The Right To Die (Part 2) – by Dr. Richard B. Fife

As someone who has developed and trained hospice ethics committees since 1991, I have always stressed that ethics committees should use a principle-based approach. That is, they should look at the situation in light of well-established ethical principles. These principles are generally recognized as beneficence, nonmaleficence, autonomy, justice and fidelity. The principles of beneficence and nonmaleficence are not the same, but they do share much common ground. Beneficence speaks to what is of most benefit to the patient while nonmaleficence usually means “do no harm.” For decades, these were the dominant principles; and, most decisions were made by the physician or institution. However, the Karen Ann Quinlan case would help establish autonomy as the dominant ethical principle over the next several decades. That importance would be highlighted in the tragic case of Nancy Cruzan in Missouri in the mid-1980’s. Nancy Cruzan was a 23-year-old woman who was involved in a single car accident. She was left in a persistent vegetative state. After her parents accepted that she would never regain consciousness, they asked the court to allow the removal of life-support equipment, including artificial nutrition and hydration. However, as Nancy had never completed an advance directive, both the hospital and the court were reluctant to allow a discontinuation of life support. It was a reluctance that would keep Nancy in a suspended state of consciousness for years. Hers would be the first patient rights and right-to-die case that would make it all the way to the Supreme Court. The only question that was put before the Supreme Court was “Can the state of Missouri require clear and convincing evidence of Nancy’s own wishes in deciding whether to grant permission to Nancy’s parents.” In 1990. The Supreme Court ruled in favor of Nancy’s parents; from that landmark case, would emerge the federal Patient Self-Determination Act, which became effective on December 1, 1991. This Act would go a long way to somewhat ensure informed consent and the dominance of authority as guiding principles.
As autonomy was often viewed as the prime ethical principle in medical ethics, it would point the way for those who would advocate physician-assisted suicide. For many, the right to die is seen as the extrapolation of the principle of autonomy – one should be able to choose the moment and means of one’s death. In the last part of the 1990’s several cases would underline this point, including the well-publicized case of Terri Schiavo in the state of Florida. Medical ethics are never static but continue to evolve. Each new case – Quinlan, Cruzan, Schiavo – has stretched our understanding of end of life ethics. Perhaps there is also a more communal ethos – what will the decision mean to others surviving the death? – that may challenge the primacy of autonomy even as it remains a key ethical principle. Because of the strong moral traditions of hospice and respect for life, end-of-life ethics will always be a concern. The founder of modern hospice, Dame Cicely Saunders, taught that dying is a natural process that is neither to be hastened nor delayed. If not hope for a cure, hospice can offer hope for something else – hope for the suffering to be controlled; hope for emotional support; hope for resolving some family relations; hope for relieving feelings of guilt; hope for the quality of life to be improved and measured.
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