RIGHT TO DIE: A CHOICE THAT REACHED THUS FAR

RIGHT TO DIE
The worth and essence of life lies on the one that yields it. Human beings must be given the right
to decide for himself what to do with it. As Sartre (1946) thought: “Life has no meaning a priori…it
is up to you to give it a meaning, and value is nothing but the meaning that you choose.” Choice
is a right given to each individual to decide on things, judiciously and sensibly in order for a person
to arrive at a decision.
The phrase “Right to Die” has been used to give connotation to the one of the most talked-about
and deliberated subject matter on the end-of-life decisions by many. This is an umbrella of different
concepts and issues that consist of passive and active euthanasia, palliative care, suicide, assisted-
suicide, and physician-assisted suicide, a suicide that seems to be an assortment of active
euthanasia and assisted suicide by a licensed-physician (Cornell Law School, 2020). This term has
been used in many issues in the area of end-of-life discussions. Those discussions led to stirring
and shaking some sensibilities and moralities of physicians, especially here in the Philippines.
Many ethical and legal issues surround this discursive and cumbersome topic.
ASSISTED SUICIDE
Assisted suicide or commonly known as euthanasia is an act of permitting a person to terminate
his or her own life to end the suffering. It could be through administering a lethal substance to a
person upon his or her wish that ultimately ends an individual’s life. This is usually done by a
licensed physician (Pereira, 2011, and University of Missouri School of Medicine, 2020).
According to the University of Missouri School of Medicine (UMSM) (2020), this idea stems out
from the concerns of giving an individual a dignified death rather than leave them in a painful and
distressful situation. There are two types of euthanasia, the active and the passive type of
euthanasia. Active euthanasia involves direct participation in ending the life of the patient. It could
be injecting a lethal substance into the patient’s body (UMSM, 2020). On the other hand, passive
euthanasia also involves acts in hastening the death of an individual but in with an intention of not
providing medical treatment or action that could potentially delay the death (Garrard and
Wilkinson, 2005). According to Math and Chaturvedi (2012), euthanasia usually deals with a
person that is terminally ill, with a chronic debilitating illness, decides competently to end his or
her own life, patients refusing medical treatment, not capable of benefiting from the treatments,
and those who are suffering from pain that is intolerable that would result into a burdensome life.
Rules and Regulations – International
The practice of euthanasia is legally practiced in some countries around the world. One of which
is the Netherlands. The government of the Netherlands stated that euthanasia or assisted suicide is
only legal when the Dutch law on termination of life request is followed. This is usually done with
permission and guidance from a review committee (municipal level and regional level) to ensure
transparency and consistency in due care in performing euthanasia. In Kuwait, performing
euthanasia is an illegal act. However, Abohaimed et al (2019) reported that the perception and
attitudes of physicians in Kuwait are diverse towards euthanasia.
Rules and Regulations – Philippines
In the Philippines, euthanasia and assisted suicide are considered illegal acts. Many have been
pushing for the legalization of the practice of euthanasia in this country but until now, it is nowhere
near to become a law and be legalized. Nevertheless, there is a Code of Ethics for Medical
Professionals and some Philippine laws and ratified treaties in the international law that indirectly
addresses some issues regarding euthanasia and assisted-suicide in the country. Assisting in the
act of suicide or euthanasia of an individual is a violation of some provisions in the Philippine
Medical Association (PMA) Code of Ethics of the Medical Profession. This violates Article I
Section 1.1 of the PMA Code of Ethics. Principle of Respect for Life. “The right to life is
inviolable. Life is a necessary condition for all other human goods. It must be protected and
fostered at all stages beginning from conception to its natural death”. This means that in practicing
medicine in the Philippines, life is given the utmost importance and reverence. Life is also defined
and distinguished here that it originates upon conception and ends upon the natural death of a
person. It also violates the PMA Code of Ethics Article I Section 1.5. Primum Non Nocere. It was
stated that the foremost responsibility of the physician is to do no harm. Active euthanasia such as
administering a certain dose of lethal substance would at the end of the day bring harm to the
patient. Moreover, any violation of the said provisions in the PMA Code of Ethics will be penalized
according to Article X of the Code of Ethics of the PMA known as the Penal Provisions. It states
that “Violation of any section of the Code of Ethics shall constitute unethical and unprofessional
conduct, and therefore be a sufficient ground for the reprimand, suspension, or revocation of the
certificate of registration of the offending physician in accordance with the provision of the
Medical Act of 1959 as amended and Republic Act 8981 (PRC Modernization Act of 2000)”.
Suicide assisted by a physician is an act that is considered to be illegal under Philippine laws. The
Article 253 of the Revised Penal Code of the Philippines states that “Giving assistance to Suicide
– Any person who shall assist another to commit suicide shall suffer the penalty of prision mayor;
if such person leads his assistance to another to the extent of doing the killing himself, he shall
suffer the penalty of reclusion temporal. However, if the suicide is not consummated, the penalty
of arresto mayor in its medium and maximum periods shall be imposed”. The act of supporting a
certain individual, be it in a direct participation such as commencing the killing himself or in an
indirect participation such as assisting in his suicidal plans, is punishable by law according to this
code (Madanguit, 2013). Under the 1987 Philippine Constitution, Article III Section 1 of the Bill
of Rights indicated that “No person shall be deprived of life, liberty, or property without due
process of law, nor shall be denied the equal protection of the laws”. The Philippines adopted and
ratified the International Covenant on Civil and Political Rights (ICCPR) of the United Nations
Human Rights Council (UNHRC). According to the UNHRC (2013), Article 6 Section 1 of the
IPCCR stated that “Every human being has an inherent right to life. This right shall be protected
by law. No one shall be arbitrarily deprived of his life”. The right of an individual citizen of this
country is paramount and is always considered vital in every law and ratified treaties made by the
Philippine government. The right to life is important and of which all other rights of a citizen are
consequences thereof. It always takes into consideration the benefits for the welfare of its citizenry
and to assess its potential risks. The law is clear and definite regarding assisted suicide that it is
illegal and every individual has the right to life as what the law has recognized and upheld. It can
be resolved that many international laws and the Philippine laws are amalgamated in safeguarding
and protection of the right to life of each and every one. In the context of assisted suicide, assisting
a person in his or her suicide plans, be it in direct or indirect participation, is deemed as an offense
and infringement of the rights given to him or her (Madanguit, 2013).
LEGAL WITHDRAWAL FROM LIFE SUPPORT
Crucial decisions on whether to withhold or withdraw life support is never an easy job and it is a
substantial and a big challenge among health care providers. This daunting task lies in evading the
paradox and incongruity of personal ethics and morality and the sense of duty the health care
worker has taken an oath with (Reigner et al, 2019). Withdrawing life support can be a
cumbersome task for all the persons involved in decision-making. In some instances, when a
person is competent enough to make his or her own decision, he or she has the capacity to decide
on the matter at hand. Additionally, decisions on withdrawing the life support of the patient is also
passed to the family or on behalf of the patient to decide when he or she is not competent and has
no capacity to decide for him/herself (American Medical Association, 2020).
Rules and Regulations – International
Many, if not few, countries around the world have proper guidelines, procedures, and laws dealing
with the withdrawal of life support from the patients. Through the standard of advanced informed
consent, countries such as the United States of America, withdrawal of life support is legal. Most
of the courts use the principle in the Quinlan case by the New Jersey Supreme Court which ruled
that the patient has the rights, as well as the people on behalf to decide, to refuse life-supporting
machines or equipment. The same principle of ruling was also used by the California Court of
Appeals which stated that a physician with the consent from patient and patient’s family is not
liable for any violation of laws (Luce and Alpers, 2000).
Rules and Regulations – Philippines
Withdrawal from life support is different from assisted suicide in the sense that there are legal and
ethical parameters and guidelines to be followed in the process of withdrawing life support. There
are also provisions in the PMA Code of Ethics and the Philippine Constitution that can serve as
the basis for this action. According to the PMA Code of Ethics Article 1 Section 1.2. Principle of
Respect for Person. “Every person has an intrinsic worth and dignity. Trust shall be central to
physician-patient relationship. Physicians shall respect patient autonomy”. This provision puts the
patient’s right to have autonomy over his or her own body and life as paramount in the practice of
medicine in the Philippines. Article I Section 1.4 of the PMA Code of Ethics states that Principle
of Beneficence. “The interest of the patient shall be placed above those of the physician. Societal
pressures, financial gains and administrative exigencies shall not compromise this principle.” This
also means that whatever may the decision of the patient be, be it against what the physician wanted
to do or congruent to it, the physician must respect and abide by what is the patient’s decision.
Moreover, PMA Code of Ethics Article III Section 3.6 states that: Autonomy. “A physician shall
obtain voluntary informed consent prior to performing any procedure or treatment. The patient’s
decision must be based on his/her free will and choice. The physician shall provide all relevant
information in a simple and understandable manner leading patients to either accept or refuse a
proposed action. The physician shall inform the patient about the consequences of his/her choices.
When a patient is incompetent to decide, the consent must be given by the next of kin, or his/her
legally authorized representative.” This gives the patient all the more power and control over
himself/herself. Patient autonomy is the first and foremost priority in any actions and decisions
taken by the physician. The older version of the PMA Code of Ethics has Article II Section 5 which
indicated that a patient can refuse a medical treatment and the physician shall respect this decision.
It was not included in the current version of the PMA Code of Ethics but this served as one of the
bases for the cases of life support withdrawal by some hospitals and physicians. Capule (2015)
described that most physicians nowadays are not having a hard time in giving a decision regarding
the refusal of treatment of the patient for the reason that the physicians respect the patient’s right.
However, whenever it comes to dealing with life-support withdrawal, most of the physicians in
the Philippines are hesitant and tend to be more cautious in deciding and doing the act of
withdrawing the life-supporting intervention. The complex moral and ethical values of a physician
are suddenly taken aback and grapple when faced with this kind of harsh reality.
DO NOT RESUSCITATE (DNR)
Death is unescapable for some people. Whenever there is a looming death of a patient, physicians
lean towards doing everything within their capacities and give whatever is needed in order to save
the life or prolong it a bit longer. However, not everything is in the physicians’ hands and certainly
cannot do everything. According to Manalo (2013) and Capule (2015), physicians in the
Philippines are confronted with a much-avoided predicament of terminating life support and do
nothing when the patient goes into a cardiorespiratory arrest whenever there is an advanced
directive of DNR. A Do Not Resuscitate is an order made by physicians if the patient or the family
or anyone that is a legal representative on the patient’s behalf wishes not to receive any medical
interventions. According to Leon-Intal (2015), a person can state his or her wish whether to
prolong life or not through refusing any measurements such as Cardiopulmonary Resuscitation
(CPR) called a living will or health care directives. In any case, if there are no advanced directives
from the patient, an informed consent is obtained from the family or legal representative before a
physician orders a Do Not Resuscitate directive. This is for the physicians to avoid not just legal
corollaries as well as not to be burdened by remorse, of the societal culture in the Philippines
towards end-of-life issues, sadness and concerns towards the interplay of emotions of the family
(Manalo, 2013). Moreover, Manalo (2013) implied that physicians are not comfortable and have
a tendency to avoid any discussion regarding end-of-life making CPR or DNR conversations in
non-urgent circumstances with the patient or the family not likely to happen.
In making Do Not Resuscitate decisions where the patient has no DNR decisions, the family
members or legal representatives that act as substitutes in decision making are encouraged to make
a moral choice in valuing the life of the patient. One of the problems uncovered in this kind of
situation is when DNR is chosen over the other, the notion of many would be that it is just letting
the patient die and in effect picture the physician and the family members as people who are
nonchalant and could care less about the life of the patient (Manalo, 2013). An autonomously
singed DNR form is a legal file that consents a person to convey their desire on medical care to
the loved ones and to the health care workers when it came to a scenario wherein they are not
competent and capable of deciding (Abando et al, 2018). In circumstances wherein the patient has
autonomously signed a DNR form, many difficulties are also faced by the physicians and family
members in this kind of state of affairs. Even though the physicians in the Philippines respect and
put patient autonomy as a paramount principle, it is inevitable to have mixed outlooks and have a
conundrum towards this experience. However, according to Article II Section 2 of the PMA Code
of Ethics: “While recognizing that it is the prior right of the patient to choose his physician, a
physician is under no obligation to accept a patient unless the situation is an emergency or he is
the only physician in the community.” In this context, a physician can refuse a person with an
advanced directive of DNR if it is against the values of the physician. The older version of this
Code of Ethics has Article II Section 5 pointed out that patients have the right to refuse any medical
treatment and this shall be respected by the physicians. In addition, the Philippine Department of
Health (2020) has a Citizen’s Charter in all public hospitals in guiding the patients of their rights.
It was stated that a patient of legal age and competent and has the capacity to decide has the right
to self-determination to make a decision regarding written advanced directives to his or her
physicians in giving terminal care when he/she suffers from terminal illness given that the patient
received an informed choice of the consequences, the patient released from the burden of
obligation those who are involved, and public health and safety will not be put into prejudgment.
Moreover, according to Manalo (2013), the Religious-cultural aspect of society is a large influence
in the acceptance and decision-making of the family. The perspective here in the Philippines
regarding the withdrawal of life support and DNR is likened to killing the patient. It should be also
put in mind that Manalo (2013) suggested that in any case, there should be acceptance and the
health care team is in one accord in the decision of the patient. It was also stated that withholding
therapy such as DNR for this matter, requires patient autonomy and patient wellbeing, the two
justifications for arriving at an ethical decision. Patient autonomy is the center of the issue of DNR.
Patient autonomy has been the center of the issue in a signed DNR form. It has been recognized
by the PMA and the World Medical Association (WMA) that while medical doctors should act in
accordance to his or her conscience and the best interest of the patient’s wellbeing, the patient’s
autonomy and justice must be of equivalent value to the former (Manalo, 2013).
CHANGES AND CONCLUSION
There were provisions on the Constitution, other laws, and Code of Ethics regarding the rights of
the patient on his life. However, up to this date, there were no enacted laws in the Philippines that
directly addresses the issues on the right to die. There are proposed changes in the perspective
towards right to die in the Philippines. According to Garcia (2017), there were proposed bills in
the House of Representative (House Bill 564, Magna Carta of Patient’s Rights) and Senate of the
Philippines (Senate Bill 1887, Natural Death Act) that identifies the essential rights of an adult
persons to choose for their personal health care. This includes withholding or withdrawal of
treatment in the event of terminal illness or condition wherein the patient cannot decide for himself.
However, due to a strong opposition from the Catholic Church, these proposed laws were left to
die. Having these laws would give a clear basis for the decisions and actions of patients, family
members, and physicians (Garcia, 2017). Moreover, Garcia (2017) stated the state recognizes its
people’s right to life and in that sense it also recognizes its people’s right to health, which includes
the right to choose. Agony and distress is not part of being healthy, especially those who are
suffering from chronic and terminal illnesses. It was reasoned that denying the patient to choosing
to die is also denying him of his rights to health, welfare, and dignity. It was added that death is
part of life and it does not end life, but it is a state wherein life is concluded. The Philippine
Supreme Court invoked the right of life in the case of Imbong vs Ochoa (Section 2, RA 10354), it
should be also invoked in relation to the right to die.
DO NOT RESUSCITATE FORM (retrieved from:
https://rojosonwritingsonhospitaladministration.wordpress.com/2017/11/05/do-not-resuscitate-
forms-enjoining-other-hospitals-in-the-philippines-to-share-2/)
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