Right to die vs. right to live - page 2
the following posting is in reference to a class project regarding the topic of the right to live versus the right to die. our group of senior nursing students, at the university of west florida,... Read More
Mar 9, '07I feel that as a professional that cares for people with all kinds of beliefs, that the farthest that nurses can go in changing things is to advocate for patients in a case by case basis, and to encourage advance directives on admission, discharge, and at any other point of care at which the conversation is appropriate.
I believe that patient advocacy is not limited to speaking up with the doctors when the current orders are not sufficient or in cases where treatment continues despite the patients spoken wish that he/she is ready to die. Patient advocacy can be most important in those cases where the personal politics within a family are felt to be pressuring the doctors or the patients to make decisions that are clearly outside of the previously spoken wishes of the patient. Care conferences are wonderful, but a patient that is tired, terminal and ready to die can be easily swayed by the grief and pleading of family members that will never accept the fact that their loved one will die, and soon, irregardless of their determination otherwise. These are the cases in which nursing advocacy should be the strongest, because it is often in quiet, private moments with nursing staff that patients talk most openly about their wishes.
To go farther than this, to publicly advocate any change in public policy in our professional roles as nurses, only serves to ignore the fact that there are many patients and families that believe that there is no situation that is hopeless, there is no situation in which support should be withdrawn. Those patients and families deserve to trust that their wishes will be supported just as strongly and with as much determination as any other. To have nurses openly avocating for changes, would cause these families to worry that their family members will receive substandard care and to have them worry about nurses "taking matters into their own hands".
Personally, my feelings in this area are very set, very clear, and my family and friends have no doubt what my wishes would be. In the past, before I became a nurse, I even worked for political campaigns that dealt toward making public change. Even now I would work for such causes privately. However I would never use my professional position as a nurse to publicly advocate for such changes because I have too much respect for my patients to do anything that would make them trust their caregivers any less.
I know that many of us are not answering the OP's questions, such is the risk with such a weighted topic. We tend to go on tangents, and from the length of this post, I am very guilty of that. Sorry everyone
Mar 9, '07Quote from BSNin2007I am not under any circumstances suggesting that nurses publically advocate in favor of legislation allowing "assisted suicide" or withholding livesaving treatments. I would however advocate for legislation that would ENFORCE a document that was signed by a person of sound mind. Does this always happen with AD's? I think most of us know the answer to that question.ponytailman, Thank you for your honesty and input. I guess what the ultimate goal of such a discussion is whether or not healthcare professionals as a whole need to be active in promoting legislation that puts our patients human rights first. We all have heard of cases where advanced directives are not adhered to because of battling family members rather than actual patient wishes. When does the healthcare profession as a whole make a stand one way or another. Is it the rights of the patient, or the families or the position of the establishment. I do not suggest that every case will fall into a category where it will be easy t say "This is definately the right thing to do" however I do think that the parameters need to be more clearly defined.
Mar 9, '07"One poster stated that people who have advance directives do so becasue they wisdh to live (paraphrased).. for me it's the opposite. I have my advance directive so some yahoo doesn't get it in their minds to keep my going long after I should. "
When I stated that about advanced directives, I didn't mean everyone who had them wanted life saving treatment. I meant to say that everyone has differing opinions about what they personally would want and not a "one size fits all" answer. It was really a response to the question in the OP that stated:
"What reason is there to doubt that any person in Nancy's circumstances would want--if they were capable of even wanting--feeding to be continued?"
Mar 9, '07Quote from bsnin2007i think that there are some things people just can't know. unfortunately, god has assigned us to take care of his world. so we just have to do the best we can. it probably all comes down to one's religious beliefs. :uhoh21:the following posting is in reference to a class project regarding the topic of the right to live versus the right to die. our group of senior nursing students, at the university of west florida, will be presenting this topic for a healthcare issues course. please note that any replies may be incorporated in our powerpoint presentation to elicit group participation. we will present a scenario as well as questions to consider. please post your responses regarding this matter based on how you feel the situation should have been managed.
the right to diethe court first addressed the issue of the right to die in the 1990 case of cruzan v. director, missouri department of health. in cruzan, the court considered whether missouri could insist on proof by "clear and convincing evidence" of a comatose patient's desire to terminate her life before allowing her family's wish to disconnect her feeding tube to be carried out. although eight of nine justices--only scalia disagreed--concluded that the right to die was a liberty protected by the due process clause, a bare majority of the court upheld the state's insistence upon clear and specific evidence that the patient would wish to have intravenous feeding discontinued. the cruzan decision spurred considerable evidence in "living wills" which clearly express an individuals desire to discontinue treatment or feeding in specified circumstances. (later, additional evidence of nancy's wishes was discovered and feeding was discontinued, leading to her death.)
the issue: does the constitution protect the decision to end one's own life, at least if one is terminally ill or in great pain?
seven years later the court faced right to die issues again in two cases involving challenges to laws criminalizing physician-assisted suicide. the lower courts in each case, one involving a washington state law and another a new york statute, found the laws unconstitutional--at least as applied (the 9th circuit decision rested on due process right-to-privacy grounds, the 2nd circuit decision on equal protection grounds.) the supreme court reversed in both cases, finding the laws to be constitutional. although the court interpreted cruzan as recognizing a right to refuse medical treatment, the court found no constitutional basis for a right to assisted suicide. three justices in concurring opinions (o'connor, breyer, stevens) indicated that they might be willing to uphold "more particularized challenges" to such laws, such as--for example--an as applied challenge to a state's refusal to assist a terminally ill patient in severe pain from ending his or her life.
in 2006, in gonzales v oregon, the court decided another right-to-die case, although this one primarily on administrative law grounds, not constitutional grounds. voting 6 to 3, the court ruled that attorney general ashcroft exceeded his powers under the controlled substances act when he threatened prosecution against oregon doctors prescribing lethal drugs under that state's death with dignity act. writing for the majority, justice kennedy concluded that regulation of medical practices was primarily a job for the states and that ashcroft failed to recognize "the background principles of our federal system."
questions1. doctors examining nancy cruzan concluded that she was in a persistent vegetative state, had no awareness of her environment, and had no hope of ever having awareness of her environment. what reason is there to doubt that any person in nancy's circumstances would want--if they were capable of even wanting--feeding to be continued? was there any evidence at all suggesting nancy would want to continue to "live"?
2. in what sense could nancy cruzan even be considered a "person"? what are the essential attributes of a person? she wasn't a petunia. what would she be if not a person?
3. since nancy could feel neither embarrassment nor pain, isn't it really only the empathetic interests of the family at stake? how do we really know what she felt? really know?
4. what if missouri defined nancy as dead and ordered her feeding discontinued against the wishes of her parents? would they have any constitutional claim?
5. was missouri using nancy as a symbol? as a symbol for what?
6. should it matter whether the decision involved was to discontinue feeding rather than extraordinary treatment such as a ventilator?
7. could missouri have prevented the cruzans from taking nancy to another state that would allow their wishes to be carried out?
8. if there was a right to assisted suicide, as the 9th circuit found, why should the right be limited to terminally ill and competent adults? why would persons in great pain, or who are severely depressed, also have such a right? maybe they should.
9. does the distinction between passive euthanasia (withdrawal of feeding tubes, for example) and active euthanasia (administration of lethal drugs, for example) make sense to you? yes and no.
10. what state interests supporting laws against physician-assisted suicide do you think are the strongest?
linder, d. (2007). does the constitution protect the decision to end one’s own life, at
least if own is terminally ill or in great pain? exploring constitutional law. retrieved
february 22, 2007, from
please peruse the above and consider your own position. as nursing students who will be graduating in two months, many of us haven’t had this experience. while we all have individual opinions we, as a group, believe the positions of our peers is of great significance. we welcome responses, from pre-nursing students as well as vested clinicians, in the hope that we, as well as you, will take something of consequence from this discussion.
Mar 9, '07Just my opinion everyone should have to sign a Living Will or some other statement everytime they renew their drivers license. So everything is in writing.
Mar 9, '07Quote from prowlingMAI think offering the opportunity for people to do so at that time, or another time that is universal (as universal as possible) would be a great idea. How about if our primary care doctors offered us a copy of the standard forms most emergency rooms carry and put it in our file at our yearly checkup?Who better to know our wishes than our physician? Yes I know many of us don't have A PCP, myself included, but the more opportunities we have to do something, the greater chance we may take one of these opportunites. I realize my idealism borders on delusional, especially at my age, but I believe there is an answer, and hashing out ideas together may provide us with one that may just work.Just my opinion everyone should have to sign a Living Will or some other statement everytime they renew their drivers license. So everything is in writing.
Apr 8, '101. I cannot see any possible way that a person in Nancy's case would want to continue to receive feeding from a tube in her situation. There comes a time when we need to just trust the professionals that have seen this scenario played out time and time again. When the best case scenario that comes from continued feedings is merely sustained life that excludes awareness, emotion, love, or any other part of life that we all enjoy, we are probably obligated to allow them to die. This sounds harsh, but when someone is in a PVS for whatever reason, we have to assume that the physicians taking care of these people know what they are talking about when they say there is no hope left. There is no evidence in Nancy's case that would suggest that she would have any desire to continue as she is. At the same time, there is no evidence that suggests the alternative either.
2. I would suspect that for every person that was asked this question, you would have that many different answers. I think that Nancy would obviously be considered a person. To me, the definition of a person is the body of the human being. With that said, I maintain that she is a person, though she is a person that cannot take care of herself, cannot think for herself, and cannot make any decisions for herself. All of these things that she lacks is what would be applied to the attributes that define a conscious person.
3. I certainly think that because of Nancy's inability to feel pain or embarrassment, the entire dilemma is in the hands of the family. The family members are the only ones invovled with a true emotional stake in this case.
4. This is a tricky question because it goes back to the question of what defines death. There could be stark differences in what the state considers dead and what the family considers death to be. I don't believe that there would be any constitutional claim to going against their wishes. I think that if a patient has insurance or other financial means of paying for the treatment, then nobody should be able to tell them when they must stop. I don't think that the state should be involved unless there is a dispute within a family on whether or not to "unplug" a patient.
5. I don't think there was any "symbolism" whatsoever. I think this is a vague question and I'm not really sure why it was asked.
6. I feel that the end result is the same, death. Obviously, there would be no need for a ventilator if the patient was already breathing and just needed a feeding tube in place.
7. I don't think the state has any right whatsoever to determine what state a patient receives treatment in, or lack thereof.
8. I think that the decision for any individual to end their own lives rests within that individual alone. I am not a proponent of physician assisted suicide in the least, but if it becomes lawful, I think it must be reserved for those capable of making the decision on their own.
9. I think that there is a difference that must be looked at. I believe that passive euthanasia is probably a more ethical tactic than active. Active euthanasia just takes on an air of murder in my opinion. Whenever you intentionally administer something to someone to cause death, i think you are committing murder. Withholding medications that may be keeping someone alive but not improving their prognosis doesn't seem to have such a negative connotation.
Apr 9, '101. doctors examining nancy cruzan concluded that she was in a persistent vegetative state, had no awareness of her environment, and had no hope of ever having awareness of her environment. what reason is there to doubt that any person in nancy's circumstances would want--if they were capable of even wanting--feeding to be continued? was there any evidence at all suggesting nancy would want to continue to "live"? one could make the argument that only the very close family of nancy (for some patients that includes friends, etc) can answer that question for her. her health care professionals could only comment on this if nancy had ever directly communicated a specific wish to them.
2. in what sense could nancy cruzan even be considered a "person"? what are the essential attributes of a person? [color="#ff0000"]spiritually or physically?"
3. since nancy could feel neither embarrassment nor pain, isn't it really only the empathetic interests of the family at stake? [color="#ff0000"]i would suggest that we really don't have any idea what she "feels". although we have many methods of measuring the physical, we don't have good ways to measure the spiritual. having said that, whether or not she can feel embarrassed, she remains entitled to dignified care. her family should advocate for nancy in that way! further, i would offer the notion that the feelings of the family, and their care, should be a concern of the health care team.
4. what if missouri defined nancy as dead and ordered her feeding discontinued against the wishes of her parents? would they have any constitutional claim? [color="#ff0000"]would the parents have the claim?, or the state? i think if the state is paying for the care, and the professionals are telling them that there is no hope of meaningful recovery as well as suggestion that nancy had other wishes they can make a case. i think there is case law that might address this issue
5. was missouri using nancy as a symbol? as a symbol for what? [color="#ff0000"]
6. should it matter whether the decision involved was to discontinue feeding rather than extraordinary treatment such as a ventilator? [color="#ff0000"]it very much matters. it is much easier for a family to see a ventilator and assign some level of suffering to that experience. family, by and large, do not associate provision of nutrition with suffering...even when there is evidence that it is causing more harm than good. every living thing lives while it eats, when it stops eating it dies. when dying patients begin to refuse food some family members become fixated upon food. imagine how difficult the choice to choose to remove nutrition from your loved one knowing that the very thing will cause the decline toward death.
7. could missouri have prevented the cruzans from taking nancy to another state that would allow their wishes to be carried out? [color="#ff0000"]there would be no grounds for that action...where is the state's injury if she leaves? i seriously doubt the state would even consider spending money on that course of action.
8. if there was a right to assisted suicide, as the 9th circuit found, why should the right be limited to terminally ill and competent adults? why would persons in great pain, or who are severely depressed, also have such a right? [color="#ff0000"]i do not believe in assisted suicide so i cannot really answer your first question other than to say, if it were a right why would a society not want it limited to those who are adult and mentally competent?...terminal is sometimes in the eye of the beholder. people who are in great pain first have a right to adequate pain control as part of the health care. i would suggest that if we provided better pain management for that person he/she might not be interested in assisted suicide. it would not make sense to allow a person with a diagnosed mental illness to make a life and death choice and, as a nurse, you could be held liable if you obtained informed consent from someone whom is known to have a poorly controlled mental illness.
9. does the distinction between passive euthanasia (withdrawal of feeding tubes, for example) and active euthanasia (administration of lethal drugs, for example) make sense to you? [color="#ff0000"]as a hospice professional, the distinction is as clear as the blue sky over lake michigan on a brisk september morning! when the wishes of the patient are known, it is absolutely appropriate to withdraw supportive interventions. there is an enormous difference between removing intrusive medical intervention at the wish of the patient or dpoa vs. administering a lethal dose of a medication with the intent to cause death.
10. what state interests supporting laws against physician-assisted suicide do you think are the strongest? [color="#ff0000"]sorry, i have no idea.[color="#ff0000"]Last edit by tewdles on Apr 9, '10
Jul 25, '11I found the questions at the end to be very thought provoking. The point still stands that the patient's autonomy is very important. Nancy Cruzan was initially not allowed to be shut off of the feeding tube, because she had not expressed this desire. The argument can also be made about weighing the difference between beneficence and nonmaleficence. I think that keeping Nancy Cruzan on the feeding tube is actually harming her. In her persistent vegetative state, she could be feeling pain we just don't know. I do not see the good on keeping her on the feeding tube, the doctors all agreed that she was beyond help. There is no justice in denying the right to die to Nancy Cruzan.
Apr 6, '12I believe Physician assisted suicide should be illegal. I look at physicians as someone who is supposed to help you live as long as you can. It can be hard as a health care professional to separate personal feelings and professional responsibilities. Doctors do have the right to refuse to participate in PAS though. Even if that is the law in your state, doctor's personal morals might not allow them to assist a patient in dying. But I also believe that there are exceptions for different circumstances. No one would enjoy living in a brain dead state. Nobody wants to be a "vegetable" for the rest of their life. At that point, it is up to the patient's family. I honestly would not know what I would want if one of my family members were ever in that stage. It's hard to say what you would do until you are actually in that situation. I know there are people that would want to be kept alive though. Patients can choose to discontinue treatment which for some could lead to death. That is legal and the choice of the patient. That would be the legal way to allow one to die although that might be more painful for the patient. It might even be harder on the family that way. I do not believe that a healthcare professional in the health care facility that the patient is admitted to, should be able to make a decision for the patient at all. Some people say that families are selfish if they keep the patient around for as long as they can. I can see where they are coming from but I also see that it is selfish of the family to not keep the patient around. Some family members might want the patient gone so they can have some of the money or estate. I would like to think that there aren't family members out there that are that selfish, but I know there are. For some patients though, letting them go would be the most peaceful way for them to die. If you take them off of medications or treatments, they could die a very painful death. It would be helpful though if patients had previously filled out an advanced directive while they can still make decisions for them. That saves the family a hard decision. Overall, I believe ultimately it should be the patient's decision.