ETHICAL DILEMMA DEBATE

Topic: A Nurses Role in

Assisted Suicide
NURS 362 - FALL 2015
Group Members: Elizabeth, Charleen, Tomi, Darren & Young-jin

Would you participate in

Assisted Suicide?

How can an ethical nurse, dedicated to

healing, participate in an act that purposely
ends a patients life?

Brittany Maynard, as promised, ends her life at 29

DX: Stage 4 Malignant Brain tumor Terminally ill

Goodbye to all my dear friends and family that I love. Today is the
day I have chosen to pass away with dignity in the face of my
terminal illness, this terrible brain cancer that has taken so much
from me but would have taken so much more.

SYNOPSIS OF THE ISSUE

the issue

The ethical dilemma of assisted suicide revolves around the

conflict between the patients right to autonomy and the
nurses ethical duty to the principles of beneficence and
nonmaleficence.

SYNOPSIS OF THE ISSUE

the issue (continued)
The American Nurses Association (ANA) believes that the nurse should not participate in
assisted suicide. Such an act is in violation of the Code for Nurses with Interpretive Statements
(Code for Nurses) and the ethical traditions of the profession.
Nurses, individually and collectively, have an obligation to provide comprehensive and
compassionate end-of-life care which includes the promotion of comfort and the relief of pain,
and at times, forgoing life-sustaining treatments

At times, it may be difficult to find a balance between the preservation of life and the
facilitation of a dignified death. Nurses need to recognize their own feelings (fear, anger, etc.)
and the effect these agonizing tensions may have on a nurse. They may consider intentionally
hastening a patient's death as a humane and compassionate response, yet the traditional
goals and values of the profession mitigate against it.

SYNOPSIS OF THE ISSUE

ethical principles violated with assisted suicide...

LEAST HARM

The profession of nursing is built upon the Hippocratic tradition "do no harm" and an ethic of moral
opposition to killing another human being.
The ethical framework of the profession as explained through the Code for Nurses explicitly prohibits
deliberately terminating the life of any human being.

BENEFICENCE

By "doing good" is it found in the practice of medicine where the health of an individual is bettered by
treatment from a physician or nurse.
This principle is also related to the principle of utility, which states that we should attempt generate the
largest ratio of good over evil possible in the world.

The theory of Utility supports what is best for most people. The value of the act is determined by its usefulness,
with the main emphasis on the outcome or consequences. This theory examines what creates the most
happiness for the most people.

ETHICAL ANALYSIS
ethical principles supporting assisted suicide

AUTONOMY/ADVOCACY

The principle of respect for a person and his/her decisions even though the
decisions may create risks to his/her health.
Patients have right to die or choose the methods of their death.

BENEFICENCE

The principle of promoting goodness, kindness, and charity.

Assisted suicide will help patients end suffering from excruciating pain and die with
dignity.

SYNOPSIS OF THE ISSUE

courses of action alternative to Assisted Suicide

Nurses can become active, aggressive patient advocates for better

palliative care even if the end result is a shorter life.

Careful assessment and optimal symptom control and supportive care, the suffering of most patients with lifethreatening illnesses could be reduced sufficiently to eliminate their desire for hastened death

Hospice, a philosophy of care that provides support for the patient

while allowing death with dignity.

assist with medications

Nurses must remain dedicated to caring for patients and dedicated to

promoting maximum health, even in the midst of a terminal illness.

SYNOPSIS OF THE ISSUE

courses of action supporting Assisted Suicide
There is a continuum of end-of-life choices that encompasses a broad spectrum of interventions that are
but are not limited to:
-alleviation of suffering
-adequate pain control
-do-not-resuscitate orders
-withdrawing/withholding artificially provided nutrition and hydration
-requests for assisted suicide

Throughout this continuum nurses can respond to patients with compassion, faithfulness and support.
Yet, nurses must understand the subtleties and distinctions of these issues in order to respond in a
reasonable and ethically permissible manner.

ETHICAL ANALYSIS
Other Complications

Pros

Cons

Reduction of health care costs

Familys financial & emotional incentive to

see patient to die

Family members better prepared for

accepting patients death

Potential creation of perverse incentives

for insurance providers

The save of vital organs. Patients wish

honored

Ambivalence in determining the duration of

life left and the level of suffering

ETHICAL ANALYSIS
Relevant Values
Christy ODonnell is a 46-year-old single mother from Santa Clara, CA. She was
diagnosed with a stage 4 lung cancer and have struggled with excruciating pain due
to her intolerance to morphine. Her fight for the right to die has been brought to
national attention since a lawsuit was filed in July 2015 in CA by Compassion and
Choice, a nonprofit aid-in-dying group, for her and two other terminally ill patients.
In her Youtube video, she stated, The most fear I have is that my daughter will find
me lying dead when she comes home.
This month, the Gov. in CA, Jerry Brown, signed the End of Life Option Act.
transforming Dr.-prescribed suicide into a medical treatment in CA.

ETHICAL ANALYSIS
Rights
Patient Self-Determination Act of 1990. Patients have the right to:

Participate in their own healthcare decisions

Accept or refuse medical treatment
Make advance health care directives

Self-Determination at End-of-Life, the right-to-die

Nurses serve as patient advocates and should respect the wishes of the patient
without bias

ETHICAL ANALYSIS
laws

PAS is legal in five U.S. states - mandated by state law in Oregon, Vermont,
Washington and California and by court ruling in Montana.
In Oregon, since the enactment in 1997, 895 patients have been assisted in dying as
of 2015.
California approved the bill in October, 2015.
Around the world, Netherlands, Germany, Switzerland, Belgium, & Japan legalized.
Hawaii almost enacted legalization of Assisted Suicide similar to Oregon in 2002.

Pt eligibility:

18 yrs or older
Capable of making and communicating health care decision for own and mentally competent
Must have a terminal illness as well as a prognosis of six months or less to live.

ETHICAL ANALYSIS
laws
Physician protocol:

If physician determines that the pts judgment is impaired, the pt must be referred
for a psychological examination.
The physician must inform the pt of alternative, including palliative care, hospice and
pain management options.

Pt request timeline:

First oral request to physician

15 day waiting period
Second oral request to physician
Written request to physician

Oregon Nurses Association assisted suicide guidelines

ETHICAL DECISION MAKING

process
According to Cherry & Jacob, theories provide a cognitive plan for considering
ethical issues; principles offer guiding truths on which to base the ethical decision.
ETHICAL DECISION MAKING MODEL
1.
2.
3.
4.

Identify the ethical issues and

problems.
Identify and analyze available
alternatives for action.
Select one alternative.
Justify the selection.

ETHICAL DECISION MAKING

1.

Identify the ethical issues and problems.

How can a nurse dedicated in healing, participate in an act that purposely ends a patients life? Should physician assisted suicide be
allowed?
2. Identify & analyze available alternatives for action.
-

(Questions to think about)

What are the possibilities for action, and how do the different affected parties (patient, family, MD, and nurse) want to resolve the
problem?
What ethical principles are needed for each alternative?
What is needed for each alternative, and what are their implications for future action?
Are there any additional ethical problems that the alternatives raise?

On one hand there is the patients rights to autonomy and on the other hand the nurses ethical duty to the principles of nonmaleficence (to do no harm)
and beneficence (doing good).
Found in the code of ethics for nurses from the ANA: nursing care is directed toward meeting the comprehensive needs of patients and their families
across the continuum of care. This is particularly vital in the care of patients and families at the end-of-life to prevent and relieve the cascade of
symptoms and suffering that are commonly associated with dying...Nurses may not act with the sole intent of ending a patients life even though such
action may be motivated by compassion, respect for patient autonomy and quality of life considerations

ETHICAL DECISION MAKING

3. Selective one alternative.
Together the decision makers and professions values for the care
of others to come up with a purposeful and reasoned decision.
-

According to ANA, there is palative sedation. The primary

intent of palliative and hospice care is to relieve or minimize
suffering through effective symptom management in order
to enhance the patients quality of life and support patients
and families in the dying process.

Palliative sedation is the controlled and monitored use of

non-opioid medications intended to lower the patients level
of consciousness to the extent necessary, for relief of
unendurable symptoms

ETHICAL DECISION MAKING

4. Justify the selection.
Here the rational justification for which the decision was based is shared to justify the decision made.
Questions to assess the pts request for dying:
1.
2.
3.

What reason does the patient give for the request?

Does the patient view suicide as the only option?
What is the social, cultural, and religious context?

These questions assist nurses in better understanding the meaning of these requests and help patients deal
with the emotional suffering that may accompany this burden.

ETHICAL DECISION MAKING

REFERENCES
American Nurses Association (2015). Short Definitions of Ethical Principles and Theories Familiar words, what do they mean? Retrieved from http:
//www.nursingworld.org/MainMenuCategories/EthicsStandards/Resources/Ethics-Definitions.pdf
American Nursing Association (2015). ANA Position Statement: Assisted Suicide. Retrieved from http://www.nursingworld.
org/mainmenucategories/ethicsstandards/ethics-position-statements/prtetsuic14456.html
American Public Health Association (2008). Patients rights to self-determination at the end of life. Retrieved from
https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/29/13/28/patients-rights-to-self-determination-atthe-end-of-life
Anderson, Ryan T. (2015). Always care, never kill: how physician-assisted suicide endangers the weak, corrupts medicine, compromises the family,
and violates human dignity and equality. Retrieved from http://report.heritage.org/bg3004
Cherry, B. (2014). Contemporary nursing: Issues, trends, & management (6th ed.). St. Louis, Mo.: Elsevier.
CNN. (2015). Physician-assisted suicide fast facts. Retrieved from www.cnn.com/2014/11/26/us/physician-assisted-suicide-fast-facts/
Death with Dignity National Center. (2015). Death with dignity around the U.S. Retrieved from www.deathwithdignity.org/advocates/national
Dyer, Dale E. (1999). Assisted Suicide. Retrieved from http://www.juns.nursing.arizona.edu/Dyer.htm

REFERENCES
Ersek, M. (2004). The continuing challenge of assisted death. Journal of Hospice and Palliative Nursing. Retreived from http://www.medscape.
com/viewarticle/468566_5
Euthanasia, Assisted Suicide, and Aid in Dying. (2013, April 24). Retrieved from http://www.nursingworld.
org/MainMenuCategories/EthicsStandards/Ethics-Position-Statements/Euthanasia-Assisted-Suicide-and-Aid-in-Dying.pdf
Lachman, Vicki. (March/April, 2010). Medsurg nursing. Physician-assisted suicide: Compassionate liberation or murder? Vol.19/No.2. Retrieved from www.
nursingworld.org/MaintainCategories/EthicsStandards/End-of-Life/Physician
Slosar, J. (2004, February). Ethical Decisions in Health Care. Retrieved from https://www.chausa.org/publications/health-progress/article/januaryfebruary-2004/ethical-decisions-in-health-care
Tucker, Kathryn (2014). Endoflife law and policy in hawaii aid in dying. Retrieved from https://www.compassionandchoices.org/userfiles/End-of-LifeLaw-and-Policy-in-Hawaii-Aid-in-Dying.pdf
University of Washington School of Medicine. (2013). Physician aid-in-dying. Retrieved from https://depts.washington.edu/bioethx/topics/pad.html