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Should  People Have the Choice to End their Lives?  

Should People Have The Choice to End Their Lives?

As our nation grows older and enjoys constantly improving medical technology, growing numbers of Americans confront issues and decisions about death and dying. For the first time in history, because of advances in medical technology, we are asked to decide when death should occur.

At the same time, societal institutions (the courts, legislatures and the medical profession, to name just a few) must grapple with public policy and ramifications of these same realities.

I. What Is Death? 

Consider these issues

• With today's technology, how do we know when death has occurred?
• Is there a point at which a terminally ill patient’s life should be ended and if so, how?
• How should decisions about ending life be made and who should make them?

1. The most obvious answer is death is the end of life. Death is built into the life cycle. But what are the signs that tell us when someone is dead?

 

In earlier times, the doctor would listen for the heartbeat. Sometimes a feather was placed on the lips just below the nose and everyone would watch to see if it was moved by breathing.

Such simple ways of determining death opened the door for errors. Some persons presumed to be dead, were really in a deep coma and at times were buried alive.

Did you Know?
The fear of waking in the tomb was so great that some people arranged to have a rope extending from the crypt to a bell that could be tolled if the person awakened in the tomb (and thus the old saying "saved by the bell").

Old criteria still remain. No heart beat, no breathing, but now technology allows us to add a flat EEG or electro encephalogram, the measurement of the electric activity of the brain. But even these criteria must be cautioned.

2. A CBS program, 60 Minutes, described an operation performed on a woman with a brain aneurysm (a broken blood vessel in the brain). To repair the broken vessel the pulsating of the heart had to be stopped.  The woman’s blood was circulated through a cooling device until her heart stopped. There was no breathing and the EEG was flat. This allowed surgeons to remove the aneurysm. After 8 minutes the blood was warmed and re-circulated. The heart started to beat, breathing began, and the EEG registered brain activity.

Questions to consider: 

• Was the woman dead for 8 minutes?
  
• If so, what label can be attached to this temporary death?
  
• The usual term for irreversible death is  "clinical death" which means the permanent cessation of a heartbeat and breathing. But that label does not work because the person was not irreversibly dead, in other words, death was reversible.

II. Brain Death:

Some argue that because the brain is the integrating organ of the body and the central part of the human system when "brain death" occurs the person is thought to be dead. 

Would a patient in an irreversible coma or in a persistent (constant) vegetative state, no longer able to process data received through the senses (or at least not able to communicate their processing to the outside world) be considered dead?

With today’s technology (because machines can breath for us and trigger heart beats), we are in a dilemma as to what or when a person is considered dead and all life support can be withdrawn.

1. There are 4 criteria offered by the Harvard Medical School to define the criteria for determining brain death which have been widely accepted. If all criteria are met, the person is, for all practical purposes, presumed to be dead.

• Lack of receptivity and response to external stimuli. Total unawareness of the external world. Even the most painful stimuli evoked no vocal response or grimace, nor quickening of respiration’s or limb withdrawal.
  
• Absence of spontaneous muscular movement and spontaneous breathing after the respirator (artificial breathing machine) has been turned off for a 3 minute period.
  
• Absence of observable reflexes, including brain and spinal reflexes. No pupil response to bright light, no evidence of swallowing, yawning or vocalization.
  
• Absence of brain activity determined by a flat EEG. The procedure is repeated with no change within a 24 hour period.
  

III. Public Attitudes Towards Death and Dying

Americans bring extensive personal experience with death and terminal illness to the debate over end-of-life issues, so attitudes are driven by both personal experience and the media ( the reports we hear about other people's experiences).

Studies by the Benton Foundation show that most people view death and dying as a private, family matter. And while people hold distinct attitudes on how they would like to end their lives, if they are terminally ill, they are reluctant to impose their views on how life should end as the standard for others.

1. The distinction between "allowing" a terminally ill patient to die and "actively" killing a patient is a crucial one for most of us.

Most of us are likely to prefer less interference with the natural course of events.

Even though the majority of people support the decision to withdraw life support for a terminally ill patient, we are less comfortable with doctor-assisted suicide.

Did you know that there are demographic differences in our opinions about doctor-assisted suicide?

African Americans are far less supportive of doctor assisted suicide than whites. In general suicide rates among blacks is lower than among whites. 
    1. NBC pole shows that 60% of whites vs. 40% blacks support the practice.
    2. A Gallup pole in 1996 showed 57% whites support and only 29% blacks.
    3. And only about 30% of blacks vs. 52% of whites approve of the actions of Dr. Kevorkian.
More research needs to be conducted to understand these differences.

In general people with higher education and incomes levels are more likely to favor assisted suicide.

1. Nearly 60% of those with post graduate levels support legalizing physician assisted suicide.
2. Only 40% of those with less than a high school education do.
3. Incomes of over $75,000 , 67% support the practice.
4. Incomes of less than $20,000 only 45% are supportive.

2. What Do Physicians Say?

Studies show that physicians support legalizing doctor–assisted suicide in numbers similar to the general public. Fewer than 50% say they would be willing to help a patient commit suicide if they requested it.

Most express fears about patients asking to die for the wrong reasons – i.e. financial pressures, depression or emotional turmoil.

A poll of Oregon doctors found that 93% are concerned that patients might request assisted suicide because they fear being a burden to others.

They doubt their own capacity to know for certain that a patient’s request to die is legitimate. For example more than 50% say they are not confident they would be able to recognize depression and fear patients requesting permanent solutions to a treatable mental problem.

Despite these concerns, many doctors acknowledge that they have assisted terminally ill patients die.

 

III Euthanasia and Physician Assisted Suicide - the role in aiding the dying for health care professionals.

1. Differences between Euthanasia and Physician Assisted Suicide

A. Euthanasia is described as intentional killing.

Historically there are two types:

1. voluntary euthanasia – the withdrawal of life sustaining treatments at the patients request
   
2. passive euthanasia – the doctor does nothing to prolong life
   
3. there is now a third type referred to as an obitiatrist, a person who creates death like Dr.Kivorkian. Usually a drug is given by someone other than the patient.

 

2. Physician assisted suicide is described as the person who wants to die takes their own life. The doctor provides the drug.

2. What are some of the controversial issues?

First, there is a medical creed for doctors that says " do no harm". The implication is that death is harm. Others argue, that for many, death is a welcomed relief from pain and suffering.

Historically, doctors have a contract of trust with society. Many wonder if physician assisted suicide would break that trust.

Many worry about the potential abuse of the elderly, sick, and weak, who are already vulnerable. Will they be made to feel obligated to end their lives? 

And many oppose the practice based on religious beliefs.

3.These issues center around these main ideas.

1. Is it crewel to prolong intense suffering and do people have the right to decide for themselves?
2. Those that oppose the practices fear that  the government would not limit it to mercy killings. 
3. Many in the Christian faith note that only God has the right to give life and thus to take it away.
4. Here are two comics for you to consider 

comic 1

 comic 2   (this one she is saying "I must answer to God and my conscious for what I want to do". 

 

IV Right To Die And Advance Directives

When someone is so ill that they can not speak for themselves, without clear direction from the patient or family, it is difficult for health care wishes to be known. Especially regarding tube feedings or hydration.

Doctors need to know personal preferences of the patient before making life and death decisions-- do nothing or everything! This is further complicated when the patient is in the hospital, because by historical definition hospitals have an obligation to forestall death.

1. Lets review some of the lingo, some of it is from week four

Definitions.

• Life support – use of any technique, therapy or device to assist in sustaining life.
  
• No Code or DNR (do not resuscitate) - essentially means that if the heart or breathing stops, the patient does not wish to be resuscitated

Did you know?

In several polls, most nursing home residents said that if they were to stop breathing, they prefer life-sustaining treatments?

• Advance Directives- sets forth guidelines regarding the level of medical intervention they desire.
  
• Living Will – states your desire not to receive life-sustaining treatment. It is used to delineate the situation in which a person would refuse life-prolonging interventions if they are incapacitated or other wise unable to make decisions at that time.
  
• Advance Health Care Directive - Allow you to give instructions about your own health care. You can name someone else to make health care decisions for you and you can write down your wishes regarding donation of organs and designate your primary physician . This form replaces the previous Durable Power of Attorney for Health Care in California. 
  
• Here is a very good overview of issues to consider for end of life decisions  https://caregiver.org/end-life-decision-making. You can find links to the forms under their "What We Do" tab.

When you complete the form, you should indicate your specific desires regarding treatment or circumstances in which you might want life-sustaining treatment withheld.

You may want to specify who may visit you in the hospital or who will be responsible for funeral or burial arrangements. 

 

B. Living Will – For some people it may also be appropriate for them to complete a Living will. However, lawyers say that many people are uncomfortable with the broad scope of the form after they read it.

The living will is a written document in which an individual conveys his or her desires to die a natural death and not be kept alive by artificial means.

The problems lie in trying to anticipate all possible scenarios.

Many people who ask for no life-sustaining treatments fail to realize that some medical conditions are reversible after a short treatment using life-sustaining measures such as  shock or some traumas like car accidents.

Unlike the Advance Health Care Directive  the wishes in this document are not legally enforceable in California and are subject to the willingness of the health care provider.

Most experts agree that every Californian should have an Advance Directive form. 

Despite the usefulness of these documents, there are some problems . First, relatively few patients actually complete a advance directive of any kind. Public polls show that nearly 90% of us do not want to be maintained on life support without prospect of recovery, yet, less than 15% have stated these wishes in a legal document. How many of you have actually discussed what you would want to have happen if you became terminally ill or were in a life-threatening accident? 

Often even though a dying person has made their wishes known, families who are not prepared for the death of the person want doctors to do everything to save the life of their family member. For this, and other reasons, sometimes doctors will not acknowledge the document. It is important to discuss the document with your doctor and family members before you become critically ill.

This is an issue that is best discussed with your family, your health care provider, and/or your attorney.

V. Suicide

1.When we think of older people dying we usually don’t think of suicide.

1. The highest rate of suicide in the U. S. is found among those over the age of 65 (19.7 per 100,000 as opposed to 11.9 for all other ages) and on the rise especially for men over the age of 50 . http://www.nia.nih.gov/HealthInformation/Publications/endoflife/08_planning.htm
   
2. The rate of attempted suicides compared to completed suicides of those aged 15-24 is estimated as 100 to 1; that means that for every 100 attempts, only one is successful. 

It is much different among the elderly. For every one that attempts suicide, the success rate is one. In other words the ratio has been estimated to be 1 to 1.

Younger people tend to use suicidal methods for what appear to be cries for help and attention. Among the elderly, the intent is to end life.

Other Interesting Facts:

Nearly ¾ of older people who commit suicide have recently visited their primary care provider.

Many believe that the elderly suicide rate is higher than statistics reveal due to the fact that deaths are more likely attributed to old age and are not investigated as suicide. Often death is listed as a fatal accident.

White Men are more likely to commit suicide than other groups of people. It is thought that this is because of the loss of status and power that can accompany illness. These illnesses or physical losses  can mentally incapacitate a person.

Men are especially vulnerable in our society where emphasis is placed a man's strength and capacity. For many men it can be humiliating to become feeble and unable to take care of one's self and be dependent upon others for everything from going to the bathroom to putting on clothes . No one want to become a burden on others. In the U. S we prize independence and the ability to look after ourselves.

Black woman have the lowest rate of suicide. This might be because of strong social networks and stronger involvement in family, church and community.

VI. Cultural responses to death:

1. Over the centuries, humans living in different parts of the world have developed varying response to death and dying. For example, in the Neanderthal burials that archaeologists date back 50,000 years, artifacts including stone implements and shells were buried with the dead.

Were these tokens tools and decorations that belonged to the dead person or were they tokens of respect for the dead person? Did these early people believe that there was an afterlife in which tools and weapons would be useful? We cannot know.

Humans all over the world develop rituals associated with the dead. We combine supernaturalism with the practical need to dispose of human remains properly safely and with respect.

Most of us are familiar with western cultural responses to death and dying. Although changing somewhat, these customs originated in Judaism, Christianity and Islam.

Historically it was customary for a widow to wear black and refrain from social activities for several months or up to a year. This was a symbol of her emotional distress.

Relatives provided comfort and support and the culture allowed for a long adaptation period of bereavement. The opposite is true today. Most work places expect the survivor to return to work ready to resume a full workload in 3 to 5 days.

2. Today, as our society becomes increasingly multicultural it is important to be sensitive to ways of approaching death and dying that come from other cultures. Hinduism, Buddhism, Taoism, Confucianism, Native American cultures each has their own rituals to make the transition from life to death.

Here are some resources for you to consider

Buddhist: . http://www.buddhanet.net/d_cermon.htm

American, On Our Own Terms:  http://www.pbs.org/wnet/onourownterms/

That's it for this week- --

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