Right to die vs. right to live

[BSNin2007]

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 die

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?

the 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.)

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."

questions

1. 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?

3. since nancy could feel neither embarrassment nor pain, isn't it really only the empathetic interests of the family at stake?

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?

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?

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

http://www.law.umkc.edu/faculty/projects/ftrials/conlaw/righttodie.htm

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.

[ponytailman]

Your post on the topic right to die vs right to live is a challenging one both personally and professionally. Unfortunatlely, if you are a direct care nurse taking care of a patient in this position and I have it is your professional responsibility to follow the current legal doctor orders irregardless of your personal feelings on what is happening. As a nurse you are obligated to make sure your patient is receiving the care ordered and regulated by your facility and state's standard's of care and unless otherwise ordered follow through. If your personal feelings or morals say otherwise, it is your responsiblity to let others know and arrange other nurses to provide the physicians orders or if you feel the current orders wrong or invalid use your position to question. Each nurse is a patient's advocate,how we advocate can,will and does ultimately effect the patient entrusted to us.

[BSNin2007]

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.

[adnstudent2007]

I'm going to answer just a couple of the questions. These are just my personal opinions.

The fact that we have advanced directives at all indicate that there are people who would in fact want to be kept alive. These may be for any number of reasons, but there are people who want every possible thing done for them-no giving up and they do indicate this on their advanced directives. I also know of some extraordinary sad cases (which I can't give details due to HIPAA) but due to personal circumstances must be kept alive for unusual reasons. I don't think anyone should have to prove that they would want to live. Proof should be required to show they wouldn't want to be on continual life support.

I was unaware that there are places that assisted suicide may be considered legal. I do believe that there is a big difference in discontinuing futile medical treatments and actively assisted in suicide.

While there are a few high profile cases regarding the right to die, it seams like most questionable cases are handled at the hospital level, possibly with an ethics committee. I would be uncomfortable with the health profession having too much input on these cases simply because there are so many diverse beliefs on this topic. It is an ethical/legal concept which health providers have valuable input, but shouldn't be the deciding factor.

[BSNin2007]

I would like to clarify that I am in no way stating that if in fact someone wants extraordinary measures to be taken that anyone should have the right to say otherwise. By the same token, if someone does not want these measeures taken isn't that also their right?

[adnstudent2007]

I think it was just the way the bottom questions were phrased (possibly by your instructor) that seemed to incline the answers a particular way.

[BSNin2007]

this is the source from which i retrieved the piece and the questions. i am not supporting either side, i am looking for your opinion(s). i appreciate your input greatly and encourage opinions and facts from all sources.

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

http://www.law.umkc.edu/faculty/proj...righttodie.htm

[HM2VikingRN, RN]

I think the real question becomes "Does an individual patient have a constitutional right to adequate pain management be that opiates, cannabis etc" My understanding of the issue is that patients who have access to adequate pain management are very unlikely to seek a premature end.

[Janus Rising]

Toughy! Please note that these are my personal opinions and not my professional ones:

On a personal level, I am a big proponent of assisted suicide for the terminally ill, yet as a Nurse (student) I am not "allowed" to follow that train of thought. I honestly believe that if a client has the ability to clearly make their needs and wishes known that those needs and wishes should be followed.

As far as vegetative clients, I think it's selfish on the part of families and usually the state to keep these people alive forever. After a certain amount of time, if there is no improvement, they should be allowed to go in peace.

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. My wife isn't keen on talking about stuff like this, but she understands where I'm coming from and will honor my wishes. We even have an agreement about our daughter (who's 1) just in case. I sincerely feel that advance directives, etc. should be the focus of a massive public education push just liek cigarettes and AIDS.

[RunnerRN, BSN, RN]

I have very strong feelings on this issue, as does most of my family. We have all filled out advance directives, as well as DPOAs. I'm 25! I'm still shocked by the number of people who, even after the Nancy Cruzan and similar cases, don't have advance directives OR haven't even spoken to their families about their wishes. This discussion has gotten to be a family joke for us "ALL RIGHT RunnerRN. We know you dont' want to be kept alive if there isn't hope of recovery. And yes, we know full well you want to donate your organs."

I do bring the subject up with my patients at discharge (I work in the ED) and direct them to the websites where one can fill these out.

I don't think I answered any of your questions. I guess what I'm trying to say is that because no one can make that decision for a person except for THAT PERSON, it is so important to have these documents and discussion while still able.

In school, we did a similar project. There was an excellent movie that a teacher showed called "Whose life is it anyway?" about a young man who was involved in a car accident, and was paralyzed. He was trying to get the right to withdraw his own treatment and die. She stopped the movie at a point where we had all gotten emotionally involved, and had us discuss how we thought it had ended. Great points brought up by all. I also remember a classmate showing a news magazine style video about a woman whose young husband had ALS, and she helped him commit suicide. Very powerful stories. I'm sorry I can't remember the name of the show, but I'm sure it wouldn't be too difficult to find it.

Anyway, good luck with this project. Very polarizing subject matter!

(When this topic was done in my class, AD packets were passed out at the end. It was really interesting to see the way the wording was, and the options that were available.)

[HM2VikingRN, RN]

We have done five wishes packets in 2 separate classes for Nursing school.....

[BSNin2007]

We have done five wishes packets in 2 separate classes for Nursing school.....

Please clarify what you mean by a five wishes packet.

Is it a form of AD?

Is it a standard form?

If so, where can I access it?