early ‘Y’OS, I A PROBLEM IS strongly agree that excellent palliawas so threatening to medicine. tive care is a worthy end. Yet implicit Imagine what it would be like to care in this language and the language of for a patient with cancer before official American Nurses Association chemotherapy or radiation or documents is the reasoning that advanced surgical techniques or improved palliative care would elimsophisticated pain management. We inate or at least markedly reduce would have only Nightingale’s requests for PAS. Such reasoning principles of good nutrition, rest, seems to suggest that palliative care cleanliness, and ventilation. Yet can alleviate all the symptoms of today Nightingale’s prescriptions every dying person, making his or sound remarkably like important her death good or at least acceptcomfort measures. able. I have seen patients who could not swallow their own saliva, and Contemporary therapeutics is very the best of our symptom manageCAUSti-‘HARM. young, beginning only about ment strategies could not help. Even 100 years ago, but in that time the the best palliative care is not a panacea; it cannot alleviate all sufferadvances have been remarkable. Unquestionably, the very existence of these therapeutics ing and control all symptoms. To argue otherwise is an increases physicians’ abilities to do something in response arrogance and a falsehood that does not engender trustto disease. A problem is that doing something is no longer worthiness. I, for one, do not trust those who make such an unquestioned good because many of these therapeutics claims; they do not leave me with an attitude of optimism themselves can cause harm. For example, the ablation of about their goodwill and competence. bone marrow necessary in bone marrow transplants can make a person mortally ill. Certainly, we do this with Indeed, it seems to me that the argument about trust could the ultimate aim of increasing long-term survival, but that be reversed. If our life has become unlivable, if we no does not change the fact that in some cases we have longer recognize it as our own, if health care providers are the power to take people to the door of death faster than concerned with our well-being, if health care providers their disease. have the power to end our suffering, and if we request it, how does permitting PAS destroy trust in health care Questions appropriate to our new-found medical progress providers? I am using “our” and “we” because all of us will be patients one day. Certainly medicine cannot claim are in order. What does doing everything mean when we can do almost anything? What can we say about the trust causing death by a painless means is not competent. If that of patients in health care providers when our therapies capability is present, and patients desire it, is trust not enable us to cause profound harm even as we aim to tranviolated? In such a situation, the patient’s attitude of optiscend this? Those who make the argument about the mism still would apply to the practitioner’s competence but not to his or her good will. betrayal or undermining of trust fail to appreciate the harm our therapeutics can do even in the name of good. Every nurse has horror stories about how patients’ wishes and During the debates over Proposition 161 in California, those of their families were overlooked in the quest to do which would have allowed PAS, I heard one physician who everything. Furthermore, some who make this argument was adamantly opposed to PAS (and active to that end) fail to realize that nursing bears an instrumental relationship say such assistance was a profound act of love, that the act to medicine; that is, nurses carry out the therapeutic plan was simply too intimate for him to help anyone outside of determined almost exclusively by medicine. Not only his own family. I deeply appreciated his courage to say patients but also nurses have been harmed by this2 this in a public forum, and I agree with him that directly helping someone to die in this way is a profound and intiMany nurses and nursing organizations who argue against mate act. But still I wonder what are we to make of this? PAS because it would violate trust say such things as, “Nurses have always been leaders and advocates for the Several other things could be said in this regard, and delivery of dignified and humane end-of-life care.“? As although lack of space precludes that, I will raise just a
APRIL
1997.
VOL.
2
NO.
2
HOME
CARE PROVIDER
95
A QUESTION
OF ETHICS
few of them as questions. Why, in spite of the “death and dying movement,” have we made so little progress in 25 years? Why, even with living wills and durable powers of attorney, do we still witness the refusal to honor patients’ and families’ wishes? Why does the case of Baby Linares (mentioned in an earlier issue) fill so many of us with moral outrage and profound sorrow? Why aren’t people convicted for helping others die? Why is this issue becoming even more intense? So very much more could be said about trust. I have barely scratched the surface in attempting to show that arguments against PAS on the grounds that trust would be eroded are simplistic and, in some cases, simply wrong. My goal in these few pages has been a call to reflect on the notion of trust as a moral virtue in relation to health care providers and PAS. I am not making a case for the legalization of PAS, and I certainly am not suggesting that, even if legalized, health care providers be compelled to act against their own conscience. I am requesting that each of us think about the notion of trust, that we be honest with ourselves and our patients, and that we exercise caution in claiming to speak for everyone. These actions may help patients know what they can count on us for and should help us to know what we can count on ourselves for.
REFERENCES 1. Jones
K. Trust as an affective
2. liaschenko world.
J. Artificial Nursing
3. Malone Nursing
Ethics
BL. Quoted Matters
attitude.
personhood: 1995;2:
1996; ethics
107j
1]:4-25.
in a medical
18.596.
in: ANA
(Wisconsin
Ethics nursing
opposes Edition)
physician-assisted 1997;8(
suicide
1): 1
Fax for Facts Receive free information
about products and service\ advcl-tlsed
in Home Care Provider.
Fax for Facts is quick and convenient. Here’s all yc~, do D Complete the “Reader Message” section below D Check the box next to the advertiser(s) from whom you’d like to receive more information. D Photocopy this page and fax it to the advertiser(5) LISIIX the appropriate fax number(s) shown. Use this page to receive information from as many advertisers as you wish. Reader
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D American Academy of Home Care Physicians .03 Seminar See advertisement D American Subacute Care Association 61 Conference See advertisement CI Buchanan and Associates .75 Continuing Education in Nursing 0 Janssen Pharmaceutics 54-56 Duragesic See advertisement Ll Joint Commission .Insidr hack cover Publication See advertisement 5 Metropolitan Jewish Geriatric Center Clinical Plus See advertisement 5 Mosby .Inside tront cover Publications See advertisement Ci Tucker Publications, Inc. 19 Publications (630)
969-3865
From page 91
Answer to Snap Judgment This young man had acute urticaria of unknown cause. Acute urticaria lasts from a few days to a few weeks. It presents with plaques larger than 2 cm (large areas of this young man’s body were covered with urticarial plaques). There is no dermographism, so this young man had none. Treatment in this case was antihistamines. When the hives did not resolve in 2 days, oral steroids
96
HOME
were prescribed,
CARE PROVIDER
which
resolved
his symptoms.
APRIL 1997,
VOL
2 NO.
2
RN, PhD
In the first week of January, the U.S. Supreme Court began hearing arguments in the matter of assisted suicide. The prohibition against physician-assisted suicide (PAS) in Oregon, New York, and Washington is being challenged. As might be expected, the reasoning on both sides of the issue is deeply passionate; advocates and detractors cut across religion, philosophy, legal positions, and everyday experience. In my view, some arguments on both sides are less compelling than others. One theory I find peculiar and particularly troubling is the argument that allowing PAS would breach (or destroy) the trust the patient has placed in the health care provider-a major argument used by organized nursing. Perhaps I find it difficult to understand fully because I have yet to find this argument described in any detail by nursing authors. Certainly trust is of singular importance to human life because, as many philosophers have noted, its absence would make life impossible. Trust is related to action; we trust or do not trust people to do something. Trust is an attitude of optimism about the goodwill and competence of another that leads us to think we can count on the other person for something.’ The competence, however, is limited to some domain. For example, it would be strange, not to mention incorrect, if patients were to trust us with the electrical wiring of their houses. In general, patients trust health care providers to be concerned about their well-being and to be technically competent in the domain of health-related matters. No disagreement exists between those in favor of PAS and those opposed in terms of what constitutes the goal or aim of the health
94 HOME
CARE PROVIDER
professions: to do good by the patient and avoid harm. The difference comes in the meaning of these terms. Two views seem to exist among those who oppose PAS on the grounds of betrayal of trust. Some who make the betrayal-of-trust argument seem to assume death is the greatest harm that can befall anyone, and therefore health care providers must do everything in their power to forestall death. The other line of reasoning, the one most common to the official position of nursing, does not contend that death is the greatest harm. But this position does seem to maintain, however, that the only death acceptable is one in keeping with nursing’s (and others’) definition of a “good” death. Such a death takes a “natural” course even while the best palliative care available is used. Most of the time many of us would agree that health care providers should do everything in their power to help a patient avoid death. But within the context of contemporary therapeutics, everything can be very troubling. Everything made sense when one could do almost nothing. For most of human history, little could be offered to alter the outcome of disease in the sick individual. Florence Nightingale’s theory of healing was to put the body in the best possible condition for nature to heal. But this was really al1 there was. Essentially what medicine had to offer was the power
APRIL 1997, VOL. 2 NO. 2
‘
A QUESTION
OF ETHICS
of the relationship between physician and patient. Historically, this fact was a major reason that nursing
someone involved in the “death and dying movement” in the early ‘Y’OS, I A PROBLEM IS strongly agree that excellent palliawas so threatening to medicine. tive care is a worthy end. Yet implicit Imagine what it would be like to care in this language and the language of for a patient with cancer before official American Nurses Association chemotherapy or radiation or documents is the reasoning that advanced surgical techniques or improved palliative care would elimsophisticated pain management. We inate or at least markedly reduce would have only Nightingale’s requests for PAS. Such reasoning principles of good nutrition, rest, seems to suggest that palliative care cleanliness, and ventilation. Yet can alleviate all the symptoms of today Nightingale’s prescriptions every dying person, making his or sound remarkably like important her death good or at least acceptcomfort measures. able. I have seen patients who could not swallow their own saliva, and Contemporary therapeutics is very the best of our symptom manageCAUSti-‘HARM. young, beginning only about ment strategies could not help. Even 100 years ago, but in that time the the best palliative care is not a panacea; it cannot alleviate all sufferadvances have been remarkable. Unquestionably, the very existence of these therapeutics ing and control all symptoms. To argue otherwise is an increases physicians’ abilities to do something in response arrogance and a falsehood that does not engender trustto disease. A problem is that doing something is no longer worthiness. I, for one, do not trust those who make such an unquestioned good because many of these therapeutics claims; they do not leave me with an attitude of optimism themselves can cause harm. For example, the ablation of about their goodwill and competence. bone marrow necessary in bone marrow transplants can make a person mortally ill. Certainly, we do this with Indeed, it seems to me that the argument about trust could the ultimate aim of increasing long-term survival, but that be reversed. If our life has become unlivable, if we no does not change the fact that in some cases we have longer recognize it as our own, if health care providers are the power to take people to the door of death faster than concerned with our well-being, if health care providers their disease. have the power to end our suffering, and if we request it, how does permitting PAS destroy trust in health care Questions appropriate to our new-found medical progress providers? I am using “our” and “we” because all of us will be patients one day. Certainly medicine cannot claim are in order. What does doing everything mean when we can do almost anything? What can we say about the trust causing death by a painless means is not competent. If that of patients in health care providers when our therapies capability is present, and patients desire it, is trust not enable us to cause profound harm even as we aim to tranviolated? In such a situation, the patient’s attitude of optiscend this? Those who make the argument about the mism still would apply to the practitioner’s competence but not to his or her good will. betrayal or undermining of trust fail to appreciate the harm our therapeutics can do even in the name of good. Every nurse has horror stories about how patients’ wishes and During the debates over Proposition 161 in California, those of their families were overlooked in the quest to do which would have allowed PAS, I heard one physician who everything. Furthermore, some who make this argument was adamantly opposed to PAS (and active to that end) fail to realize that nursing bears an instrumental relationship say such assistance was a profound act of love, that the act to medicine; that is, nurses carry out the therapeutic plan was simply too intimate for him to help anyone outside of determined almost exclusively by medicine. Not only his own family. I deeply appreciated his courage to say patients but also nurses have been harmed by this2 this in a public forum, and I agree with him that directly helping someone to die in this way is a profound and intiMany nurses and nursing organizations who argue against mate act. But still I wonder what are we to make of this? PAS because it would violate trust say such things as, “Nurses have always been leaders and advocates for the Several other things could be said in this regard, and delivery of dignified and humane end-of-life care.“? As although lack of space precludes that, I will raise just a
APRIL
1997.
VOL.
2
NO.
2
HOME
CARE PROVIDER
95
A QUESTION
OF ETHICS
few of them as questions. Why, in spite of the “death and dying movement,” have we made so little progress in 25 years? Why, even with living wills and durable powers of attorney, do we still witness the refusal to honor patients’ and families’ wishes? Why does the case of Baby Linares (mentioned in an earlier issue) fill so many of us with moral outrage and profound sorrow? Why aren’t people convicted for helping others die? Why is this issue becoming even more intense? So very much more could be said about trust. I have barely scratched the surface in attempting to show that arguments against PAS on the grounds that trust would be eroded are simplistic and, in some cases, simply wrong. My goal in these few pages has been a call to reflect on the notion of trust as a moral virtue in relation to health care providers and PAS. I am not making a case for the legalization of PAS, and I certainly am not suggesting that, even if legalized, health care providers be compelled to act against their own conscience. I am requesting that each of us think about the notion of trust, that we be honest with ourselves and our patients, and that we exercise caution in claiming to speak for everyone. These actions may help patients know what they can count on us for and should help us to know what we can count on ourselves for.
REFERENCES 1. Jones
K. Trust as an affective
2. liaschenko world.
J. Artificial Nursing
3. Malone Nursing
Ethics
BL. Quoted Matters
attitude.
personhood: 1995;2:
1996; ethics
107j
1]:4-25.
in a medical
18.596.
in: ANA
(Wisconsin
Ethics nursing
opposes Edition)
physician-assisted 1997;8(
suicide
1): 1
Fax for Facts Receive free information
about products and service\ advcl-tlsed
in Home Care Provider.
Fax for Facts is quick and convenient. Here’s all yc~, do D Complete the “Reader Message” section below D Check the box next to the advertiser(s) from whom you’d like to receive more information. D Photocopy this page and fax it to the advertiser(5) LISIIX the appropriate fax number(s) shown. Use this page to receive information from as many advertisers as you wish. Reader
Message
Reader name Address City/State/Zip Fax
Telephone Please send me information products I’ve checked (as Home Care Provider).
about
Send information by (check one) 5 Fax D First class mail Index
the
advertisers/
seen in the April 1907 I\WC ot
EI Have a sxlc~pcrson
call
to Advertisers
D American Academy of Home Care Physicians .03 Seminar See advertisement D American Subacute Care Association 61 Conference See advertisement CI Buchanan and Associates .75 Continuing Education in Nursing 0 Janssen Pharmaceutics 54-56 Duragesic See advertisement Ll Joint Commission .Insidr hack cover Publication See advertisement 5 Metropolitan Jewish Geriatric Center Clinical Plus See advertisement 5 Mosby .Inside tront cover Publications See advertisement Ci Tucker Publications, Inc. 19 Publications (630)
969-3865
From page 91
Answer to Snap Judgment This young man had acute urticaria of unknown cause. Acute urticaria lasts from a few days to a few weeks. It presents with plaques larger than 2 cm (large areas of this young man’s body were covered with urticarial plaques). There is no dermographism, so this young man had none. Treatment in this case was antihistamines. When the hives did not resolve in 2 days, oral steroids
96
HOME
were prescribed,
CARE PROVIDER
which
resolved
his symptoms.
APRIL 1997,
VOL
2 NO.
2