Nonmaleficence Vs Beneficence: Ethical Principles On Physician Assisted Death

As the “baby boomer” Americans start reaching retirement age, the older adult hospital population is rising, and it is important for people with chronic diseases to have advanced directives for end-of-life care. In fact, only about 26.3% of U.S. adults have an advanced directive for end-of-life preferences. These documents can ensure that patient’s decisions are respected in the event of a serious illness. Medical professionals base their work ethics on respecting the moral principles of autonomy, nonmaleficence, beneficence, and justice for each patient. But when patient wishes run against moral ethics, there can be difficulty in determining right from wrong without legal documentation. “The ethical principle of autonomy is respect for an individual’s right to self-determination”. 

We see this in hospitals when a competent patient refuses medical treatment, regardless of the health outcome. This may be due to religious beliefs or personal preference, but it is important for the patient to have those rights respected. So why then is it legal to deny patients their autonomy when dying? “Denying an individual’s access to relief in suffering can be viewed as a fundamental disrespect for one’s autonomy”. The negative outcome to denying a patient’s right to die can be a painful, undignified, and a costly death. Even after the patient’s death, the traumatic experience and expenses can be left behind to living family members. A patient’s right to die is a very controversial issue that covers delicate subjects involving ethics, religion, medicine, and the law. The case of Terri Schiavo brought to light the reality of everyday American patients facing this medical-ethical issue of prolonging death through medical interventions. Her medical intervention was something as simple as a Percutaneous Endoscopic Gastrostomy (PEG) tube, which provided artificial nutrition and hydration. 

The conflict came about when her husband’s wishes, against her parent’s wishes, were to remove the PEG tube and not sustaining her life any further. The “Christian Right” was the moving force behind the political aspects of the Shiavo case. They argued that by pulling the plug, removing the feeding tube and letting the patient die, was a form of euthanasia. “The ethical principle of nonmaleficence is preventing harm or ‘a norm of avoiding the causation of harm’”. Physician assisted death can be seen as inflicting harm in the form of death, under the principle of nonmaleficence. However, if a person freely authorizes and requests aid-in-dying without pain and suffering, then that can be considered neither harming nor wrong doing. This can be seen as a compassionate thing to do for a patient suffering through treatment without relief. In the Terri Shiavo case, she was not assumed to be suffering or under any pain, prior to feeding tube removal. It is my opinion that maleficence or harm was done when the court ordered her feeding tube to be removed. She lasted 13 days through starvation and dehydration, and that in my opinion, acted against the ethical principle of nonmaleficence. “The ethical principle of beneficence is doing the most good”. 

Physician assisted death can be viewed as a compassionate act in ending the suffering of a patient. At the same time, others may believe that these acts can be a form of abandonment to the patient and not beneficent. In the case of Terri Shiavo, it is my belief that she was abandoned without palliative care. In this case, the patient was breathing on her own and was starved for 13 days before death. Any healthy person might starve to death in the same situation. I feel that the court order was immoral and of no beneficence to the patient in the way they let her die by starvation and dehydration. “The ethical principle of justice is about fair treatment” to the patient. 

Allowing patients to refuse treatment can help them die faster, but not all situations are the same. For some patients, their death may be quicker without treatment, while others can be longer and more painful. Dying through physician assisted death may be seen as justice to the patient in helping them die without suffering. But how is this fair for those that cannot afford to seek physicians for aid-in-death? Where is the justice for those economically disadvantaged? In conclusion, I am not completely against the idea of physician assisted death, so long as the patient has complete autonomy in deciding his/her end-of-life care. I also don’t believe that physician assisted death is for everyone and anyone, as only specific end-of-life scenarios should be warranted. I believe that physician assisted death has the potential for abuse, so laws would need to be in order to control the use. I do believe that patients should die with their dignity when there are no other medical alternatives in relieving their suffering of a terminal illness. However, in the case of Terri Shiavo, I do not believe that dying by starvation and dehydration was the best way for her to die with her dignity. Every patient situation will be different, and every patient has different end-of-life expectations. Fast-forwarding our thoughts to our end-of-life care is not something that comes naturally for most people. But it is important and should be highly recommended/educated to patients in having living wills or advanced directives in place with specific request for end-of-life care, especially in our older population.