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					Maria Behrens
Bioethics 10:50-12:05
        In Michael B. Gills article, “Is the Legalization of Physician-Assisted Suicide

Compatible with Good End-of-Life Care?” he refutes six of the most argued claims concerning

how physician-assisted suicide is unjustifiable while giving good end-of-life care. In the

subsequent essay, I will analyze one of these six claims in favor of physician-assisted suicide

(PAS). I will argue how killing, or assisting in the death of a patient, is sometimes the proper

end-of-life care needed; and under outstanding circumstances, should be morally permissible for

health providers to perform.

       The claim I will be examining is, “Will Better End-of-Life Care Eliminate Requests for

PAS?” Gill states that there are a number of people against PAS who believe that if an extremely

ill patient were to receive optimal end-of-life care, it would exponentially decrease their interest

in wanting to die. This “better care” would give the patient the desire and perseverance to

continue living until death was imminent and eventually overcame the physical body. Gill

presented a number of quotes depicting that if more compassion, care, and alleviation of

suffering occurred, there would be fewer people wishing to hasten death. Daniel Lee said, “If we

were to do a better job of responding to suffering individuals in a loving, caring manner, [PAS]

would in all likelihood be an option rarely, if ever, chosen” (Gill, 28). Proponents of this

ideology view “succumbing” to PAS as a defeat to our health care system-a failure to present an

alternative response to the request of death from an ailing patient. Another similar view explored

was:

                …there is no suffering that cannot be relieved or removed if patients have the

                opportunity for expert clinical support and care by trained staff. Our efforts


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               should be raising the levels of skill among the healthcare team to relieve

               suffering, not getting rid of the problem by assisting in the elimination of the

               patient (Robinson, Gill, 28).

       If this were a solid claim, terminally ill patients receiving superior end-of-life care would

rarely, if ever, request PAS. However, Gill conveys that there have been a number of studies

performed on populations receiving high quality end-of-life care, which have consistently shown

that large numbers of patients are requesting PAS, stating they would like to accelerate death. In

various studies performed, it was found that even with good end-of-life care, somewhere

between 12% and 20% of the population sample have requested [a desire] to accelerate the

process of death, and have inquired about PAS. A study of 140 AIDS patients who were

receiving quality care from their health practitioners, and attended by a compassionate,

accommodating staff of caregivers found that, regardless of these attentive services provided,

“12.1% used medications to hasten death” (Gill, 28). In 2000, a separate study of 92 patients

living with stage IV cancer at a New Jersey hospital found that 17% possessed a strong desire to

receive PAS. Yet another year 2000 study involving 70 participants found that 12% of people

would have asked for PAS to be performed if the option were made legal (Ibid). In the

Netherlands where PAS/euthanasia is legal a study of almost 300 patients was performed and

found that 20% of patients died due to PAS or euthanasia. These patients were receiving the

same quality end-of-life care from hospice and trained home health aides (Gill, 28). Gill points

out that there are still a substantial number of people receiving proper care who still wish to

hasten death, and would readily request PAS if it were deemed legal in the states.

       Gill does not dispute the fact that having better end-of-life care will cause less people to

request the termination of life, because in all likelihood, it will save lives. Rather, he is showing


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that even among terminally ill individuals receiving this high quality care, there are still a

substantial number of patients requesting PAS and wishing their lives would come to an end. He

argues the potential for ‘good end-of-life care’ to save the lives of individuals seeking PAS is

reason enough for such care to be available to all terminally-ill patients; because, “…it is

uncontroversially regrettable if a person commits suicide but would not have done so if her end-

of-life care had been better” (Gill, 29). If people are obtaining mediocre end-of-life care, PAS

should not be granted to them on request. Gill argues that the legalization of PAS should only be

considered in areas where proper end-of-life care is prevalent. This still does not negate the fact

that there are a large number of people who are receiving proper end-of-life care and still possess

reasons for wanting to accelerate the death process (Gill, 29).

       For the purposes of this essay, the acts of commission- directly “killing” a patient (if

requested), and omission- “allowing a patient to die,” (if requested), both fall under the umbrella

of PAS. [I want to make it clear that] Gill makes no distinction between these acts of commission

and omission with respect to the performance of PAS for better end-of-life care. According to

Gill, omission and commission are both directly causing death because they are honoring the

terminally ill person’s requests and the subsequent intention of PAS is known. It can be argued

that omission is indirectly killing the person because no person is “formally or finally causing the

death” (Bishop, 222) but, the lack of medical intervention and knowing that without it the person

will die is viewed as a direct causal factor in the process of death (Ibid).

       Gill’s conclusive claim that better end-of-life care will not eliminate all of the requests

for PAS is true. He construes the argument showing that though better end-of-life care may

indeed save lives, it does not mitigate the core reasons people would prefer to die rather than to

live with a terminal illness. He backs up this claim with statistical evidence from various studies


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illustrating the interest that a significant percentage of people still have in PAS, while

concurrently being treated with superior care. If a person is at the end (whether being in months,

weeks, or days) of her life and would prefer to die immediately she has the choice to. Rather than

waiting for the systemic failure of organs and loss of most, or all, bodily functions to occur, the

possible pain and suffering to prolong and progress itself, the gradual reduction in mental

capacities, and the incessant depletion of hope for a quick and painless death to ensue, the

individual possess the right to leave this world when they would like, in any way pleased. The

request for PAS should be granted by the patient’s palliative health care provider with no

justification needed other than the obvious; though, the individual must be terminally ill and be

“knocking at death’s door” for the action to transpire.

        A suicidal teen would not fit the ‘PAS-qualification criteria’, but an individual suffering

from a terminal illness like stage IV cancer, full-blown AIDS, heart failure, pulmonary fibrosis,

or a similar lethal illness would qualify under these criteria. The above conditions have no

known cure- only treatments that attempt to slow the progression of the illness and hopefully

relieve, or manage, some of the signs and symptoms the individual is experiencing. The patient

would have to be past the point of treatment and previously exhausted, or have been no longer

responsive to medical intervention. Once all of the measures to try and cure the patient suffering

from the illness fail, quality end-of-life care (if resources available) is given to the patient.

        Quality end-of-life care relates to the services that Hospice care offers and other home-

health aides, as well as the compassion family and friends provide to the dying patient.

According to the National Institute of Health, Hospice and caregivers treat the patient to

maintain comfort, provide emotional and spiritual support, peace, and a positive outlook during

their final days of life. Comfort is maintained primarily through the use of medicine to relieve


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pain and other typical symptoms, such as nausea, dyspnea, and constipation (NIH: “End-of-Life

Care…”).

       After these “preliminary death stages” occur, the patient eventually succumbs to the

worsening illness and often spends her last few days sedated and connected to a plethora of

machines in the ICU of a hospital. Better end-of-life care should in no way entail a patient dying

in a drug-induced semi-conscious state. If a patient were to have received the PAS she requested

or expressed a desire for, she would not be in such a medicinal-trance state, waiting for her heart

to beat for the last time and the life-support machine to be switched off. During the final days of

life, many patients would undoubtedly prefer to be in the comfort of their own homes surrounded

by nostalgic memories flooding the walls and where meaningful moments transpired. These are

all events which typically define the patient’s life and provide a sense of comfort for her. The

distinct sights, smells, and overall aura of an individual’s accomplishments, struggles, joys, and

defining moments prevail in her home. A patient staying in a hospital during her last few days is

stripped of this “companionship” that a home has provided for them. A patient is moved from

this recognizable, usually enjoyable environment, to a bleak hospital room with unfamiliar, and

often unpleasant smells, harsh sounds, and an overall depressing atmosphere. Lengthy

hospitalizations over the course of terminal illnesses are known to be extremely common, with

most individuals suffering from terminal illnesses spending their last days in one.

       Individuals that had desired PAS after receiving good end-of-life care from caregivers are

typically brought into the ICU for their final days of life. These individuals often die in the ICU,

or other wing of the hospital, frequently on heavy pain medications and relaxers which cause a

highly sedative state (Smith, 2006). When patients are in a sedative state, they are not cognitively

coherent, nor are they actively realizing any events that are transpiring—they are simply lying in


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a bed waiting to die. While in this soporific state, patients are unable to interact meaningfully

with their loved ones, so the families are merely watching them wither away. If a patient were to

receive PAS earlier on in her sickness, she may be able to die dignifiedly in her own home. If a

patient were to die in her own home, she would be able to have as many people as she wished

surrounding her. She would also be able to smile and communicate with loved ones until death

were to commence (usually quickly), and she would still be somewhat cognitively coherent

(since the illness would not yet cause a debilitating state). The sounds of PAS are much more

appealing than the ones of being forced into a hospital room where providers are calculating

every minuscule change in vitals, until life-sustaining organs cease to function. It is no wonder

why patients request PAS even with good end-of-life care.

        For hospital services that were not requested by the patient, it is morally impermissible

to force the already ailing patient into such further distress and prolongation of life, often times

just so doctors can feel like medical heroes and say, “We did everything we could.” [That is

everything except listening to and respecting the patient’s dying wish for PAS to relieve their

suffering!]. These final end-of-life services are seen as being the kinds of treatment “champion

[providers] of end-of-life care” boast about (Gill, 40). The services a hospital offers are

admirable and the doctors that work in them save and sustain lives through quality end-of-life

care; however, if a patient specifically requests PAS and it is not granted, the actions of the

hospital are seen to her as disrespectful, and as a ‘maintenance of her misery.’ Additionally, the

final days of life are in no way cheap- typically estimating to over $10,000 worth of care each

day (Dasta, McLaughlin)! There is absolutely no need to sustain a life which possesses no desire

to be sustained after receiving quality care. It is also irresponsible for the money to be spent on

an individual who has decided she no longer wishes to live in the medical state she is in.


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       Gill’s argument does have a weakness to it. He stated, “…we should consider legalizing

PAS only in those places where good end-of-life care is available, as it is uncontroversially

regrettable for a person to commit suicide only because she is not receiving proper end-of-life

care” (Gill, 28). Though the base of Gill’s point is apparent, it weakens his argument and shows

a bias of performing PAS only to individuals with the resources available for obtaining good

end-of-life care. Keep in mind there are millions of Americans living without health insurance,

and obtaining good end-of-life care is not always an option; so, under Gill’s argument, the poorer

people without access to this superior end-of-life care would be the ones to suffer more and be

forced to die in an unpleasant state- regardless of whether or not they requested PAS. Gill is

effectively stating that a person unable to obtain good end-of-life care for whatever reason would

be ineligible to receive PAS, despite their level of suffering. To put Gill’s suggestion into a more

contextual form, consider the two following scenarios:

       Scenario one: Tom is an upper-class man suffering from stage IV cancer. He has been

receiving high-quality treatment throughout the course of the illness, but the cancer has finally

metastasized and is no longer responsive to curative treatment. Tom has been receiving optimal

end-of-life care but has decided he would like to die at home with his family and closest friends

around him, while still coherent and able to communicate. Tom does not want his loved ones to

see him hooked up to a bunch of life-sustaining machines in a highly sedative state, so he

requests PAS, and is ultimately granted his wish. Tom sets a date for the lethal injection, and

when it comes, passes peacefully in the comfort of his own home surrounded by his loved ones.

According to Gill’s proposal, the “optimal end-of-life care” Tom had been receiving was the sole

reason doctors allowed his request to be granted.




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       Scenario two: Ann is a poor woman who has been suffering from pulmonary fibrosis.

She has been receiving minimal treatment over the course of her illness, causing it to progress

quickly and become extremely detrimental to her health and overall sense of well-being; much

more so than if she were able to afford proper end-of-life care. Ann can no longer work and she

has no family but, she has made peace with dying and is looking forward to it because she will

no longer be suffering. Ann has no means of obtaining quality end-of-life care due to financial

restrictions, her immigrant status and rural location, but remains in constant agony from her

illness. She feels totally hopeless, and has no desire to go on, even if she were to receive “better

end-of-life care.” Ann can no longer take the suffering and finally requests PAS from the local

hospital. However, she is denied when the hospital sees that she has not yet received quality end-

of-life care, even though she does not have the means or family to do so. Ann is admitted into the

hospital where she is forced to “wait to die,” and continues to suffer, feeling desperate. Her

memory dwindles and she can no longer comprehend what the doctors are telling her. She is in a

complete sedative state and either bleakly stares at individuals passing by, or is unconscious.

When Ann eventually dies, she is hooked up to a life support machine in the ICU of a hospital

for six days; costing the hospital thousands of dollars. She passed away by herself, with no

meaningful memories or valuable keepsakes present from her home. If she had received PAS,

Ann would have been able to die with dignity in the comfort of her own home, rather than in a

medically-induced coma—oblivious to everyone and everything.

       In examining these two cases, it is clear that according to Gill’s argument, it would be the

poorer individual, Ann, who would not be able to receive PAS due to the lack of resources for

good end-of-life care available to her. The wealthier man, Tom, was granted PAS because he had

already received quality end-of-life care. In my opinion, a superior argument to Gill’s would be


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to allow PAS to be performed on all suffering, terminally-ill individuals who request the service.

This way, there would be no discrepancy in decision-making for allowing someone to receive

PAS—whether they were able to receive quality end-of-life care or not. If PAS were legalized to

include the poor and the rich, the young and the old, all would be able to die when they please

and choose the circumstances of their death.




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                                           References

Dasta, Joseph F., Trent P. McLaughlin, Samir H. Mody, and Catherine Tak Piech. "Daily Cost of
an Intensive Care Unit Day: The Contribution of Mechanical Ventilation*." Critical Care
Medicine 33.6 (2005): 1266-271. Print.

"End-of-Life Care: Questions and Answers - National Cancer Institute." Comprehensive Cancer
Information - National Cancer Institute. National Institutes of Health, 30 Oct. 2002. Web. 12
Apr. 2011. <http://www.cancer.gov/cancertopics/factsheet/Support/end-of-life-care>.

GILL, M. B. (2009). Is the Legalization of Physician-Assisted Suicide Compatible with Good
End-of-Life Care?. Journal of Applied Philosophy, 26(1), 27-45. doi:10.1111/j.1468-
5930.2009.00407.x. Retrieved March 30, 2011, from Research Library.

J P Bishop. (2006). Euthanasia, efficiency, and the historical distinction between killing a
patient and allowing a patient to die. Journal of Medical Ethics, 32(4), 220-224. Retrieved April
13, 2011, from Research Library. (Document ID: 1031951801).

Smith, Michael. "Multiple Organ Failure Main ICU Death Cause." Medpage Today. University
of Pennsylvania School of Medicine, 3 Nov. 2006. Web. 10 Apr. 2011.
<http://www.medpagetoday.com/HematologyOncology/OtherCancers/4436>.




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