Assisted Suicide and the Right to Die

History
Although the issues of assisted suicide and the right to die have made headlines for over 20 years, these ideas are not new. In the ancient civilization of Rome, suicide was not punishable if "it was caused by impatience of pain orsickness, or by weariness of life . . . lunacy, or fear of dishonor." Irrational suicide was punishable by the emperor's seizure of all of the victim's property, disinheriting the heirs. The Romans' philosophy was "To live nobly also means to die nobly and at the right time." By the mid-twentieth century,technological advances kept terminally ill and vegetative patients alive longer than ever before. These patients previously would have died quickly from an inability to eat and drink and other complications. But advances in medicalscience brought right to die issues into the lives of many dying patients and their families. Doctors, patients and families were forced to make decisions about when life should end.
An Ethical Dilemma
The 1975 case of Karen Ann Quinlan was publicized nationwide, illustrating the ethical dilemma that exists because of the use of modern medical equipmentsuch as mechanical respirators and feeding tubes. Quinlan had suffered a respiratory arrest, leaving her in a permanent vegetative state. Her family, in along legal battle, argued that their daughter would not want to be kept alive in this way, with no hope for recovery. The court eventually granted the Quinlans the right to remove Karen from life support. This case helped define this gray but growing area of ethical and legal controversy. Court cases, suchas the U.S. Supreme Court case of Cruzan v. Director, Missouri Departmentof Health (1990), have helped define policy on these issues. Society hasbecome more accepting of policies that honor a terminally ill patient's request to withhold or withdraw medical interventions. However, the issue of assisted suicide, the act of hastening death, has not achieved the same level ofcomfort for many people.
In June of 1997, the U.S. Supreme Court reaffirmed the right to die in its decisions in the Washington v. Glucksberg and Vacco v. Quill cases, but emphasized the difference between these types of end-of-life decisions, "pulling the plug," and physician-assisted suicide. In these cases the Court found that assisted suicide was not a constitutional right and left it to the states to decide whether or not to legalize assisted suicide. An individual's right to refuse treatment is still valid when he or she becomes incompetent. All 50 states and the District of Columbia authorize the use of a writtenadvance medical directive to help honor the decisions of those who are not able to speak for themselves but who have recorded their wishes in a living will or medical power of attorney. Oregon was the first state authorizing physician-assisted suicide in specific circumstances. While Oregon voters had approved the Oregon Death With Dignity Act in November of 1994, the act was challenged in court and enactment was delayed. In February of 1997, the U.S. Supreme Court refused to hear the appeal after the Ninth Circuit Court of Appealsheld that the plaintiffs did not have cause to challenge the act. In a repeatvoter referendum in November of 1997, Oregon voters refused to repeal the act. Assisted suicide proponents view the issue as an extension of an individual's right to decide on his or her final care. Opponents argue that if assisted suicide is legalized on a national basis, many elderly and dependent individuals will feel guilty for being alive and for not making a substantial contribution to society and will feel obligated to commit suicide.
One supporter of the cause, Dr. Jack Kevorkian of Michigan, otherwise known as "Dr. Death," deserves mention since he has assisted over 120 individuals with their own suicides. Dr. Kevorkian has been jailed, gone on hunger strikes,lost his medical license, dropped the bodies of his patients at the hospitalafter their deaths, and appeared in court countless times in such attire asa sackcloth and in seventeenth century costumes. His outlandish behavior hasattracted attention to the right to die/assisted suicide cause, but some supporters say his behavior has done more harm than good. In 1999, he was convicted of second-degree murder, in a conviction that is expected to be appealed.
Eight Representative Cases
Recent court cases which played roles in the overall development of policy were:
Sneider v. Abeliuk (California, 1997): The plaintiff sought to recovermedical expenses incurred for undesired treatment rendered after a valid decision was made to withhold life support. The action was based on battery, invasion of privacy, interference with personal relationships and violation of constitutional rights. A jury trial was held and the jurors ruled unanimouslythat the medical center was not at fault. However, the claims of battery fornonconsensual medical care have been well established in a variety of medicalsituations.
McIver v. Krischer (Florida, 1997): The court maintained that a terminally ill, competent adult, acting under no undue influence, has a constitutional right to choose to accelerate his own death by requesting from his physician a fatal dose of prescription drugs and then thereafter administering themto himself. The court ruled that a state ban on assisted suicide violated both the Florida Privacy Amendment and the Equal Protection Clause of the Fourteenth Amendment to the United States Constitution. The state appealed and theFlorida Supreme Court heard oral arguments on 9 May 1997. In Krischer v.McIver the Court, in a 5-1 ruling, reversed the decision of the trial court, asserting that Florida's ban on physician-assisted suicide did not violate the Privacy Amendment to Florida's state constitution. Also, the Court, inconformance with the U.S. Supreme Court's recent decisions, held that the bandid not violate the Equal Protection Clause or the Due Process Clause of theU.S. Constitution.
In re Fetus Brown (Illinois, 1997): This case was brought to the appellate court to determine whether a competent, pregnant woman's right to refusemedical treatment can be overridden by the state's interest in the survivalof a viable fetus. In this particular case, the pregnant woman was a Jehovah's Witness who refused blood transfusions after a surgery which would save both her life and the life of the fetus. Upon a decision of the circuit court, the woman was restrained, sedated and received a blood transfusion. Several days later she delivered a healthy baby. The woman appealed the circuit court'sdecision to the appellate court. The appellate court held that "the State may not override a pregnant woman's competent treatment decision, including refusal of recommended invasive medical procedures, to save the life of a viablefetus."
Osgood v. Genesys Regional Medical Center (Michigan, 1997): A Michigancircuit court asserted that Genesys Regional Medical Center was guilty of battery when it misrepresented the nature of the medical procedures it performed as the procedures were in direct opposition to the patient advocate's directions and the directions of the durable power of attorney for health care. Ajury awarded damages of approximately $16 million for mental anguish and forincurred and anticipated expenses for medical care and treatment. However, the court reduced the damage award. After further settlement negotiations, neither party appealed the decision.
Anderson v. St. Frances-St. George Hospital (Ohio, 1996): The Ohio Supreme Court specifically recognized that nonconsensual medical treatment is considered battery and may entitle a plaintiff to some relief. The plaintiff was resuscitated despite the existence of a properly issued do-not-resuscitateorder and then suffered a disabling stroke several days later. The court, byrefusing to recognize a cause of action for "wrongful life" leaves a person with an assault and battery cause of action. However, by using standard and restrictive "causation" analysis, the court ensured that not even battery damages would be recoverable, unless the battery caused subsequent medical injurywhich caused damage to the patient.
Lee v. Oregon (Oregon, 1997): The U.S. district court held that Oregon's Death with Dignity Act (Measure 16), the first law in the nation to legally authorize physician-assisted suicide, violated the Equal Protection Clausebecause the safeguards were not sufficient to protect the rights of terminally ill patients who may seek assisted suicide. The Ninth Circuit Court of Appeals, in a 3-0 vote, found that the plaintiffs had no legal standing to challenge Measure 16 because they failed to show any threat of immediate harm and their claim rested upon a "chain of speculative contingencies." The court didnot decide the constitutional merits of physician-assisted suicide. The U.S.Supreme Court refused to hear the appeal and in November of 1997 the Oregon voters, in a repeat voter referendum on the issue, refused to repeal the act.
In re Fiori (Pennsylvania, 1996): The court ruled that where there isinsufficient evidence of a patient's wishes as to the withdrawal of life-sustaining treatment and the patient is in a permanent vegetative state, then close family members may substitute their own judgment and, with the concurrenceof two qualified physicians, order the withdrawal of life-sustaining treatment without seeking court approval. The court was careful to note that the ruling addressed only the narrow issue of whether life support may be terminatedfor a person in a persistent vegetative state who, when competent, never expressed desires as to specific medical treatment or withdrawal of such.
Compassion In Dying v. Washington (Washington, 1996): The Ninth Circuit Court, after an en banc hearing, ruled that the Washington State statute that prohibits assisted suicide is unconstitutional because it implicates the liberty interest of the Fourteenth Amendment. The court specifically ruled that the U.S. Constitution protects the right of competent, terminally ill patients to receive, and the right of physicians to prescribe, medicationsfor the purpose of committing suicide.
Refusal of Treatment
An individual has a constitutional right to request the withdrawal or withholding of medical treatment, even if doing so will result in the person's death. Honoring a person's right to refuse medical treatment, especially at the end of life, is the most widely practiced and accepted right to die procedure in our society. Recent debates over the futility of certain medical treatments, rationing of treatment and the growth of managed care have caused patients'rights advocates to examine the other side of patient autonomy - the right to request or demand treatment. Some ethicists and health care professionals believe that patient autonomy has already gone too far and should be subject to limitations, and that a patient or a patient's family does not have the right to request treatment that is inappropriate or futile. However, a consensushas not been reached about what constitutes inappropriate or futile treatment. As a result, no explicit blueprints exist for circumstances in which patients and their families disagree with their doctor's advice to abandon treatment. The assumption has been that most health care providers, assured that thelaw permits them to do so, will respect their patient's decisions, or that of their patient's appointed representative. Because of that erroneous assumption, most advance directive laws have imposed no adverse consequences on providers who do not follow the instructions of an advance directive, and may have advanced the belief among some that noncompliance is legally acceptable. Inrecent years, the outcomes of medical battery cases in which a health care provider imposes medical treatment contrary to the instructions left in an advance directive may change that climate. Claims of battery against physiciansfor medical care not requested or agreed-upon have been recognized despite the fact that the medical procedure may have been harmless, beneficial, or life-sustaining. If it was performed without the consent of the patient, or the patient's agent, it can be considered a battery.
One case involving medical futility was the 1992 case of "Baby K," an infantborn with anencephaly in a Virginia hospital. Anencephalic babies, who are born missing most of their brain, are treated with comfort measures only. However, "Baby K's" mother insisted on aggressive treatment. The physicians treating her believed that it was inappropriate to pursue aggressive treatment foran anencephalic baby and asked a federal court in Virginia to rule on the case. The court ruled that the hospital cannot deny emergency care to any patient, including "Baby K." Ethicists remain divided on this and other such decisions. Some insist that such painful decisions should be made by those closestto the patient. Others contend that the court's ruling to continue futile treatment threatens the medical profession's integrity. As rising health care costs increasingly become a societal focus, difficult decisions must be faced regarding whether or not patient autonomy should be limited and how. The courts are becoming more and more willing to find that battery has occurred in cases in which a health care provider refused to honor the directions left in anadvance directive or given by an appointed agent. This trend may serve to make health care providers more aware of the legal responsibility to honor their patients' right to self-determination.