Medical Ethics

Concepts/Physician Assisted Suicide

September 5, 2023
Prof. Silberman
 Medical—Bioethics Issues

 Informed Consent

 Human Enhancements—Emerging Technologies

 Patients Right to Decline Treatment,

 End of Life Decisions— Palliative Care;

 Organ and Device Allocations

 Priority of Treatments—Under What Conditions?

 Robotics and Autonomous Robotics

 Reproductive Bioethics;
 Dual Loyalties--Issues

 Cost/Benefit Medical Plans,

 Quality of Life vs. Length of Life;

 Costs of Innovative New Medicines—Personal Directed

Treatments;
 When is it permissible to alter treatment based upon the
abilities for payments?
Overlap to Military—Do Rules Change?

 Wounded and sick must be protected in all circumstances;

 Must be treated humanely must receive, to fullest extent practicable,

and with least possible delay, the medical care and attention required
by their condition;
 There must be no distinction in the treatment of the wounded and sick
on anything other than clinical grounds;
 Forces must care for wounded and sick of enemy forces taken prisoner
as they would care for their own, and;
 No one shall be compelled to perform acts contrary to rules of medical
ethics, or to refrain from action which is required by those rules.
 Rules in Triage

 IDMD

 Immediate;

 Delayed;

 Minor;

 Deceased
 Triage And Moral Pressure

 Feelings “treat your own” ahead of enemy are natural,

especially if you have witnessed your own getting hurt;
 If we are allowed to be influenced by personal beliefs it
could lead to objectively unethical decisions in other areas.
 Patient Consent

 Perhaps the greatest cornerstone in medical ethics;

 Nuremberg War Trials revealed the most horrible of medical

experiments;
 Seawater immersions solely to test survival times;

 Deliberate injections of disease in humans;

 Atmosphere survival tests to gain knowledge for pilots;

 Should we use this knowledge? “fruit of the poisonous tree.”

 Patient Capacity

 Minor saying, “don’t you even think of doing that.”

 What about intellectually disabled, is there a lawful consent?

 Experiments of injecting hepatitis into mental patients,

Willowbrook
 Comprehension?

 Totality of circumstances?

 How is consent question framed—permissible nudging.

 How Is Message Conveyed?

 Body language may be compelling;

 Pointing, thumbs up, grinning, where you point your foot,

all have different meanings in different cultures;
 Medical terms may be confusing standing alone;

 Crossed arms;

 Pause in response back;

 Silence is not always an affirmation.

Consent—Can Be Express or Implied

 Consent Forms are evidence of consent but not necessarily

the last word;
 It is quality and clarity that should serve as principal
consideration;
 In emergency situations consent may certainly be implied,
but individual locations may have specific rules;
 Mandatory Vaccinations

 For school—upheld—unless for demonstrated religious

objection or health reason (allergy or other health
objection to vaccine)
 For healthcare workers upheld—NY rule—Roll up your
sleeve or mask if in patient contact;
 Infections on ties, clothing, carriers even though not
personally infected;
 DNA now possible to track who has not been vaccinated.
 Privacy-Confidentiality

 HIPPA and insurance issues;

 Speaking in crowded noisy areas—elevators;

 Is the dividing curtain really enough?—who is being

protected—not just main patient;
 Haste makes poor choices.
 Competence

 Basic question—Is it unethical for a healthcare provider to act

above his or her level of competence?
 When is it ever permitted?

 “Where Drs. are requested to undertake a procedure that they

believe exceeds their competence and could harm patients, they
should, where possible, request supervision from a senior or
more experienced colleague, to ensure that that any risks to
patients are minimized.”
 If the more senior or experienced colleague is not available than
the Dr. should refrain from the procedure.
 When Is A Healthcare Worker Not A
Healthcare Worker?

 Assistance at PAS—Kevorkian;

 Oregon and Washington state laws;

 Physicians at lethal injections?—recent examples with

Eighth Amendment—Is it Cruel and Unusual Punishment?
 Rochin test—Shocks the conscious—stomach pumping;

 Being compelled to testify and the 5th Amendment.

 Children And Medical Ethics

 History of Polio and Polio vaccine notable example;

 Jonas Salk and Salk vaccine proved to be great- Franklin

Roosevelt at age 39 contracted infantile polio;
 Public really at a standstill-didn’t know what to do, should
you send your child away to summer camp if you could—
get away from heat and crowding of cities, or would child
be worse off in a bunk with other children?
Polio Clinical Trials Massive Consent

 Background—1954 75% of polio cases < 20 years old;

 50% of infected children <10 years old;

 Clinical trial conducted—1.8 million children- grades 1-3 215

schools;
 Double-Blind Trial

 650,000 vaccine

 750,000 placebo;

 430,000 neither
 Polio Trial (cont’d)

 July 12, 1955 polio vaccine declared effective, 1955 vaccine

licensed by federal government;
 Questions to ask;

 What is proper relationship parent to child?

 What are the obligations of parents?

 What are obligations of society?

 Child Medical Ethics and Decisions

 Who decides?

 What medical approach to a child’s care;

 What information is shared?

 Is it ever ok not to treat? Jehovah’s Witnesses;

 When may a child enroll in a study?

 When is a child considered an adult for these types of

decisions?
 Ethics Background

 What is it?—examination of what is right and wrong;

 Making what may be implied or assumed in our conduct or

behavior explicit;
 Ethics may also be an examination of power relationships.
 Why Ethics is Beneficial

 Helps guide our actions when there are many options and
the right path may not be so clear;
 It can provide clear or “clearer” ways to act;

 Ethics can bolster our initial decisions, or not, if there is a

difference in opinion about how to proceed.
 Ethics And The Law

 Often treated in tandem with each other;

 People-society generally wish to have a morality-based

legal system whether that be just and fair punishments
and general respected freedoms;
 No birth control rules placed within our privacy and
bedrooms, but stand by, recent Dobbs decision;
 Tracing the history of ethics through legal cases is a good
way to examine the developments.
 Patients and Human Autonomy

 Enjoys a long tradition in American history;

 We place great value on our rights and freedoms;

 We have a “must not” rather than a requirement to do”;

 States may only step in to stop certain rights if there is “compelling”

state interest;
 We enjoy many rights—some expressly stated within Bill of Rights, first
10 amendments to the Constitution, but there are many implied rights
coming out of the basic rights;
 These are are termed the “penumbra” of rights that emanate from the
basic rights
 Medical Patient Autonomy

 Not that long lived—but evolved to a much more patient

centered position;
 1847 Code of Medical Ethics;

 “Obedience of the patient to the physician should be

prompt and implicit”
 He the patient should never let his own crude opinions of
them to interfere as it may cause a judicious treatment to
be rendered ineffectual or even harmful.
 Collaborative Effort Of Physician And
Patient

 Right of Patient to refuse treatment on any procedure;

 Physician’s “ I know what’s right and you should listen”;

 Calling for the pitch and waving it off;

 Who controls?
 Collaborative Efforts

 Patient’s right to refuse any recommended treatment;

 Adopted under AMA’s “Fundamental Element of the

Physician-Patient Relationship”;
 June 1990, JAMA, 1990, 262: 3/33, Updated 1993;
 Establishing Principles of Informed
Consent

 Mary Schloendorff agreed to be examined under

anesthesia to decide if fibroid tumor was malignant or not;
 Mary did not give consent to physician to remove tumor;

 The surgeon removed the tumor anyway;

 Mary sued—Results—the operation to which she did not

consent constituted a medical battery.
Case Became Known as the Schloendorff
Rule.

 Justice Cardozo, ”Every human being of adult years and

sound mind has right to determine what shall be done
with his own body, and surgeon who performs operation
without his patient’s consent commits an assault for which
he is liable in damages”;
 This is true except in cases of emergency where patient is
unconscious and where it is necessary to operate before
consent can be obtained.
 How Much Information Is Required to be
Told?

 Canterbury, 19 year-old clerk-typist working for FBI in DC;

 He experienced severe back pain between shoulder-blades

consults with two doctors and consents to operation,
laminectomy to correct his ruptured disc;
 Because of his age—Dr. Spence, neurosurgeon, calls his
mother living in West Virginia explains operation—but
does not explain possible outcomes.
 Canterbury v. Spence (cont’d)

 Canterbury has operation falls out of bed while attempting

to “void”;
 Becomes paralyzed from the waist down;

 Cannot work anymore for FBI, he always needs to be near

a bathroom and needs frequent use;
 Court held, there was a duty to disclose possible risk of
paralysis from operation—which included risk involved in
totality of treatment.
 What Information Required To Be Given
To Patients?

 Duty to disclose gained recognition among the

jurisdictions;
 Majority of courts and customs have made duty to disclose
on whether or not physicians practicing follow applicable
standard of care;
 BUT—full disclosure “a norm we are unwilling to adopt”—
literally it seems obviously prohibitive and unrealistic…
 Unnecessary from the patient’s perspective as well;
 Disclosure--What Is Left?

 Risk of (non-disclosure) material when a reasonable

person… would be likely to attach significance;
 Thus, we have a “reasonable person” standard;

 Reasonable person standard frequently used in many

areas of law—what would a reasonable person or, a
professional do?
 Courts and juries interpret.
 Nazi Human Experimentation

 Leads to Nuremberg Code; Primary duty of researcher is to gain informed

consent without coercion or fraud;
 Ten points of the Nuremberg Code;

 1) Voluntary consent of the human subject absolutely essential—includes

legal capacity;
 2) Experiment should be to conduct fruitful results for the good of society-not
random or achieved by other means;
 3) Experiment should be so designed and based on the results of animal
experimentation;
 4) Experiment to be designed to avoid all unnecessary physical and mental
suffering and injury.
 Nuremberg Code (cont’d)

 5) No experiment where there is prior reason to believe

that death or disabling injury will occur, except where the
experimental physicians also serve as subjects;
 6) Degree of risk never to exceed that determined by the
humanitarian importance of the problem to be solved;
 7) Proper preparations to be made and adequate facilities
to protect subjects against even remote possibilities of
harm.
 Nuremberg Code (cont’d)

 8) Only scientifically qualified persons to conduct

experiment with highest level of skills through all stages;
 9) Human subject is free to bring experiment to an end at
all stages of experiment;
 10; Scientist in charge must be prepared to end
experiment at any stage if probable cause to believe in the
exercise of good faith that experiment likely to result in
injury, disability, or death to the experimental subject.
Tuskegee Syphilis Experiment

 Point of experiment, to determine whether those affected

were better off being treated or not being treated;
 1932—prior to penicillin—chief method used arsenic based
medication;
 Length of Study 1932-1972;

 During course of study development of penicillin and other

antibiotics would have clearly been effective to the subjects.
 399 African American sharecroppers recruited;
 Tuskegee Led to Belmont Report

 Belmont Report—Primary respect for informed consent

and the welfare of research subjects;
 Autonomy now dominates our treatment of patient
ethics;
 Why, generally held individuals rather than physicians,
researchers as a whole are better to protect our interests;
 But society frequently overrides patient’s individual
interests when society benefits as a whole.
 Oregon Death With Dignity Act

 Act requires that patient must be:– adult (18 years of age
or older)– resident of Oregon– capable (defined as able to
make and communicate health care decisions;)
 Diagnosed with a terminal illness that will lead to death
within 6 months;
 Patients meeting these requirements are eligible to
request a prescription for lethal medication from a
licensed Oregon physician.
How Good Are Estimates of Prognosis?

 Gripp (University Hospital Dusseldorf) investigated

subjective prediction of survival;
 216 patients referred for palliative radiotherapy. Survival (<1
month, 1‐6 months, >6 months) was appraised correctly by
61.3% of a pool of physicians, 54.9% of experienced
radiation oncologists, and 62.7% of tumor board physicians.
 Correct assessments of patients who died within 1 month
were rare. 48‐78% of patients were predicted to survive 1‐6
months, and 17‐23% were predicted to survive > 6 months.
 Oregon Death With Dignity Act

 Oregon Death with Dignity Act• To receive a prescription for

lethal medication, the following steps must be fulfilled:
 Patient must make two oral requests to their physician,
separated by at least 15 days.
 Patient must provide written witnessed request to their
physician (two witnesses);
 Prescribing physician and a consulting physician must confirm
diagnosis and prognosis. Prescribing physician and consulting
physician must determine whether patient is capable.
Oregon Death With Dignity Act (cont’d)

 Requirements– If either physician believes patient's

judgment is impaired by psychiatric or psychological
disorder, patient must be referred for psychological exam.

Prescribing physician must inform patient of feasible

alternatives to assisted suicide including comfort care,
hospice care, and pain control.

Prescribing physician must request, but may not require,

patient to notify next‐of‐kin of the prescription request.
 Oregon Death With Dignity Stats

 27 patients participating resembled 6,981 other Oregonians

who died from similar underlying illnesses with respect to
age, race, and residence;
 However, as education increased so did likelihood of
participation. Patients with college education eight times
more likely to participate than people without high school
education (95% Confidence Interval [2‐43]);
 Patients with post‐baccalaureate education 19 times more
likely to participate than people without high school
education (95% Confidence Interval [4‐88]).
 Netherlands PAS

 Euthanasia and PAS since 1980s, criminal code exception: physicians

commit no offense if follow “due care”
 •1.7% of deaths by euthanasia & 0.1% by PAS;

 Guidelines require, voluntary informed and well‐considered request; current

or future – Physician must agree no reasonable alternative available;
 Physician must consult with another, independent physician action
performed with due care;
 Reported to the appropriate authorities;
 •Does not require terminal illness; does require “unbearable and hopeless
suffering.”
U.S. Position On Death With Dignity

 United States Supreme Court• June 1997;

 Unanimous decision, no Constitutionally recognized

“right to assistance in dying”;
 Back to the “Laboratory of the States”

 Decision based largely on input from the AMA.

 AMA Brief to Supreme Court

 American Medical Association brief to the Court:– “The

pain of most terminally ill patients can be controlled
throughout the dying process without heavy sedation or
anesthesia. . .

For a very few patients, however, sedation to a sleep‐like

state may be necessary in the last days or weeks of life to
prevent the patient from experiencing severe pain.”
U.S. Supreme Court Language

 With this assurance from the medical profession, Justices

O'Connor, Breyer, and Ginsburg wrote in their concurring
opinions:
 That the case for a right to assisted suicide had not been
made.
 If a right to assisted suicide turned on the need to relieve
the suffering of patients, the alternative of terminal
sedation made such a right unnecessary.
Oregon Death With Dignity Provisions

 Allows terminally ill Oregon residents to obtain and use

prescriptions from their physicians for self‐administered,
lethal medications;
 Under Act, ending one's life in accordance with the law
does not constitute suicide;
 The Death with Dignity Act legalizes PAS, but specifically
prohibits euthanasia, where a physician or other person
directly administers a medication to end another's life.
 Other Permissive Societies

 Switzerland‐started 1918 effective 1942, allows assisted suicide

but outlaws euthanasia, clinics for “tourists” sprung up 1980s;
 • Australia, PAS 1995, but since illegal;

 Spain ‐ Likely to pass new legislation soon;

 Thailand – euthanasia legal since March 2007;

 Albania – euthanasia legal since 1999• Belgium – euthanasia

legal since 2002 • Japan – passive euthanasia since ~ 1995 ,
Canada suicide not a crime, but PAS still is.
 Netherlands Addendum

 Netherlands allows euthanasia of severely disabled

children (for the last 15 yrs.'), birth defect has to be severe
enough to be generally accepted as incompatible with life;
 Consent of both parents required;

 England considering similar legislation (Nov’06);

 Congressional Republicans intervened on behalf of Terri

Schiavo’s parents in blocking removal of feeding tube
despite her husband’s decision.
 2016 Update U.S. “Death With Dignity”
Laws

 PAS, or "medical aid in dying", legal in eleven jurisdictions:

California, Colorado, DC, Hawaii, Montana, Maine, New
Jersey, New Mexico, Oregon, Vermont, Washington.
 Legislation introduced in 2015- 18 states;

 Acceptance is growing—1947 about 37% ok with it;

 2003-over 70% ok with it;

 Those finding it morally wrong—2002 about 50%, 2015-

38%
 Assignment

 1 Do you feel it is morally wrong to take one’s life if faced

with a terminal illness, why or why not?
 2. Do you feel that where PAS , or DWDA statutes are legal
that medical practice should also allow euthanasia as in the
Netherlands? Why or why not?
 Your writing should be a one to two page analysis. A total
of ten points will be assigned to this writing assignment.
 The paper is due prior to next class on Tuesday September
12,.