EXECUTIVE SUMMARY

With physician-assisted dying currently legal in six states, hospitals are facing ethical questions on responding to requests and addressing conscientious objectors. Ethicists can do the following:

  • Inform clinicians who express discomfort with the practice that conscientious objection is an option.
  • Offer to find an alternative person to assist to replace a conscientious objector.
  • Develop policies on responding to requests.
  • Suggest the ethics committee develop a policy for offering patients the alternative option of stopping eating and drinking.

Physician-assisted dying raises multiple ethical questions in the hospital setting, including how to respond to requests and assess decision-making capacity.

“You also have to consider whether the people assisting can live with this,” says Timothy E. Quill, MD, professor of medicine, psychiatry, and medical humanities at University of Rochester (NY)’s Palliative Care Program.

Physician-assisted dying is now legal in six states: Oregon, Washington, Montana, Vermont, California, and Colorado. “Most have laws saying you, as a clinician, can be a conscientious objector,” says Quill. “[Clinicians] still have the ethical right, in some sense, to say no — although if you live in a rural place and it’s the only game in town, that’s a little tougher.”

Some physicians who have assisted in a patient’s death find it very difficult, and others find it very meaningful. “It’s always a big deal to do this,” says Quill. “Yet you do it because it’s what you feel obligated to do, and it doesn’t make sense not to do it, in some cases.”

Striking the right balance between meeting the patient’s needs and supporting clinical staff who are uncomfortable is challenging. “In my view, we still need to put a little heat on people who are conscientious objectors,” says Quill. While clinicians need to respect their own ethical boundaries, it’s important not to reinforce abandoning the patient. Quill sees the following possible roles for the ethicist:

  • If a clinician is uncomfortable with physician-assisted dying in a state where it’s legally permitted, the ethicist can suggest the option of conscientious objection.
  • The ethicist might also suggest to the clinician that he or she has an obligation to help find, or at least allow, another person to assist.
  • If the clinician is uncomfortable finding another person to assist, the ethicist might take on this responsibility.

Quill says that in states where physician-assisted dying is legal, the ethical issues “are somewhat similar to questions that might come up with palliative sedation or stopping life support.” Some important considerations include assessment of the patient’s decision-making capacity, access to palliative care, and general agreement on the ethical and legal permissibility.

Once physician-assisted dying becomes legal in a state, hospitals should not hesitate to develop a policy on how requests will be handled. “Don’t wait until the first case comes in, because then you are flying by the seat of your pants,” says Quill. “It’s incumbent on an institution to handle it in an ethically sound way, given that it’s legal.”

Some hospitals, reluctant to offer physician-assisted dying, might instead offer palliative sedation. Quill doesn’t see this as a viable alternative for these cases. “The indications are quite different. Usually people getting sedated are in immediate extremis right now,” he explains. “Patients asking about physician-assisted dying are more worried about what’s going to happen down the road.”

Highly Contentious Issue

In a recent paper, the authors identified the following central ethical issues involving physician-assisted suicide and euthanasia in medical practice:1

  • the benefit or harm of death itself,
  • the relationship between physician-assisted suicide and euthanasia and withholding or withdrawing life support,
  • the morality of a physician deliberately causing death, and
  • the management of conscientious objection related to physician-assisted suicide and euthanasia in the critical care setting.

“Our findings emphasize that one’s view of physician-assisted suicide and euthanasia derive from one’s most basic beliefs about morality and the source of ethical value,” says Ewan C. Goligher, MD, PhD, the study’s lead author. Goligher is an intensivist at Mount Sinai Hospital in Toronto and a member of the Interdepartmental Division of Critical Care Medicine at the University of Toronto.

The project began as a dialogue among concerned intensivists from different countries and different points of view. The group realized they needed input from ethicists. Daniel P. Sulmasy, MD, PhD, MACP, was one of the ethicists invited to present arguments on both sides of the issue. “Good ethicists should know the arguments on both sides well enough to do this,” says Sulmasy, André Hellegers professor of biomedical ethics at Georgetown University Medical Center’s Edmund D. Pellegrino Center for Clinical Bioethics in Washington, DC.

None of the authors changed their minds as a result of working on the paper. “The most wonderful result, however, was a mutually respectful dialogue on a highly contentious issue,” Sulmasy says. “Bioethics, as a field, needs more of that.”

The debate centered on the question of whether the patient’s moral significance derives from their exercise of autonomy, or simply from their ontology — who they are as a person. Goligher explains, “Failure to resolve this issue makes the disagreement over assisted death an intractable issue.”

Despite this disagreement, the group arrived at a consensus on how requests for physician-assisted dying can be reasonably accommodated. “Several of us insisted that there was no obligation to make an effective referral,” says Goligher. “We all agreed that a transfer of care to another intensivist does not count as a case of effective referral.”

The researchers’ hope is that physicians will carefully consider how they would respond to the questions raised in the paper. “Physicians, departments, and hospital systems need to be prepared to handle conscientious objection in a respectful and accommodating manner, in order to ensure that the patient’s well-being remains the highest priority for all,” says Goligher.

Sulmasy says that clinicians should “not merely react to opinion polls” and instead, think seriously about the following questions:

  • Is it ethically good and right for clinicians to kill patients or to help them to kill themselves?
  • Is such killing justified fully by the patient’s autonomous authorization? Or is the ethics of medicine broader and deeper than that?
  • Is the killing of patients by physicians only wrong if it is involuntary? Or do concerns about the implications for the patient-physician relationship, about killing and the meaning of medicine, and the social implications of legalizing such practices, outweigh the preferences of a few patients?

“These are weighty issues, making this perhaps the central question in medical ethics today,” says Sulmasy.

Consider Alternative Options

Quill is sometimes asked to provide ethical input by other physicians who are considering physician-assisted dying in the home setting, in a state where it’s not legal.

“What’s legal is not always what’s ethical, depending on your point of view,” says Quill. If physicians are thinking about secretly assisting someone, Quill encourages them to try to find a way to help that is legal. Physicians don’t always realize the full implications of helping someone illegally. “Both the clinician and the patient and family have to keep a big secret,” he notes. “And if it does get discovered, you might become a test case and bad things can potentially happen to you.”

Most physicians are aware that if suffering becomes very severe, they can legally and ethically sedate patients as a last resort. “But the option that’s most relevant in this circumstance is stopping of eating and drinking,” says Quill. The concept has never been legally tested in the courts, so the legality is unclear, “but the physician’s assistance is more indirect, so it’s much safer legally for physicians,” says Quill. “It’s hard to do for patients, but it does put the option completely in their hands.” It’s not that clinicians are withholding food and drink — it’s that the patient is choosing not to have it.

The physician is involved in assessment of the patient and management of symptoms, but the patient is the one opting to decline food and drink. “Unlike physician-assisted dying, this is a process that can be done completely out in the open,” says Quill.

Quill believes stopping eating and drinking is an important option to be able to offer patients. “I have had patients who would never do a physician-assisted dying — it would have been completely out of their moral realm — but did this,” he says. A nun told Quill she viewed it as a “fast for God.”

“If somebody is in a bad situation and asks you, couldn’t I have physician-assisted dying, and is talking about wanting an escape, having them have to discover stopping and eating and drinking on their own is not fair,” says Quill. Clinicians could instead respond by stating, “Here’s something some people have chosen to do…”

Quill has seen some patients who clearly wanted physician-assisted dying and would have qualified for it, and would have been given it if the practice were not illegal in their state. Stopping food and drink is another option for this group of patients. “This practice is starting to get a little more play in the ethics and clinical literature. But some pretty powerful forces are likely to push back,” says Quill.

If done in the hospital setting, Quill recommends getting an ethical consult. “You want people to know others are weighing in on this, and that it’s a choice that patients can ethically make,” he explains.

While developing a policy on the practice is time-consuming, it allows ethicists to carefully consider all of the issues involved. “This is good meaty stuff for ethics committees,” says Quill. “It’s a good thing for them to think through in advance of a real case.” With a policy in place, clinicians would likely feel more ethically grounded in offering the option of stopping food and drink.

“For example, when we are talking about taking somebody off life support, or giving somebody a lot of medicine to manage terminal shortness of breath, we almost always put our policy on ventilator withdrawal on the top of the chart,” says Quill. If a team member expresses concerns about the ethics of withdrawing life support, the clinician and the ethicist can point to the policy.

A policy with a strong informed consent process, and support of hospital administrators, is important. “If somebody calls the newspaper and says you are starving people to death in your palliative care unit, you don’t want the ethics committee thinking this through the first time in the middle of a controversy,” says Quill.

REFERENCE

  1. Goligher EC, Ely EW, Sulmasy DP, et al. Physician-assisted suicide and euthanasia in the ICU: A dialogue on core ethical issues. Crit Care Med 2017; 45(2):149-155.

SOURCES

  • Ewan C. Goligher, MD, PhD, Intensivist, Mount Sinai Hospital, Interdepartmental Division of Critical Care Medicine, University of Toronto, Ontario, Canada. Phone: (416) 586-8449. Email: ewan.goligher@mail.utoronto.ca.
  • Daniel P. Sulmasy, MD, PhD, MACP, André Hellegers Professor of Biomedical Ethics, Edmund D. Pellegrino Center for Clinical Bioethics, Georgetown University Medical Center, Washington, DC. Phone: (202) 687-1122. Fax: (202) 687-8955. Email: sulmasyd@georgetown.edu.
  • Timothy E. Quill, MD, Professor of Medicine, Psychiatry and Medical Humanities, Center for Ethics, Humanities and Palliative Care, University of Rochester (NY) School of Medicine. Phone: (585) 273-1154. Fax: (585) 275-7403. Email: timothy_quill@urmc.rochester.edu.