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Workplace Challenges

CLINICIAN-ASSISTED SUICIDE: Merciful Release or Unlawful Death?

SALLADAY, SUSAN A.

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Journal of Christian Nursing: October 2004 - Volume 21 - Issue 4 - p 14-17
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In Brief

Figure
Figure

Jack Ogden, a sixty-eight-year-old male, admitted with end-stage congestive heart failure and depression, B seems unusually cheerful today. A frequent patient on this unit, Jack lives alone and has no family. He has been reading the book Final Exit1 and confides to Ellen, his primary nurse, that he's planning to use techniques described in the book to bring about his own merciful release from suffering as soon as he's discharged from the hospital. He shares that the hospital chaplain has agreed to be present with him in his home to act as his advocate during his transition to heaven and invites Ellen to witness his release as well.

In June 1997 the United States Supreme Court determined that there is no constitutional right to die; however, many ethical questions still surround care at life's end. Although the Supreme Court voted unanimously to uphold state laws forbidding physician-assisted suicide, they did not preclude states from passing laws that might eventually establish a constitutional right to die. In fact, five of the nine justices indicated that they might support such a right in the future.2 The moral acceptability of euthanasia and clinician-assisted suicide continues to be hotly debated in health care literature, in the media, in legislative chambers and, for health care providers, through the personal concerns of patients.

Jack Ogden was not asking anyone to hasten his death. He intended to do it himself, but he was involving his nurse and chaplain by informing them of his intentions and inviting them to be present.

Many times discussions about this assumed right to die are not as straightforward as they seem. Often, those who support euthanasia and assisted suicide use subtle strategies to present their objectives in the most attractive way. Some use euphemisms to disguise, obscure or soften the issues. A euphemism is an inoffensive term or mild expression substituted for one that may offend or suggest something unpleasant. In discussions about euthanasia, the word kill is never used. Jack was not going to kill himself, he hoped for a merciful release from his suffering. He did not speak of dying, but of a transition to heaven.

The terms deliverance, merciful release, right to die, good death, rational suicide and others have been introduced into the everyday vocabulary of health care providers as euphemisms for the foreseeable possibility of killing patients or assisting them to kill themselves. Does the acceptance of these terms by clinicians soften the way to an acceptance of the action itself, just as the pro-choice position transformed a baby, infant or child into a product of conception? Are euphemisms allowing euthanasia and assisted suicide to become more justifiable options for health care providers and their patients?

Increasing numbers of people are asking for health care providers to assist in achieving their goal of a good healthJoyce Fontana

A strategy common to advertising is the identification of a need, the introduction of an idealized product and creation of a corresponding demand. For euthanasia and assisted suicide to become legally available through the health care system, they must first be socially acceptable. Increasing patient demand is one method of attempting to justify the acceptability of euthanasia in the health care system. Then, by invoking the health care provider's obligation to respect the patient's right of autonomy and self-determination, a seeming rationale is provided for clinician-assisted suicide.

In a recent article, Rational Suicide in the Terminally Ill, nurse educator Joyce Fontana states: “Patients in the American health care system today, perhaps influenced by the right-to-die movement, have begun to see a good death as a right. Increasing numbers of people are asking for health care providers to assist in achieving their goal of a good death.”3 Fontana affirms that there is conflicting philosophical thought surrounding this issue but goes on to argue that the real concern for health care providers should not be philosophical differences but the patient's right of self-determination.

She explains that suicide is not a new practice, illustrating her point by describing how in ancient Greece, the sick and elderly voluntarily ended their own lives. “Banquets were held regularly for the elderly and infirm of Greece in the first century B.C. where poison was ceremoniously consumed and participants celebrated their lives rather than suffering their deaths.”4 She further explains that voluntary suicide was sanctioned by society in ancient Rome; however, as Christianity became established, suicide was prohibited. “Saint Augustine and later Saint Thomas Aquinas held strong beliefs that suicide for any reason was wrong, and although it continued to be common in the Middle Ages, to Christians it remained a terrible sin.”5 She explains that the idea of a “good death” began to reemerge during the Renaissance and Enlightenment periods, resulting in greater acceptance of the practice. Although this trend extended into the 19th century with social philosophers emphasizing individual freedom, she concludes, “One cannot overestimate, however, the influence of the church in maintaining the sinful nature of suicide that kept it from being openly accepted as it was in ancient times.”6

Fontana seems to suggest that:

  • An ideal possibility for good death in the face of a terminal illness is rational suicide, a possibility which should be as socially acceptable today as it was in ancient times;
  • Patients have the right to have whatever they choose in today's health care system;
  • Christianity (e.g., the church) is a negative, controlling social force obstructing individual freedom, tolerance and patients' rights to choose;
  • The politically correct position in health care today, a system heavily supportive of the right of autonomy, should be to honor a patient's self-determination in choosing a good death.

Of course, someone might also argue along the same lines that slavery was widely accepted as good in ancient times and could be considered an economically beneficial option today if it weren't prohibited by Christian sentiment.

Fontana seems to join other euthanasia advocates who identify a target or a negative force against which those who are suffering must struggle to achieve a noble outcome. These proponents will often cast biblical values in a negative light, viewing them as restrictive, rigid and unsympathetic.

Fontana acknowledges that some ancient and modern philosophers did not address any inherent sanctity of life and rejected immortality. She notes that secular notions that supported the acceptance of suicide included individual freedom, autonomy, rational self-interest and pragmatism. Christianity began to change public opinion because Christian leaders, including Augustine and Thomas Aquinas who believed “suicide even in the name of mercy, was wrong because it violated a commandment and both life and suffering were God's will.”7

Although Fontana states that Thomas Aquinas “believed that only God, who created life, has the right to end it and humans have a duty to God to safeguard life,”8 this position does not appear to have compelling import or truth for her to seriously consider.

Fontana asserts that the right-to-die movement will gain momentum and that nurses will increasingly care for terminally ill patients who are considering suicide. She introduces the case of a woman with a terminal illness who decided to follow the instructions in the book Final Exit to end her life but in so doing, did not die but lapsed into a coma and was admitted to a hospital.

Some nurses, including Fontana, cared lovingly for the patient. Others questioned why she was in an acute care facility since she was not receiving acute care (the patient was eventually transported to a freestanding hospice). Fontana observes that some nurses held a “Christian position that (this patient) had committed a great sin and was going to hell. Such beliefs were clearly stated in our discussions and those who held that view held it strongly….The ethics committee agreed that nurses with these strong personal convictions should not participate in her care.”9 These three groups are presented as mutually exclusive and polarized in the article such that a caring nurse couldn't also question why the patient remained in an acute care setting, and a Christian nurse could not lovingly care for a patient who has beliefs that differ from her own.

Fontana urges nurses to adopt a position that is “grounded in philosophical and ethical principles articulated to secure patients' welfare—even if that means protecting their right to a self-determined death by rational suicide” rather than a position that “merely [italics added] indicates an opinion.”10 Is it true that if clinicians accept that patients have autonomy—the right of self-determination—they must accept a patient's right to die? Can clinicians respect their patients and honor their health care choices without acknowledging a right to die? It is essential to note that a particular patient may wish to die or even choose to die, but that wishes or choices, of themselves, do not constitute a right to die.

An understanding of the different ethical and philosophical positions used to justify or deny the morality of euthanasia and clinician-assisted suicide is essential for Christian nurses. Christian nurses need a clearer understanding of strategies that appeal to emotion, conscience and guilt, rather than logic per se. Although many actions could be taken, Table 1 provides a few possible actions a nurse could take in a situation like Jack Ogden's. Consider why you may believe some of these are morally right actions or why would you not choose some of these options. As Christians, we need to think through complex and difficult ethical situations to develop appropriate nursing interventions, as well as be able to share God's love and truth with non-Christian nurses and/or patients.

Table 1
Table 1:
POSSIBLE NURSING ACTIONS WHEN PATIENTS PLAN A FINAL EXIT

WHAT DOES THE BIBLE SAY ABOUT EUTHANASIA AND ASSISTED SUICIDE?

Whenever these issues are discussed, many Christians go immediately to God's Word to find chapter and verse they can site as proof of God's will, showing us what to believe and do.

The Evangelical Dictionary of Theology states that “the Bible does not speak clearly regarding suicide,” but the several cases of suicide mentioned in Scripture are “reported rather than given any moral evaluation.”1

Saul (1 Sam 31; 2 Sam 1:1–16) and Judas Iscariot (Mt 27:5) both committed suicide. Neither of these men was dying as the result of a terminal illness. The conditions surrounding their deaths were not expressive of painless, compassionate mercy killing. Their suicides were not assisted (Saul's armor bearer refused to kill him).

The Bible has a great deal, however, to say about illness. In Christian Counseling, psychologist Dr. Gary Collins remarks, “Often sickness is accompanied by feelings of anger, discouragement, loneliness, bitterness and confusion.”2 Collins notes that Jesus' concern for the sick is so important that “almost one-fifth of the Gospels is devoted to the topic of healing. The disciples were expected to carry on this healing ministry.”3

From his reading of Scripture, Collins draws four conclusions concerning the Bible's portrayal of sickness and responses to it. Central to the biblical message is:

  1. sickness is a part of life,
  2. a Christian response is to be one of care, compassion and healing,
  3. sickness, sin and faith are not necessarily related,
  4. sickness raises some difficult questions about suffering.

Although Christians should not attempt to proof-text Scripture for easy or overly simplistic answers to questions concerning what God requires as a compassionate response to suffering and dying, the Evangelical Dictionary of Theology concludes that both religious and non-religious principles suggest that active euthanasia is less than God's best.4

1 Walter A. Elwell, ed., Evangelical Dictionary of Theology (Grand Rapids, Mich.: Baker 1985): pp 377–78. 2 Gary R. Collins, Christian Counseling, A Comprehensive Guid. (Waco, Tex.: Word, 1980), pp 397–98. 3 Ibid. 4 Elwell, 378.

1 Derek Humphry, Final Exit (New York: Dell, 1991).
    2 David G. Savage, Los Angeles Times (Home Edition), June 27, 1997:A-1.
      3 Joyce Fontana, “Rational Suicide in the Terminally Ill,” Journal of Nursing Scholarship 34, no. 2 (2002): 147.
        4 Ibid.
          5 Ibid.
            6 Ibid.
              7 Ibid., 148.
                8 Ibid.
                  9 Ibid., 150.
                    10 Ibid.
                      Copyright © 2004 InterVarsity Christian Fellowship