The end of life is not an easy period in the time of person’s existence. Getting prepared to deceasing, one wants to get the things done. It seems that older people who die because of their age accept the fact that they will not be in this world any longer in an easier way than those who die because of incurable condition. Those patients that decease in suffering are in the most difficult situations as they often cannot reduce pain with the help of drugs due to the fact that they develop resistance to them. Having a desire to stop their death throes, they often tend to ask for assisted suicide in order to pass away with dignity.
Death with dignity is the issue that continues to raise many debates. No one denies that the fact that a person has a right to meet the end of his/her life with dignity. However, not all people approve the very concept of death with dignity because of its meaning and actions implied. Despite disagreements, it is important to state that a dying person has the right to choose how to act. If one decides to stop suffering since positive health changes cannot be expected, he or she should not be forbidden to make their last minute decision and pass away in peace.
The Meaning of Dignity
When the end of life approaches, a patient with terminal disease usually tends to value every second to fully enjoy one’s last minutes in this world. One can hardly assume that a person who dies without suffering will have a desire to terminate his or her life straight away before suffering begins. There are some cases, of course, when people commit suicide when they find out the diagnosis, but these cases are not rather often and can be explained with one’s fear to even approach the moment when either physical or mental suffering begins. Escape from torment, helplessness, loneliness, and physical pain or just the situation when you are not allowed to enjoy life fully can be regarded as death with dignity.
Despite the overall approach to dignity, this concept raises many debates since it is often interpreted in a different way. Many scientists regard asking for death with dignity as a request for euthanasia or assisted suicide (Schroeder, 2008, p. 230). It is evident that if a person dying from incurable condition, knows that he/she will be in pain, have mental deviations, and see his/her relatives suffering because of the patient’s suffering or worse experiencing everything that happens in loneliness without any support, he/she wants to avoid such future. Having his or her life terminated when the hardest moment comes, a dying patient spares him/her from physical pain, his/her nearest and dearest from witnessing his/her death, and doctors from unnecessary use of life-supporting medications and interventions.
Evaluating the case of a patient with incurable form of cancer, Coulehan (2005, p. 339) describes dignity from a different perspective. In the patient’s opinion, death with dignity meant remaining active until her organism functioned, spending time with relatives, solving some issues, and enjoying “the blessings each day might hold” (Coulehan, 2005, p. 339). The problem is that physicians supported her desire, but tried to convince her that she should have tried all possible interventions in order to stay alive. Even if a patient made a decision to refuse from treatment that could not have helped, the healthcare professionals did not accept her position and insisting on medical interventions which killed her faster without any respect for her decision. At this point, disputes about dignity began.
First, the doctors knew about their helplessness in fighting the disease. Second, they were informed about the patient’s decision. Third, instead of suggesting her hospice or some sort of psychological therapy to support her mental state during the difficult stage in her life, the oncologists insisted on measures that had finally debilitated the patient’s health. Therefore, being able to support patient’s decision, healthcare providers neglected the woman’s right to die with dignity, which, in this situation, did not include adherence to euthanasia or assisted suicide.
Schroeder (2008, p. 230) reports about two contradicting definitions of dignity. The author states: “This sense of the . . . dignity of all human life has been influential in maintaining traditional western prohibitions against abortion, suicide, euthanasia, and hazardous medical experimentation on human subjects” (as cited in Schroeder, 2008, p. 231). In addition to that, Schroeder (2008, p. 231) indicates that organizations defending the right to die with dignity state that dignity is ensured if a person is given a chance to choose the option which, in his or her opinion, will be the most appropriate for him or her without violation of dignity. Therefore, assisted suicide and euthanasia can be justified as they deprive people of suffering and making their families feel their pain as well.
Chochinov (2006, p. 92) indicates that dignity can be defined as “deserving honor, respect, or esteem”. Moreover, it is also “an overarching value or goal, which shapes the delivery of service to dying patients and their families” (Chochinov, 2006, p. 92). If a person suffering from terminal illness considers that someone’s care without the ability to give something in reward, is a sort of burden on relatives or friends, and the feeling of absolute helplessness are the conditions that contradict his or her dignity, he or she should have the right to avoid them or, at least, shorten the period when dignity will be violated. Patients with incurable diseases might be depressed at the end of their lives and, therefore, have suicidal or any other death-related thoughts. If the depression cannot be overcome, or if someone is not depressed, but wishes to shorten the period of physical suffering, people providing care to such patients should understand their needs and ensure that they do not lose their esteem and respect.
Currently Existent Interventions and Moral Issues Involved
There are different methods of providing end-of-life care to the terminally ill patients. The most radical and caring patients adhere to death with dignity. Sparing doctors from the wasting time or medications and relatives from witnessing the patient’s suffering, and him/herself from both physical and emotional pain, a dying person decides to end his/her life. In order to help these people, some states in the USA legalized euthanasia and assisted suicide (Schroeder, 2008, p. 230). By these means, a person dies without suffering. Since that is the decision that the patient makes on his/her own, the respect for dignity and will of the person is ensured.
However, the opponents of this approach state that deliberate shortening of one’s life even under the request of a dying person is morally wrong (Schroeder, 2008, p. 230). Still, the opponents of death-with-dignity approach do not take into account the fact that prolonging one’s suffering for the sake of preserving life is immoral and disrespectful for the person in pain. Moreover, if one can help a person reduce the pain but deliberately refuses to do it, he or she acts immorally to a certain extent.
Another end-of-life method applied to dying patients is supporting their life in intensive-care units (ICU). Hamric and Blackhall (2007, p. 422) state that an intensive-care unit is a place where patients “receive the most technologically sophisticated care that medicine can offer”. Doctors usually place suffering patients in ICU in order to support their lives. Since healthcare providers cannot know whether the patient will survive during the treatment in ICU, they often adhere to aggressive futile treatment (Hamric & Blackhall, 2007, p. 422).
For this reason, patients with extremely serious forms of cancer have to undergo chemotherapy despite the fact that doctors do not give any positive prognosis. It is stated that healthcare professionals working with patients in intensive-care units, especially dying ones, need to provide proper communication for terminally ill people to reduce pain, anxiety, and support patients’ relatives and friends (Hamric & Blackhall, 2007, p. 422).
In spite of all these recommendations, the reality is that quality of end-of-life care did not improve from the perspective of patient’s dignity. Healthcare providers continue using aggressive treatment, including chemotherapy and surgeries in cancer patients, without thinking of the feelings of people they try to cure. There are situations when a person does not want to receive any sort of medical care in order to enjoy his or her life without added suffering from treatment interventions, like side effects of the surgery or chemotherapy. Most of the interventions used in intensive-care units are life-sustaining, so they do not ameliorate patients’ health, but prolong their suffering (Sprung et al., 2003, p. 790). Even if the situation in the United States has been amended in recent years, many physicians still prefer maintaining life of the patient, even though this life has poor quality (Sprung et al., 2003, p. 790).
Under such conditions, patients and their families are not the only parties suffering. Healthcare professionals (nurses in particular as they are the first people to provide care for patients in ICUs) can be dissatisfied as well, because they do not feel that treatment options are what the dying person really needs (Hamric & Blackhall, 2007, p. 423). They often have to face ethical dilemmas because many terminally ill people ask for mercy killing or assisted suicide in order to quit sufferring. If nurses believe that they will do the right thing assisting in patient’s death and in such a way stopping their suffering, they have to break the law since in many states assisted suicide and euthanasia are forbidden and violate the nurses’ Code of Ethics, which prohibits doing any sort of harm to the patient (as cited in ANA Center for Ethics and Human Rights, 2013, p. 7). For this reason, they cannot help a terminally ill person to die even if he or she is suffering. Therefore, if death with dignity is not ensured, both patients and nurses providing care, suffer.
Another type of care that is offered to people with incurable disorder is the palliative care. Chochinov (2006, p. 92) states that palliative care is aimed at honoring and protecting dying people so that they do not feel they lose their dignity. Although palliative care tries to ensure medical, personal, and social dignity of a patient, the truth is that the interventions remain the same, while such options as assisted suicide and euthanasia are not allowed. This type of care for dying patients is provided in hospices, where specially trained health-care professionals work with people that are dying of some terminal disease.
The best approach that can be chosen by patients, their families, and physicians, is to combine all existing interventions. If a patient chooses to refuse from treatment, he or she should not be convinced to undergo aggressive treatment if it cannot prolong life. If a terminally ill patient wants to die before his/her death comes, he/she should be allowed to do that.
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Euthanasia is closely related to the issue of dying with dignity as it is regarded as one of the means to help a person decease in peace. The term ‘euthanasia’ typically refers to a set of procedures aimed at putting to death a person suffering from constant intense pain related to incurable disease (ANA Center for Ethics and Human Rights, 2013, p. 4). Nursing evidence based practice distinguishes between the three types of euthanasia, namely, voluntary, which occurs when a patient consents to the procedure, involuntary, which occurs when a patient rejects ‘mercy killing’, and non-voluntary, which occurs when a patient is unable to grant the permission to be euthanized (ANA Center for Ethics and Human Rights, 2013, p. 4).
Euthanasia contradicts the medical code of ethics – a code of conduct for doctors – for it is considered ethically intolerable. While the nurse’s duty is to guarantee a compassionate treatment and ethically justified care to the patient, including the promotion of comfort, the alleviation of suffering, adequate pain control, and foregoing life-sustaining treatments, each of the aforementioned aspects contradicts the patient’s right to self-determination (ANA Center for Ethics and Human Rights, 2013, p. 4).
Apparently, the contradiction merely lies in a patient’s request for death that nurses cannot comply with in terms of the code of their professional ethics. Therefore, the problem of euthanasia transcends the limits of both professional ethics and the patient’s right to self-determination, as at the point when a final decision should be made euthanasia correlates with the human perception of life. In many states of the USA and many countries all over the world, euthanasia is not legalized. However, there are situations, in which healthcare providers need to adhere to ‘mercy killing’ in order to ensure that the patient’s dignity is preserved.
Assisted suicide can be regarded as another method used along with euthanasia to stop a person’s suffering. The fundamental difference between euthanasia and assisted suicide is that in case of assisted suicide a medical specialist is not viewed as a “direct agent of death” (ANA Center for Ethics and Human Rights, 2013, p. 3), but as a person who helps a patient that wants to die, providing him or her with means for killing him/herself. The reasons to ask for assisted suicide should be studied thoroughly.
In this regard, communication between a physician or a nurse and a patient can help overcome isolation and depression related to medical assessment and treatment given, and, probably, changes the decision to die (ANA Center for Ethics and Human Rights, 2013, p. 3). Therefore, assisted suicide is one of the methods to preserve dignity of a dying person as it can stop the person’s suffering, help to avoid unnecessary aggressive treatment, keep the patient’s friends and family from witnessing the death throes, allow a person to die without making others take care of him in case he/she cannot move.
Oregon’s Death with Dignity Act
Although in the United States of America the law concerning death with dignity has not been enforced on the federal level, some of 50 states evaluate the issue. Oregon was the first state to uphold Death with Dignity Act in 1997 (Oregon Public Health Division, 2014, p. 1). Addressing the problem of suffering and preserving dignity, the Oregon Public Health Division decided to legalize euthanasia and assisted suicide. Thus, people older than 18 diagnosed with some terminal disease not earlier than within the last six months are allowed to use prescribed lethal doses of medications (Oregon Public Health Division, n.d., p. 1).
In addition to the registration and age requirements, the person who wants to terminate his or her life in order to preserve dignity when dying needs to have other characteristics. Thus, this person should be considered as mentally healthy. Moreover, the patient should be fully aware of the procedure, possible outcomes and potential risks. There should be a professional consulting healthcare provider in order to assess mental state of the patient, inform him/her about the related issue, obtain one’s consent, and prescribe medication. Oregon Death with Dignity Act allows assisted suicide and voluntary euthanasia as interventions used to comply the patient’s request to die. A terminally ill patient can get assistance in death only if this person expresses the desire. Therefore, involuntary and non-voluntary euthanasia cannot be performed under this act.
Oregon Death with Dignity Act is a controversial law that was enforced as an experiment rather than a strong regulation. Since the act regulates the issue of life and death, it causes many debates. The first and the strongest objections come from faith-based opponents of euthanasia and assisted suicide (Sandeen, 2013, p. 1). Christianity forbids killing anyone since only God can decide what person comes to this world, when he or she will come, what happens to this person and when the time for physical death comes. Other opponents of the act were American Medical Association and the groups that support people with disabilities (Sandeen, 2013, p. 1).
They objected to the legalization of assisted suicide and voluntary euthanasia as they considered the act as dangerous for vulnerable individuals (disabled and impoverished people, and people of different racial belonging). Another objection from AMA and defenders of people with disabilities was the violation of physicians’ Code of Ethics for no healthcare provider can kill a patient or provide him/her with a possibility to commit suicide. Sandeen (2013, p. 1) states that when people were asked whether they support the act, more people supported the law in 2011 than in 1994 before it was initiated. Clearly, the citizens see the value of the act and consider it helpful to preserve a dying patient’s dignity.
Many terminally ill patients, their families and caretakers face the problem of death and dignity during their last months of life. As a rule, people with incurable conditions suffer from pain a lot as the dose of pain-relieving drugs they receive cannot be exceeded, and, therefore, they develop drug resistance. Another problem, dying people face, is psychological, but it stems from their physical state. Being unable to take care of themselves, patients feel that they will not be able to reward people that help them live to death. Moreover, they do not want their friends and relatives to see them changing and suffering. For this reason, terminally ill patients strive for dying with dignity.
Dignity, in this case, can be provided by different means. For some patients, it is refusal from treatment, if they know they cannot recover from their condition. This decision helps them to live longer in cases, when the aggressive treatment would kill them faster and reduce the quality of their lives. Moreover, without serious interventions such as surgery or connection to life-sustaining mechanisms, they can travel, stay at home, and spend much time with close people. For this reason, people want to preserve their dignity when dying.
The majority of scientists view dignity as honor, respect, and esteem. Death with dignity is regarded as the possibility to make one’s decision concerning the way of life before death as well as the right for diminished suffering. For this reason, death with dignity also means the chance to die whenever a terminally ill patient wants. That is why they have the right for assisted suicide or voluntary euthanasia. There are many opponents of this idea, and, therefore, only a few states, starting from Oregon, enforced the laws that could allow patients to terminate their lives before natural death. The right of person to spend last days or months of their lives and avoid suffering should be ensured as these aspects guarantee preservation of their dignity. For this reason, it is recommended to combine all possible measures (end-of-life care, assisted suicide, refusal from treatment), so that the patient could die with dignity.