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Paper Abstract: Examines moral, ethical & legal aspects in general & as they impact nursing practice. Appendix (nurse interviews). Paper Introduction: This research examines the moral, ethical, and legal aspects of euthanasia, especially as they have an impact on nursing practice. The research will set forth the historical and moral context in which the issue has emerged then discuss legal, philosophical, social, and practical elements that figure into what has become a feature of discourse of medical care in general and nursing practice in particular. One of the most notorious news stories of 1976 centered on New Jersey, where Karen Ann Quinlan's physicians disconnected artificial life-sustaining equipment from her body. For nearly three years, Karen's parents had sought permission to have the equipment turned off. Drama and conflict had surrounded the case, partly because Karen had been in her photogenic twenties, partly because the Quinlans were fighting the full weight and autho Text of the Paper: The entire text of the paper is shown below. However, the text is somewhat scrambled. We want to give you as much information as we possibly can about our papers and essays, but we cannot give them away for free. In the text below you will find that while disordered, many of the phrases are essentially intact. From this text you will be able to get a solid sense of the writing style, the concepts addressed, and the sources used in the research paper. v-vii. Ed.J.A. 296). Supreme Court. 1 8). 37). 7 ). New York: Harper & Row. (1992, May 9). New York: MacmillanPublishing Co., Inc. Protecting patients' end-of-lifechoices. And we know nothing of the context in which these patients live and are cared for (Foley & Hendin, 1999, p. But in any case, at least one analysis of mental-health treatmentteams by Yank, Barber, and Spradlin (1994) found that they were subject toregression into "dysfunctional partial systems" both among team members andbetween team and its "parent agency." Zimmermann (1994) reported similarfindings in analyses of hospice treatment teams. The very fluidity of term definition speaks to the difficulty that thehealth-care community has had in coming to terms with euthanasia and mayhave wide-ranging implications for clinical praxis (Behnke & Bok, 1975).The Patients' Self-Determination Act of 199 , which went into effect inDecember 1991, specifically guarantees patients the right to refuse medicaltreatment and requires hospitals receiving federal Medicare and Medicaidfunding to inform patients of their right to refuse medical treatment;however, as late as 1994, at least some patients were unaware of theiroptions or unable to exercise their rights in this regard, because ofhospital or doctor noncompliance on one hand, and some degree ofphilosophical opposition from the health-care community on the other(Greve, 1994; Tammelleo, 2 ). (1999, May). Supervising the trainee who treats thechronically suicidal outpatient: Theoretical perspectives and practiceapproaches. (2 , July). JAMA, The Journal of the AmericanMedical Association, 273, 363. Terminal choices : euthanasia, suicide, and theright to die. Euthanasia, derived from the Greek combining forms eu meaninggood and thanatos meaning death, has historically been identified with themercy killing of hopelessly sick human beings and animals. This law, which permits physician-assisted suicide, typically byway of palliative care, by no means settled the issue in Oregon or in themedical community more generally. Am I upholding the dying person's autonomy--his free choice in life's decisions--by helping? Health law. Western Journal ofCommunications, 58, 116-41. Zimmermann, S. By the mid-199 s, assisted suicide was believedto be a daily occurrence for doctors who engage in palliative care,administering increasingly large doses of morphine to terminally illpatients not only to guarantee pain relief but also to hasten death(Cotton, 1995). And what about the feelings of the nurses regarding euthanasia? What Chervenak and McCulloughsay is unjustified for a physician--"to think that, on the grounds ofbeneficence, the 'best' management excludes as unreasonable all otheralternatives; it cannot do so"--would seem equally unjustified for a nurse. (1969). By no means did the Quinlan case dispose of the issue of euthanasia,passive or otherwise. JAMA, The Journal of the American Medical Association,268, 354-5. What happens when the patient and family enlist the aid of thehead nurse as a PAS advocate? Pellegrino, E. Lynch, V.J. The AMA's definition ofassisted suicide, also physician assisted suicide or PAS, the situation inwhich a physician gives a patient either means or knowledge to commitsuicide but does not perform the act. Siegler, M., & Gomez, C.F. (1998). The AMA assigns no term to such asituation, although since the Quinlan case it has been commonly referred toas passive euthanasia. Preface. Further to this point,Tammelleo (2 ) cites a survey showing that 25% of nurses have watchedcolleagues, including but not limited to physicians, "deliberatelydisregard a patient's advance directive." Among ICU and critical carenurses, the figure is more than 5 %. Humphry, D., & Wickett, A. The position of nurses in end-of-life contexts is problematic notleast because of their historical function as support, but not necessarilyauthority, for institutional and physician needs. New York was the first state to formally regulate the issuing of Do-Not-Resuscitate (DNR) orders by doctors in 1987, although the lawessentially codified protocols that had been in place for years, such asobtaining advance consent from guardians or next of kin before issuing aDNR order (McClung & Kamer, 199 ). The reports do list advance-directive information and hospice participation, but there is noinformation on the financial positions of the patients involved or theextent of their participation in palliative care. Ufema(2 ), a nurse, gives an account of a terminally ill woman who had issueda DNR order and agreed to accept palliative medication, but whoseexperience of a seizure caused her to insist, in extremis and while beggingto be reintubated, that it be rescinded. Death with dignity. But the issue seemshere to stay, and seems destined to become more, not less, complicated astime goes on. For example, aphysician may refuse to permit the use of morphine to relieve a terminalpatient's pain, on the theory that excessive pain relief = euthanasia,given the double effect of palliative treatment. Legislating ethics:implications of New York's Do-Not-Resuscitate law. (1993 May). 2. Drama and conflicthad surrounded the case, partly because Karen had been in her photogenictwenties, partly because the Quinlans were fighting the full weight andauthority of the hospital that as a matter of custom, practice, andprevailing social policy refused to allow withdrawal of life support,characterized as passive euthanasia. References Behnke, J.A., & Bok, S. The content of suchautonomy raises moral and ethical issues where the decision for or againstlife is concerned. Mental health treatment teamsand leadership: a systems model. Journal of Pain and Symptom Management, 9, 16 -5. A whole range of hypotheticals can be adduced to account fordifficulties, or more exactly to raise difficult questions, in regard toeuthanasia. (1994, Feb.). B. (1983, Nov. Hemlock Society. It is an indubitable fact for those who know the subculture of the health care professions and the power structures of hospitals that nurses who openly challenge established authority structures or powerful physicians in a hospital bureaucracy most often put their jobs, their economic welfare, and their professional careers on the line, even if they are acting on behalf of the patient and have strong justification for doing so (Yarling and McElmurry, 1986, p. Moral foundation ofnursing. Educating psychiatry residents about deathand dying: A national survey. Yank, G.R., Barber, J.W., & Spradlin, W.W. 23). Foley and Hendin call for more extensive case-by-case patientdata to get a more detailed picture of the cases involved. Changes of heart, in otherwords, are bound to be a permanent part of the mix. Ethics and pain management:Respecting patient wishes. By 1991, 28 states had enactedliving-will statutes or laws that otherwise guaranteed patients the rightto refuse life-sustaining treatment (McCord, 1993). We know little of the capabilities of the physicians who are responding to those requests. The problem arises for nurses because of the potentiallegal complications that could arise if the rescinding of a DNR order wereto be ignored. It is to be expected that advocates for and against passive andvoluntary euthanasia would argue for stronger controls on any enablinglegislation along those lines. The larger problem, as Ufema notes, is that end-of-lifedecisions are difficult for all human beings. But by the time comatose Karen AnnQuinlan died in 1985, if the withdrawal of artificial life support was notan ordinary hospital protocol, it was nonetheless a more usual practice inhospitals around the country. One of the most notorious news stories of 1976 centered on New Jersey,where Karen Ann Quinlan's physicians disconnected artificial life-sustaining equipment from her body. By 1992, an estimated 7 % of deaths inall modern hospitals were the result of conscious decisions to stop medicaltreatment (Walters, 1992). What about a possible miracle cure? Grand Rapids, Mich. Kubler-Ross, E. (1989). Foley and Hendin observe that failure to bring them upis a failure of professional ethics. This is balanced by the view heldby other nurses who see the wastefulness of "futile treatment" of those whorescind DNR orders. Where more precise definitionsare given, term meanings may vary with the definers' professionaldiscipline. . DiMaggio, J.R. Behavioral Science, 39, (1994, Oct.): 293-32 . McCord, W. Unfortunately, the report is marked by its failure to address the limits of the information it has available, overreaching its data to draw unwarranted conclusions. US consensus on euthanasia?The Lancet, 339, 1164. . DiMaggio (1993) cites the reluctance of intern and resident-level physicians to deal straightforwardly with death-and-dying issues. Am I playing God? Most striking, and least justified, is its contention without substantiating patient data that patients who were assisted in suicide were receiving adequate end-of-life care. The right to die: understandingeuthanasia. Hastings Center Report, 2, 41 -18. Clinical Supervisor, 5, 99-11 . : W.B. (199 , July 26). The Oregon program is characterized as too much a laissez fairematter, a fact of particular concern to PAS opponents of the Oregon law,who argued that in the absence of a reliable standard for determininglethal doses of PAS drugs, attending physicians would be using terminalpatients as guinea pigs for the policy. 91). However, such controls fly in the face ofissues of hard-won patient autonomy. The Oregon report: Don't ask, don'ttell. Only the underlying physical condition (e.g., terminal cancer) need bereported in PAS documentation in Oregon. On death and dying. Are nurses to become clerks, or perhapstattletale gatekeepers with secret records of colleague behavior in end-of-life cases? The risks to the nursesassociated with disobeying orders are therefore difficult to overstate. In the late 198 s, NancyCruzan's parents' wish to withdraw her life support was opposed by thestate of Missouri but finally granted by the U.S. The annual rate of so-called mercy-killings rose tenfold from 192 to1985. (2 , August). Cain and Hammes forcefully argue that when "curative therapy hasfailed," pain relief "can restore decision-making capacity and enhance topatient's right to self-determination" (16 ). M., & Hammes, B. . O. The Hastings Center Report, 29, 37-43. "Death & dying: Bedside vigils." Nursing, 3 ,26. R., & McElmurry, B. Co. Nor is it clear whether becoming an antagonisticadvocate or opponent of a given end-of-life decision helps either patientor nurse. This has most recentlybeen complicated by the shift in medical decision-making authority fromprofessional-expert paternalism to patient autonomy. Meanwhile, "those administering thelaw and those sanctioned by the government to analyze its operation havebecome its advocates" and not merely information gatherers andtransmitters. Caught in the middle of this debate are nurses, who may experience thefine line between "assisted suicide, a morally objectionable means orintent (killing) [as] the treatment used to achieve a morally permissibleend (pain relief)" (Cain and Hammes, 1994, p. In 1976, California's Natural Death Act legalized use of the livingwill. (1994, April). In a review of the second annual reportof the state's Health Division, Foley and Hendin (1999) complain that PASrecords are woefully inadequate. The question then becomes less whether nurses can do an end-of-life patient good than whether they can avoid doing harm. (1987, Spring). JAMA, The Journal of theAmerican Medical Association, 268, 364-6. Yarling, R. By 1977, the year after the Quinlan decision, "fifty bills wereintroduced in thirty-eight states, and in Arkansas, California, Idaho,Nevada, New Mexico, North Carolina, Oregon, and Texas, they were signedinto law" (Humphry & Wickett, 1986, p. What about the patient's responsibility to his family? Greve, P.J.D. Bok. RN, 57, 59-62. (1994, Summer). At a time when team treatment of difficult cases has come to the fore,the role of nurses in end-of-life cases has not been strongly defined.Well, that is not quite true, if the traditional practice of regardingnurses as support staff rather than as full participants in the decision-making apparatus is characterized as nurses' contribution to a treatmentteam. Eerdmans Pub. Theresearch will set forth the historical and moral context in which the issuehas emerged then discuss legal, philosophical, social, and practicalelements that figure into what has become a feature of discourse of medicalcare in general and nursing practice in particular. (1995, Feb. A., & McCullough, L. Does the patient have a civic duty to remain alive? Some ethicists point to modern Germany's use ofcyanide in its euthanasia movement, insisting that legalized euthanasiawould result in widespread abuses (Siegler & Gomez, 1992; Gomez, 1991). The AMA distinguishes between these definitions and a situation inwhich doctor, patient, or "patient's proxy" in the form of living will,durable power of attorney, or other advanced health-care directive,authorizes withdrawal or withholding of life-support treatments whosedisadvantages outweigh the advantages. The so-called "slippery slope" (or "slippery rope" or "wedge")argument holds that passive euthanasia leads to voluntary activeeuthanasia, which leads to involuntary active euthanasia, particularly aspracticed by the Nazis. Nurses obliged to followphysicians' orders and advance directives, however, know that not allphysicians have the same attitude toward palliative care. Cotton, P. For nearly three years, Karen's parentshad sought permission to have the equipment turned off. . In a 1994 reportby the American Medical Association's Council on Ethical and Judicialaffairs, euthanasia is identified with a situation in which a physicianadministers to a patient some means of death, such as "the death-causingdrug or other agent" (Glasson, 1994, p. Humphry& Wickett say, for example, that the Nazi program is mischaracterized aseuthanasia and more properly referred to after the German form aslebensunwerten Leben, meaning life not worthy of life (1986). (1994, Spring). 1). Cain, J. In 1978, Pope John Paul II said that euthanasia wouldbe the great moral issue of the 198 s; it also turned out to be a majorlegal issue (Humphry & Wickett, 1986). Gostin, L. RN, 63, 75-81. What will the nursing staff do if a third-party intervenor such as the local Right to Life Committee gets into theact? Yet the Oregonadministrators of the program concluded that economic factors did not enterinto the patient's PAS decision (Foley & Hendin, 1999). Justifiedlimits on refusing intervention. (1991, March-April). In the years after the Quinlansfirst entered the New Jersey judicial system, with each succeeding andtroubling case, a host of end-of-life issues became an increasinglyprominent subject of moral, professional, and public-policy debate, and thenames in the cases a prominently bleak aspect of the culture: Karen AnnQuinlan, Nancy Cruzan, Baby Doe, Jack Kevorkian. The Humanist, 53, 26-29. Palliative treatment is the namegiven to the act of providing increasing drug dosages for pain relief thatmay have the so-called "double effect" of ending the patient's life. . The Dilemmas of Euthanasia. can mean (1) "a right to be allowed to die," which would be a right of non-interference and would be exercised when one simply asked to be left alone and permitted to die a natural death. Advances in Nursing Science, 86, 63-73. Quite the contrary, every killing was unexpected by the victim and involuntary (Humphry & Wickett, 1986, p. It's all very well to say that the nurse's role is to provide the bestcare possible and facilitate the delivery of health care, but where doesthat leave a distressed patient's right of self-determination vis-à-visphysician or institutional authority? Between 1975 and 1985, murder-suicides, double suicides, and assistedsuicides of the terminally ill "increased forty times as desperate elderlypeople felt obliged to take the law and fate into their own hands" (Humphry& Wickett, 1986, p. Social cognition and evaluations ofhealth care team communication effectiveness. Mosby's Medical, Nursing, & Allied HealthDictionary, 5, 3F62. Report of the council on ethical andjudicial affairs of the American Medical Association. Finally, it can mean (3) "a right to be killed by another at one's own request" (i.e., a right to assisted suicide) (Wennberg, 1989, p. 296). The Washington Post, A3. Tammelleo, A.D. Ethics, analysis of Patient Self-determination Act. Glasson, J. 18 ).Wennberg's third point differs from the AMA's definition of assistedsuicide in his view that the person assisting the suicide performs the act.But he goes on to describe the third meaning in more general terms as "theright to kill oneself through the agency of another," which could implyonly knowledge and means but not the deed. Weiser, B. Thecompetence and will of the patient are basic to the argument for assistedsuicide, reply advocates of personal autonomy and informed consent. 2). Complications attending end-of-life issues have been brought intospecific relief in Oregon, where in 1997 the Death with Dignity Act waspassed. Less easy to answer are the objections of such health-care-deliveryveterans as Elisabeth Kubler-Ross, whom Humphry and Wickett cite to theeffect that assisted-suicide advocates are really in favor of "puttingthemselves out of their own misery--the agony of seeing a loved one suffer"(1986, p. And whether they are to be obliged to track every single littletiny detail of patient and practitioner behavior where end-of-life issuesare at stake, or to refrain from recording what they judge to be abuses ofpatient preference in this area--and in either case to have little actualauthoritative input into the matter--what does all of this say about theautonomy or value of nursing as a helping profession? D. Issues In Law &Medicine, 1 , 91-97. Further, doctorswho participate in PAS are not required to engage in or be trained incounseling or formal evaluations of the emotional state of the patients whorequest PAS; other suicidal patients are required to undergo psychiatricevaluation in Oregon. Behnke & S. Chervenak, F. New York: Mosby-Year Book, Inc. In fact, we know nothing about the physical, psychological, and existential needs of the patients requesting assisted suicide. & Kamer, R.S. (1986). A danger for nurses who oppose implementation of DNR or for thatmatter assisted suicide for personal reasons is that of misplaced medicalpaternalism that negates patient autonomy. Ifthe issue is too hard, it is possible for some health-care practitioners toavoid confronting it. On the other hand, Humphry andWickett pose two main and several subsidiary questions about the right todie, from the point of view of the person assisting the suicide: 1. Nurses are uniquely positioned towatch supposed patient autonomy become subsumed by practitioner authority,and there is little evidence that they have a mechanism that would enablethem to complain, or that complaining would be anything other than adifferent kind of suicide. General Hospital Psychiatry, 15, 166-17 . Do my religious and philosophical beliefs permit me to participate in this requested death? (1975). What happens, in future, if a patient asks for assisted suicidein a state where it has been legalized, and the physician or institutionrefuses? Medicine's position is both pivotal andprecarious in assisted-suicide debate. On the other hand, the caring profession that nursing is appears tohave affected attitudes of nurses toward end-of-life practice. Foley, K., & Hendin, H. 161). J. Under the general category of euthanasia fall a number of discrete end-of-life terms, which are sometimes used interchangeably, but which hardlycarry a uniform meaning in the literature. Manyare reluctant to address the issue at all (see interview; Ufema, 2 ).Thus to be saddled with the administrative details of the issue may seemdoubly troubling to them. But Lynch (1987) points out that inany case therapists in training are especially vulnerable to misjudgment ofand manipulation by suicidal or parasuicidal patients, whether terminallyill or not. 2 doctors take controversial stand on feedingthose near death. Ufema, J. xi). (1992, July 15). Because the details of advance directives, livingwills, and durable powers of attorney for enforceable health-care "proxies"vary from state to state, the form that such controls might take is boundto vary dramatically (Tammelleo, 2 ). It also can mean (2) "a right to kill oneself," which would be a right to take one's own life free from interference by others (i.e., a right to unassisted suicide). McClung, J.A. The term right to die is connected to that of assisted suicide,interpreted differently by different commentators and sometimes differentlyby the same commentator: The phrase . Garden City, N.Y.: Anchor/Doubleday. As early as 1983, some doctors were going public with the statementthat they routinely withheld food from comatose terminal patients (Weiser,1983). J. This research examines the moral, ethical, and legal aspects ofeuthanasia, especially as they have an impact on nursing practice. That same year, thePatients' Self-Determination Act required federally funded hospitals totell patients at the time of admission about their rights to accept orrefuse medical treatment and to create advance directives, which can takevarious legal forms, about their own care (Gostin, 1992; Pellegrino, 1992). Further, the 199 Patients Self-Determination Act specifically mandates that health-care institutions,hospitals and nursing homes alike, provide written information regardingadvance directives. (1992, July 15). (1993, Jan.-Feb.). Has the PSDA made a difference? (1986, January). Wennberg, R.N. (Humphry & Wickett, 1986, p. Unfortunately, in the literature, the evidence of nursing-professioninput is that it is one thing to recognize that the issue of euthanasiacharged, and quite another to develop standards for nursing's role and fortracking that role on the record, where euthanasia surfaces as an issue.For it is nurses who are likely to be on the clinical front lines ofdifficulties attending palliation, PAS, DNR, and the conflicting prioritiesand values of affected patients, caregivers, families, physicians, andthird-party interventionists--whether right-to-life advocates or members ofthe Hemlock Society, which was organized to disseminate information abouteuthanasia (Hemlock, 1998). Theycontinue: There is no record of the Nazis assisting in a suicide or killing anyone suffering intolerably from a fatal illness. The New England Journalof Medicine, 323, 27 -2. Under the law, doctors are not required to encouragealternatives to PAS. 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