End-of-Life Issues

Defining Clinical/Legal Issues at the End of Life

This following section defines key terms and concepts pertaining to end-of-life decision making, including physician-assisted suicide (PAS), euthanasia, do-notresuscitate (DNR) orders, and advance directives. Perhaps the most controversial of these issues are PAS and euthanasia. Both these interventions involve actions that directly lead to a hastened death in a seriously ill person; however, they vary in the nature of the clinician's involvement. In PAS, the clinician provides assistance and guidance, typically in the form of a prescription for medication that the patient can use if he or she chooses to commit suicide. Of key importance, it is the patient and not the physician who ultimately administers a lethal dose of medication. In 1997, this practice was legalized in Oregon, resulting in fierce public debate. Euthanasia, on the other hand, involves the intentional administration of a lethal medication by the clinician (presumably in response to a patient's request) for the sole purpose of ending life. In 1998, one of the leading proponents of [Page 255]euthanasia, Dr. Jack Kevorkian, provided a lethal injection (i.e., euthanasia) to a patient suffering from amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig's disease) on national television. He was subsequently convicted of second-degree murder and sentenced to 10 to 25 years in prison. Although euthanasia is now legal in the Netherlands and Belgium, it remains illegal in the United States.

Both PAS and euthanasia are distinguished from the clinical practice of administering high doses of pain medication in an effort to control severe pain, often with the awareness that death is likely to occur. This practice, referred to as “the law of double effect,” differs because the express purpose of the medication is to control pain, not to end life.

In addition to interventions that have the direct effect of ending life immediately, there are a number of other death-hastening procedures that are often the source of controversy and psycholegal inquiry. For example, death can be hastened by withdrawing or refusing life-sustaining medical care, sometimes referred to as “passive euthanasia.” This includes decisions to remove mechanical ventilation (i.e., a machine to keep a comatose patient breathing), refuse needed renal dialysis, or refuse or terminate artificial nutrition and hydration. In such cases, the rejection of needed medical interventions can hasten a death that might otherwise be delayed for weeks, months, or even years. Yet while legal debate and controversy surrounds more direct interventions such as PAS and euthanasia, the right of a mentally competent adult to refuse life-sustaining interventions is uncontested.

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