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The Moral Issue of Dying with Dignity: A Nurse’s Role in Assisted Suicide

Nothing is more certain than death. But often, the path to its conclusion can be very long and painful. Which brings us to one of the most controversial and complex issues in healthcare — the role of clinicians, particularly nurses, in assisted suicide.

Seeing a patient suffer is a sight that a nurse never gets used to. Healers by nature, most nurses would never consider ending a patient’s life. When a patient dying of an incurable disease begs for a quick and painless death it often raises very hard moral questions for a nurse. A situation like this can leave a nurse second-guessing the ethical traditions of the nursing profession and leaves us with the question “what is a nurse’s role in assisted suicide?”

Dying a Good Death

Assisted suicide is a type of euthanasia, a term associated with ending a patient’s suffering by cause of death. There are two categories of euthanasia, active or passive. Active euthanasia, also called mercy killing, refers to the actions taken with the intentions of ending a patient’s life. Active euthanasia is illegal in most settings and is considered murder by most people. On the other hand, passive euthanasia refers to allowing the patient to die, making no attempt to hasten or prolong life even if the means are available. Allowing a patient to refuse life sustaining treatment and removing a feeding tube at the patient’s request are forms of passive euthanasia. The patient will die, but from natural causes.

Assisted Suicide is said to straddle the line between Active and Passive Euthanasia. The clinician supplies the means to die but the patient takes the action. There are many arguments that can be made for and against assisted suicide. Generally, many healthcare professionals feel that patients would not choose death if better palliative care were available. Some will say that today’s advanced healthcare technology may prolong a patient’s life but will not improve their quality of life. Others believe that ending a patient’s life either by neglect or by direct action is morally wrong.

Life or Death? Let Ethics Decide

The American Nurses Association (ANA) believes that a nurse should not be involved in assisted suicide. Participation is a violation of the Code for Nurses with Interpretive Statements (Code for Nurses) and the ethical traditions of the profession.

Nurses see firsthand the devastating and debilitating effects of incurable diseases and are often confronted with the despair and exhaustion of patients and families. It can be difficult, and at times trying, for nurses to find the balance between the preservation of life and the facilitation of a dignified death. Facing such agonizing scenes can cause a nurse to feel that intentionally hastening a patient’s death is a humane and compassionate response. According to the ANA, it is in these situations that nurses have to control their feelings and not allow them to influence their clinical decision making.

On the other hand, assisted suicide should not be confused with ethically justified end-of-life decisions and actions. Nurses can, and must be vigilant advocates for humane and dignified care, for the alleviation of suffering and for the non-abandonment of patients. The withholding or withdrawal of life-sustaining treatments such as mechanical ventilation, chemotherapy and artificially provided nutrition and hydration can be ethically acceptable and legal. Patients have the right to exercise their decisional authority relative to healthcare decisions, including foregoing life-sustaining treatments.

Walking a Thin Line

There is no doubt that the line between assisted suicide and compassionate end-of-life care is a thin one. Nurses are expected to offer patients medications to promote comfort and relieve suffering but not with the intent to end their life. However in the Code for Nurses it states: “The nurse may provide interventions to relieve symptoms in the dying client even when the interventions entail substantial risks of hastening death.”

Most people would agree that nurses are in a very difficult position. It’s not easy to respond to someone who requests help in taking their own life. Even the best effort at palliative care won’t prevent some patients from thinking about assisted suicide. These thoughts can be brought about by several factors including unrelieved pain, depression, feelings of loss of control, fear of isolation, concern for family and a sense of hopelessness.

It is important for nurses not to judge or isolate patients who have suicidal thoughts. Instead nurses should use this opportunity to open the lines of communications, discussions of suicide does not increase the risk of follow through. Creating an environment where a patient is comfortable expressing thoughts can help diminish feelings of isolation and provided needed support.

Legal Doesn’t Make it Moral

Assisted Suicide is illegal in most states, but in 1997 Oregon passed The Oregon Death with Dignity Act making assisted suicide legal in that state. So far, no other state has followed Oregon’s lead and that could be for fear of the opening Pandora’s Box. At this time only patients in terminal stages of incurable illness are considered candidates for assisted suicide. But if more states decide to legalize assisted suicide, what will stop the choice of death from being offered to others, such as those who have suffered for years with debilitating chronic diseases?

Many see legalized assisted suicide as doing more harm than good because some health professionals will see it as an easy, quick, painless way out of dealing with disease. In addition, caregiver convenience and economic priority could intrude in the decision making process. A family member or friend with power of attorney will have a patient’s life in their hands. They could legally decide that a person with Alzheimer’s disease would no longer want to live. Employers and insurance companies could achieve great savings by encouraging patients to choose assisted suicide. Legalization of assisted suicide could open the “box” to making death an economic choice rather than a natural process.

Comfortable Closure

A slow, painful, undignified death would be looked upon by most as a horrible journey that we wouldn’t want even our worst enemies to take. As awful as it might be, does it justify suicide?

Most nurses will stand behind their “Code of Nursing” and say no. Following the code will tell you that the answer is in better end-of-life care. Nurses have to be aggressive patient advocates for improved palliative care — even if the end result is a shorter life. Nurses must remain strong and focused on their goal of providing quality healthcare, regardless of the patient’s diagnosis and condition. Legalized assisted suicide will never be an alternative to dignified, humane end-of-life care.

References

• Dryer, Dale E. (1999) Assisted Suicide; Copyright the University of Arizona: College of Nursing
• American Nurses Association’s Position Statement on Assisted Suicide; Originated by: Task Force on the Nurse’s Role in End-of-Life Decisions Center for Ethics and Human Rights
• Lau, Michelle. (1998) NurseWeek; Assisted Suicide: What is Your Role?
• Asch, David A. M.D., M.B.A. New England Journal of Medicine; The Role of Critical Care Nurses in Euthanasia and Assisted Suicide
• Federwisch, Anne. (1998) NursweWeek; Medical futility. Who has the power to decide?