“Concierge medicine,” “retainer medicine,” “platinum medicine,” or what some refer to as “executive health programs” is a new concept but one that is here to stay. The basic concept entails a situation whereby a patient pays a set annual fee for “special medical services.” The cost of such membership ranges from $1,500 to $20,000 depending on the services that are provided, as well as the age and health of the patient. As stated above, there are numerous benefits and disadvantages to this new alternative medical practice. The main ethical issues focuses on whether concierge medicine will result in a two-tiered medical system based upon economics; is this a form of patient abandonment; and how does this new form of medical practice address the age old notion that physicians have a professional obligation to provide care for all those in need, especially the most vulnerable of patients? To determine if concierge medicine is ethical it will be evaluated by the basic ethical principles of respect for persons, beneficence, nonmaleficence and justice47.

Respect for persons incorporates two ethical convictions: first, individuals should be treated as autonomous agents; and second, persons with diminished autonomy are entitled to protection. The principle of respect for persons thus divides into two separate moral requirements: the requirement to acknowledge autonomy and the requirement to protect those with diminished autonomy48. The physician-patient relationship is a covenant that is based on mutual trust. It is a fiduciary relationship that is based on honesty. Ethicists Edmund Pellegrino and David Thomasma, who have written extensively in this area, argue that among the obligations that arise from the physician-patient relationship is technical competence: the act of the medical professional is inauthentic and a lie unless it fulfills the expectation of technical competence49. This means that patients can expect their physicians to offer the same standard of diagnostic and therapeutic services to all patients.  The American Medical Association is quite clear regarding this issue:

Concern for quality of care the patient receives should be the physician’s first consideration. However, it is
important that a retainer contract not be promoted as a promise for more or better diagnostic and therapeutic
services. Physicians must always ensure that medical care is provided only on the basis of scientific evidence,
sound medical judgment,relevant professional guidelines,and concern for economic prudence.50

Autonomy gives physicians the right to offer concierge care and patients the right to take advantage of these exclusive services. Many concierge physicians argue that this type if medicine is not only in the best interest of the patient but also in the best interest of the physician. Physicians can practice more personalized medicine without being constrained by time and income issues. Having more time to spend with patients will allow physicians to focus not only on treating diseases and injuries but also preventing them. Preventive medicine has been proven to save patients money and suffering.  The problem area that arises is the issue of patient abandonment.  The cost of concierge medicine can eliminate a number of patients from a physician’s practice as was discussed earlier in the paper. Critics argue that this could be seen as a form of patient abandonment. Advocates respond to this criticism by arguing that as long as physicians have a careful transition process that assists patients in finding new physicians and allows for continuity of care then this objection can be negated. The American Medical Association offers a strict guideline on this matter which was referred to on page thirteen.  Abandonment of patients violates their basic human right of respect for persons, because they are not being treated with dignity and respect. If a patient is abandoned for economic reasons this patient can be considered vulnerable because their medical conditions are being untreated and their quality of life suffers. This violates the principle of respect for persons because we are failing to protect those individuals with diminished autonomy.

Another area that relates directly to the principle of respect for persons is the issue of informed consent. Most commonly, informed consent refers to surgical procedures and operations.  However, in this paper, informed consent also refers to the legal contract between patient and physician.  Patients have a right to be informed about the services that are covered and not covered as well as the retainer fees for their medical care.  This contract should also provide termination language. Patients have every right to be informed about the duration of the contract and renewal arrangements. Physicians need to be very careful in following all the rules and regulations regarding opting out of Medicare and/or other third-party payers and patients need to be informed about these arrangements and their payment responsibilities. Patients cannot give informed consent unless they have adequate knowledge about their options.  One of the basic aspects of the principle of respect for persons is that a person should never be treated simply as a means, but always as an end. Failure to treat a patient because of economic issues or failure to inform a patient of the cost and extent of contracted medical services is to use patients as a means rather than an end. However, if concierge physicians have a plan of continuity of care with other physicians in the community that provide adequate notice and appropriate referrals, do not leave patients in an unstable condition and the concierge contract is clearly understood, then this objection of using a patient as a means to an end can be eliminated. Respect for persons entails giving patients the right to select their physicians and to be treated with dignity and respect.  Following the guidelines outlined by the American Medical Association regarding retainer contracts would provide the needed safeguards for patients that would show a basic respect that all human persons deserve.

Beneficence involves the obligation to prevent and remove harms and to promote the good of the person by minimizing possible harms and maximizing possible benefits. Beneficence includes nonmaleficence, which prohibits the infliction of harm, injury, or death upon others. In medical ethics this principle has been closely associated with the maxim Primum non nocere: Above all do no harm51. Advocates argue that concierge medicine is in the best interest of the patient. Patients receive special medical services that are not now provided by most primary care physicians. They receive priority same day or guaranteed next day appointments, 24/7 access to physicians, house calls, preventive care, enhanced yearly health exams, telephone and e-mail consultations, etc. Having immediate access to a physician gives many patients a special peace of mind. It also allows a physician to be proactive with patients focusing on wellness and preventive care.  Concierge medicine allows physicians to intervene early before medical issues become problematic. “Patients undergo a comprehensive yearly exam that goes well beyond the typical physical, with chest x-rays, extensive blood work, and electrocardiograms, among other tests. With the information gathered from these extensive checkups, each patient gets a unique ‘wellness plan’4.” According to recent studies, patients in a concierge practice had 61.3% fewer hospitalizations compared with similar patients in commercial insurance plans, and 74% fewer hospitalizations compared with Medicare patients of similar age, gender, and disease risk. Practicing medicine in this manner is not practicing better medicine but it is giving better care. It is maximizing medical benefits and minimizing medical harms.

Concierge medicine is also in the best interest of the physician. As stated above, many primary care physicians feel overworked, underpaid and under appreciated in their current medical practices. Due to time and financial constraints placed upon them, physicians believe they are not providing the treatment that their patients deserve. As a result, many physicians in family practice are contemplating leaving the medical field and many medical students are not opting for family practice residencies.  Concierge medicine maximizes benefits for physicians by allowing them to have a reasonable number of patients and a salary that approaches the salaries of specialty physicians. It also minimizes harms by sustaining physicians who might otherwise abandon the medical field and encourages new physicians to seek family practice as a viable professional option.

Critics argue that concierge medicine violates the principle of nonmaleficence because it could cause more harm and even injury to patients.   These critics argue that with 47 million people uninsured and with the new Patient Protection and Affordable Care Act set to be initiated, if we continue to drain the healthcare system of qualified physicians then who will care for the majority of Americans who need primary care?  It is true that concierge medicine does benefit patients in these practices and is in their best interest medically. However, critics argue that instead of concentrating on a minority of individuals why not spend this time and money on reforming a deeply flawed healthcare system.  Concierge medicine does offer the patient, who is a consumer, a choice. Those who can afford concierge medicine have the right to exclusive medical services, because medicine is now a consumer driven market. This may be true but unlike other consumer goods, physicians should be held to a higher standard than other ordinary drivers in the marketplace.  Physicians are professionals and have an obligation to provide the “gold standard” of medicine to all patients equally. Failure to do so could inflict harm, injury and even death on the most vulnerable in society, especially minority patients, Medicare patients, and those with chronic diseases.

Advocates argue that this new sense of competition between traditional and concierge medicine may be in the best interest of patients, physicians and society as a whole. The high renewal rates in concierge practices, even in this economy, demonstrate how dissatisfied many patients are with the standard medical practice in the United States. In order to maintain their patients, concierge practices might be setting a new standard for medical practice or may be returning to a standard that once existed in medicine.  Emphasis on preventive medicine may become the new standard of care. This is not better medicine but it is better care. If studies continue to prove that taking the time to listen to patients causes physicians to order fewer expensive tests because their physical exam would have told them what they need to know and preventive medicine keeps patients out of hospitals and emergency rooms, then the cost of healthcare will decrease. If the government and insurers begin reimbursing physicians more for their time and clinical services and offered salaries comparable to specialists, then the shortage of physicians could be averted and more medical students would be attracted to primary care residencies. Instead of being accused of draining the healthcare system of primary care physicians, concierge medicine could maximize medical benefits by bringing a new sense of excitement to the field of primary care both medically and financially. The result might be that “doctors in traditional practices could offer more boutique-like services without the boutique prices4.” It is possible that concierge medicine could fail not only the test of beneficence, but also fail the test of nonmaleficence if proper safeguards are not imposed by the medical profession. However, with these safeguards in place, concierge medicine could also raise the standard of patient care to a level that is in the best interest of patients, physicians and society as a whole. As a result, prevention and wellness could become mainstream and affordable, healthcare costs could decline, physicians contemplating leaving the medical field may extend their careers, and medical students may be lured into family practice if salaries approach those of specialty care. This would satisfy the tests of both beneficence and nonmaleficence by maximizing benefits and minimizing harms.

Finally, the principle of justice recognizes that each person should be treated fairly, equitably, and be given his or her due. Justice also pertains to distributive justice, which concerns the fair and equitable allocation of resources, benefits and burdens, according to a just standard. Inequality concerning access to medical care is a well-documented fact52. To allow some patients, in similar situations, to have better access to physicians and medical treatments is an egregious violation of the principle of justice.  Justice dictates that patients should be treated in a similar manner if at all possible. If there are medical treatments that are good for concierge patients, and these are prescribed for some but not others, then failure to treat all equally violates the basic tenet of justice, that is, to treat all people fairly and equitably. The principle of justice can be applied to the problem under discussion in two ways.

First, critics argue that concierge medicine is only affordable for the wealthy.  Having discussed the annual fees, it is clear that one would pay at least one thousand dollars for this practice.  These critics argue that concierge medicine threatens access to care especially for the poor and the uninsured.  Studies have shown that concierge practices see fewer African-Americans, Hispanics and Medicaid/Medicare patients33. This contributes to the growing problem in the United States regarding disparities in healthcare. This criticism is countered by advocates who claim that concierge physicians have not only more time for their patients but also for volunteering. As stated above, MDVIP has opened a clinic for over 600 Medicaid patients who receive the same services as those who pay a retainer fee for concierge medicine. MDVIP also allows concierge physicians to offer scholarships and fee waivers to approximately 10% of their patients who cannot afford concierge care28. In addition, Qliance Medical Management offers concierge type services but with a monthly retainer fee of forty-four dollars.  Qliance is targeting the working poor, the uninsured and small businesses looking for affordable and quality healthcare29. Critics contend that concierge medicine is elitist but upon further examination many practices work out to roughly $4 to $5 a day—about the same amount people spend on cigarettes or a coffee at Starbucks. This does not seem to be elitist but a matter of priorities. If healthcare is a priority, then concierge medicine can become mainstream and affordable, not an unjust practice.

Second, critics are also concerned about reimbursement issues. Physicians in concierge practices do not normally sever their ties with third-party payers. If reimbursement issues are handled improperly, then serious legal issues can arise. The American Medical Association Code of Ethics is quite clear on this issue:
Physicians who enter into retainer contracts will usually receive reimbursement from the patients’ health care plans for medical services. Physicians are ethically required to be honest in billing and reimbursement, and must observe relevant laws, rules, and contracts. It is desirable that retainer contracts separate clearly special services and amenities from reimbursable medical services. In the absence of such clarification, identification of reimbursable services should be determined on case-by-case basis.53

Michael Blau, director of the Health Law Department at McDermott, Will and Emery, in Boston argues that concierge physicians need “to draw a very bright line between the non-covered concierge services for which you’re collecting a fee, and covered services for which you’re billing54.” Blau suggests that concierge practices that bill insurers should consider setting up a complete separate business corporation alongside their professional corporation. “The business corporation, which is not authorized to engage in the practice of medicine, collects the non-covered fees; the professional corporation, which is authorized to practice medicine, accepts payment in fill for covered services from third-party payers, subject to coinsurance, deductibles and copays53.” Justice demands that resources be equitably distributed, fairly priced and properly paid for by patients. Failure to do so is ethically irresponsible and morally objectionable.
If proper guidelines and safeguards are established nationally for concierge medicine it can be medically, legally and ethically justified. However, without these guidelines and safeguards numerous problems can and will arise.

The Elephant in the Room

Most of us Americans are blessed with too much health insurance, and we do not use it wisely. The insured demand the most expensive treatment without a thought to how much it costs. We too blithely say, “my insurance will pay for it” without realizing that, in the end, we all pay for it.

The patient has an ethical responsibility to maintain or improve his or her own health as well as control costs. While it would be impossible to implement a program that forces people to live healthy lifestyles, it is reasonable to assume that healthier living would lead to lower healthcare costs.

The United States spends 18 percent of its GDP on healthcare, and the rate of increase far exceeds the rate of inflation. This trend is unsustainable. Healthcare economists estimate that between 40 and 50 percent of annual cost increases can be traced to new technologies or the intensified use of old ones. Economists say the control of technology is the most important factor in bringing costs down.

The problem is that patients expect high tech health care; doctors are primarily trained to use it, medical industries make billions selling it and the media loves to write about it. Technological innovation is as fundamental a feature of American medicine as it is in the industrial sector.

While doctors are often accused of over-prescribing diagnostic tests, this practice may be the result of patients who demand multiple tests - even if some are unnecessary. As health care technology innovates and its use increases, patients with insurance want the newest, most advanced and expensive treatments that insurance will cover. The most expensive treatments are not necessarily the best, and the patient has a duty to participate with the physician in making reasonable and cost-effective choices.

However, there is fierce opposition to any limitation in the use of medical technology; its use is deeply rooted in American culture. And politicians are reluctant to buck public opinion. Under the previous administration, Congress, with the support of physician groups and the health care industry killed two federal agencies designed to assess medical technology from a scientific and economic perspective.

Controlling healthcare costs requires a change in American culture. Since many of the effective means of controlling costs will be painful, due to our love affair with technology, resistance to change will be formidable. Effective control will force patients to give up treatments they think they need, doctors to sacrifice to a considerable extent their ancient tradition of treating patients the way they see fit, and industry to reduce its drive for profit. The fact that European countries can control costs and limit technologies without harming health is a patent rebuke to our way of doing things.

I worry about the Generation Y students in my college classroom. Upon graduation they’ll enter the workforce. Social Security and Medicare payroll deductions and escalating health insurance premiums will shrink their take-home pay each year. Today’s workers are paying the healthcare costs of today’s retired community. Will the money be gone when Generation Y reaches retirement?

Traditional virtues still receive attention in American culture, but discussion of one virtue-thrift-has all but disappeared, as affluence and extravagance have taken center stage. Perhaps we should reflect on the advice of the American Apostle of Thrift - Benjamin Franklin.

Old Ben would view our current healthcare reform discussion as a clarion call to change our ways and embrace the old-time virtue of thrift.  If all new diagnostic tests, procedures and treatments were subject to the rules of evidence-based medicine - objective evidence of superiority as opposed to traditional practice - that would be thrift. If pharmaceutical firms were required to prove the superiority of new and more expensive drugs over older and less costly ones, that would be thrift.  If medical equipment companies, which design new gadgets before the old ones get cold, were required to meet the same test, that would be thrift. If insurance companies were regulated more strictly and less ruled by the bottom line, that would be thrift.

Politicians are reluctant to propose any legislation that would place limits on the consumer. To do so, they fear, would be political suicide. Are they underestimating the virtue of the American people?  The healthcare debate is a “test of the national character. Perhaps the words of Ben Franklin have something to teach us: “Be industrious and frugal, and you will be rich”. If we elephants accept our duties and responsibilities in the healthcare reform process, our thrift will ultimately enrich us with affordable and high-quality healthcare.

Who are the stakeholders in the healthcare system? For the purposes of our discussion we define stakeholders as those entities that are integrally involved in the healthcare system and would be substantially affected by reforms to the system. The major stakeholders in the healthcare system are patients, physicians, employers, insurance companies, pharmaceutical firms and government. Insurance companies sell health coverage plans directly to patients or indirectly through employer or governmental intermediaries. Pharmaceutical firms develop and then market medications which are prescribed by doctors to treat patients. Typically they receive remuneration through insurance or governmental drug-benefit plans. Many employers offer health insurance coverage with varying deductibles and co-pays for their employees. Physicians are the providers of medical care; patients are the recipients. And government subsidizes healthcare for the elderly, the disabled and the poor. All stakeholders have duties and responsibilities.

Clearly the interrelationship among the stakeholders in the healthcare system is rather complex. Two of the stakeholders, pharmaceutical firms and insurance companies, are publically owned corporations listed on the stock exchange. Their primary responsibility is to maximize stockholder wealth. Likewise, the primary goal of employers is to make money; however, their provision of health insurance for employees is a benefit, not a source of profit. Unlike the other stakeholders physicians have direct fiduciary duties and responsibilities towards their patients. Although they receive remuneration for their services, the doctor-patient relationship is a sacred trust that transcends monetary reward. Patients have rights, duties and responsibilities. Finally, democratic government has duties and responsibilities towards its citizens, but how they are defined in regard to the provision of healthcare is an evolving American story.

Insurance Industry

Currently rising premiums and strict requirements are keeping many people from obtaining health insurance. The insurance companies remain profit driven, but the nature of their service should not be profit focused. Adequate healthcare is becoming harder to obtain due to financial hardship. The insurance companies need to find an appropriate balance between their responsibilities towards both shareholders and patients. Quarterly reports for stockholders encourage the companies to focus more on profits than affordability. This causes insurance companies to have tight regulations against preexisting conditions so that mostly healthy individuals are selected for their plans. Such patients will not utilize costly procedures as often as individuals with chronic illnesses. However, this is unethical of insurance companies because it reduces healthcare to a profit centered industry, and prevents those in need from receiving care.

Pharmaceutical Companies

Pharmaceutical companies also play a key role in the healthcare system because many patients rely on their products. The prices for drugs are rising, and there are no caps to prevent them from reaching extravagant prices. The argument that the pharmaceutical companies need to charge ever higher prices to cover research costs is simply not true. Although PHARMA spent $43 billion on R&D in 2006, it spent nearly twice as much on promotion, and it consistently has profit margins far above those of most Fortune 500 companies.

Whether or not you argue that pharmaceutical companies have a moral responsibility to ensure that people can afford their products, at the very least they have the duty to be honest and practice fair marketing. Marcia Angell, previously an editor of the New England Journal of Medicine, has written extensively about the unethical behaviors of pharmaceutical companies. Let me cite one example. Through personal experience the author who had an office practice since the early 1980s, witnessed a sinister change in the way pharmaceutical companies market their products to physicians. Previously they sent pharmacists with depth of knowledge about their products to objectively educate the physician about the benefits and risks of a particular brand medication. However, since the late 1980s pharmaceutical firms send young attractive representatives with no formal training to market their drugs by establishing a social relationship with the physician and by offering incentives to prescribe their product. Many physicians whose prescribing practices are unduly influenced by pharmaceutical representatives share the blame. They tend to respond to conversation about certain drugs rather than reading the biomedical literature. 

Physicians

Physicians play a key role in ensuring that their patients receive adequate healthcare, but also in controlling the rising costs of healthcare. They have to find a balance between having a gatekeeper role for the insurance companies and being an advocate for the patient. Assigning a gatekeeper role to primary care physicians had the intention of lowering healthcare costs because fewer tests and referrals would be made. However, this is not working and it may be best to re-evaluate the role a primary care physician has in regards to referring patients. A coordinator role may be more beneficial than gatekeeper status. Also, since primary care physicians have increased the number of patients seen in a day to compensate for their decrease in revenue, this causes an increase in defensive diagnostic testing. The doctors do not have adequate time to review the chart or spend time with the patient, so they order more tests to reduce their liability risks. These actions cause healthcare spending to increase as well. By placing the physician between these two roles, a conflict of interest is created. Ethically, the doctor has a fiduciary duty to protect the interests of his patient, but in the current managed care environment, insurance companies give incentives to physicians to order fewer referrals and to cram more patients into each workday. Edmund Pellegrino stated, “What our health policies do to the individual patient serves as a reality check to what values we hold most dear and the ethical foundation of the policies we develop and impose”. It appears that money is at the center of our values.

 

Physicians also have obligations to patients independent of insurance companies. A physician has an obligation of beneficence to do whatever is necessary to benefit his patient. However if he acts independently (”doctor knows best”) without taking into account the desires of his patient, he is practicing paternalism. Thus, the obligation of beneficence must be balanced by the principle of patient autonomy. Each patient is unique and has the right to participate completely in decisions about his health.

 

Patients

Patients also have an ethical responsibility towards their own health and towards controlling costs. While it would be impossible to implement a program that forced people to live healthy lifestyles, it is reasonable to assume that healthier living would lead to lower healthcare costs. Some companies, such as Wal-Mart and the WHO, have stopped hiring employees that smoke to reduce healthcare related costs. Often doctors are accused of over prescribing diagnostic tests, but this practice may be the result of patients who demand multiple tests even if some are unnecessary. As technology increases patients with insurance want the newest, most advanced, and expensive treatments that their insurance plan will cover, and oftentimes physicians succumb to their requests. The most expensive treatments are not necessarily the best, and the patient has a duty to participate with the physician in making reasonable and cost-effective choices.

Government

“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable rights that among these are Life, Liberty and the pursuit of Happiness”. The Declaration of Independence seems to juxtapose two rights: the right to equality and the right to liberty. Equalitarians emphasize the former; libertarians, the latter. Equalitarians hold that healthcare is a human right; libertarians hold that healthcare is a commodity. Equalitarianism emphasizes the role of government and is more appealing to democrats; libertarianism emphasizes the role of free market and is more appealing to republicans. The fundamental chiasm between these two contrasting ideologies which are operative in American culture remains an impediment to healthcare reform in the United States.

 

 

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PHARMA Press Release (Feb 12, 2007) http://www.phrma.org/news_room/press_releases/r&d_spending_by_u.s._biopharmaceutical_companies_reaches_a_record_$55.2_billion_in_2006/

Gargon M, Lexchin J. The Cost of Pushing Pills: A New Estimate of Pharmaceutical Promotion Expenditures in the United States, PLoS Med 2008 5(1) http://www.dddmag.com/news-marketing-expenses-twice-research-investment.aspx

Angell M.

 

The Truth About the Drug Companies: How They Deceive Us and What to Do About It, NY: Random House, 1985Prosser H, Soloman A, Walley T. Influences on GP’s Decisions to Prescribe New Drugs-The Importance of Who Says What. Family Practice 2003 Feb 20 (1):61-8.

Bodenheimer T, Bernard L, Casalino L. Primary Care Physicians Should Be Coordinators, Not Gatekeepers, JAMA 1999 June 2; (281):2045-2049.

DeKay ML, Asch DA. Is the Defensive Use of Diagnostic Tests Good for Patients, or Bad? Medical Decision Making 1998 (18):19-28.

Marcinko, D. The Business of Medical Practice: Advanced Profit Maximization Techniques for Savvy Doctors. Springer, 2004.

 

 

Rodriguez-Osorio CA, Dominguez-Cherit G. Medical decision making: paternalism versus patient centered (autonomous) care. Current Opinions in Critical Care 2008 Dec; 14(6):708-13.Steinbrook R. Imposing Personal Responsibility for Health New England Journal of Medicine 2006 Aug 24; (355):653-756.

　

　

 

 

　

General Christian View

Christians are mostly against euthanasia. The arguments are usually based on the beliefs that life is given by God and that human beings are made in the image of God.

Life is a gift from God.  All life is God-given. Birth and death are part of the life processes which God has created, so we should respect them. Therefore no human being has the authority to take the life of any innocent person, even if that person wants to die 

Human beings are valuable because they are made in God’s image.  Human life possesses an intrinsic dignity and value because it is created by God in his own image for the distinctive destiny of sharing in God’s own life. Saying that God created humankind in his own image doesn’t mean that people actually look like God, but that people have a unique capacity for rational existence that enables them to see what is good and to want what is good. As people develop these abilities they live a life that is as close as possible to God’s life of love. This is a good thing, and life should be preserved so that people can go on doing this.

To propose euthanasia for an individual is to judge that the current life of that individual is not worthwhile. Such a judgement is incompatible with recognising the worth and dignity of the person to be killed.  Therefore arguments based on the quality of life are completely irrelevant. Nor should anyone ask for euthanasia for themselves because no-one has the right to value anyone, even themselves, as worthless.

Position of Catholic Church

Nothing and no one can in any way permit the killing of an innocent human being, whether a fetus or an embryo, an infant or an adult, an old person, or one suffering from an incurable disease, or a person who is dying. Furthermore, no one is permitted to ask for this act of killing, either for himself or herself or for another person entrusted to his or her care, nor can he or she consent to it, either explicitly or implicitly, nor can any authority legitimately recommend or permit such an action. For it is a question of the violation of the divine law, an offense against the dignity of the human person, a crime against life, and an attack on humanity.

It may happen that, by reason of prolonged and barely tolerable pain, for deeply personal or other reasons, people may be led to believe that they can legitimately ask for death or obtain it for others. Although in these cases the guilt of the individual may be reduced or completely absent, nevertheless the error of judgment into which the conscience falls, perhaps in good faith, does not change the nature of this act of killing, which will always be in itself something to be rejected. The pleas of gravely ill people who sometimes ask for death are not to be understood as implying a true desire for euthanasia; in fact, it is almost always a case of an anguished plea for help and love. What a sick person needs, besides medical care, is love, the human and supernatural warmth with which the sick person can and ought to be surrounded by all those close to him or her, parents and children, doctors and nurses.

Position of Protestant Denominations

A number of Protestant denominations have issued statements on euthanasia and physician assisted suicide. Conservative faith groups tend to be most vocal in their opposition. Liberal denominations tend to be more in favor of individual choice.

Anglican: Rowan Williams, the Anglican Archbishop of Canterbury, has stated that although ‘There is a very strong compassionate case’ for physician-assisted dying, the Anglican Church remains opposed to the practice.Some Episcopalians believe it is morally wrong to take human life with medication to relieve suffering caused by incurable illness. Others approve of assisted dying in rare cases.

Episcopal:

Lutheran: As a church we affirm that deliberately destroying life created in the image of God is contrary to our Christian conscience. While this affirmation is clear, we also recognize that responsible health care professionals struggle to choose the lesser evil in ambiguous borderline situations — for example, when pain becomes so unmanageable that life is indistinguishable from torture.

Baptist: Assisted dying violates the sanctity of human life.

Methodist: Methodists generally accept the individual’s freedom of conscience to determine the means and timing of death. Some regional conferences have endorsed the legalization of physician assisted dying.‘Euthanasia’ or ‘mercy-killing’ of a patient by a physician or by anyone else, including the patient himself (suicide) is murder.

Presbyterian Church in America:

United Church of Christ: The Church affirms individual freedom and responsibility. It has not asserted that hastened dying is the Christian position, but the right to choose is a legitimate Christian decision.Pro-choice statements have been made by the United Church of Christ, and the Methodist Church on the US West coast. The Episcopalian, Methodist, and Presbyterian are amongst the most liberal, allowing at least individual decision making in cases of active euthanasia.

Mainline and Liberal Christian denominations:

Position of Judaism

Euthanasia, physician-assisted suicide, and all other types of suicide are almost unanimously condemned in Jewish thought, primarily because it is viewed as taking something (a human life) that belongs to God for “only He who gives life may take it away.” For Judaism, human life is, “created in the image of God.” Although life is considered to be God’s creation and good, human life is related to God in a special way: it is sacred. The sanctity of human life prescribes that, in any situation short of self-defense or martyrdom, human life must be treated as an end in itself. It may thus not be terminated or shortened because of considerations of the patient’s convenience or usefulness, or even sympathy with the suffering of the patient. Thus euthanasia may not be performed either in the interest of the patient or of anyone else.

Jewish law strongly condemns any act that shortens life and treats the killing of a person whom the doctors say will die in any event to be an act of murder. Positive euthanasia is thus ruled out. Even individual autonomy is secondary to the sanctity of human.

Position of Islam

Human life per se is a value to be respected unconditionally. The concept of a life not worth living does not exist in Islam. Justification of taking life to escape suffering is not acceptable in Islam. The Prophet Mohammad said: “Among the nations before you there was a man who got a wound and growing impatient with its pain, he took a knife and cut his hand with it and the blood did not stop until he died. Allah said, ‘My slave hurried to bring death upon himself so I have forbidden him to enter Paradise’” (Qur’an 4:29).

During one of the military campaigns one of the Muslims was killed and the companions of the prophet kept praising his gallantry and efficiency in fighting, but, to their surprise, the Prophet commented, “His lot is hell.” Upon inquiry, the companions found out that the man had been seriously injured so he supported the handle of his sword on the ground and plunged his chest onto its tip, committing suicide.

Patience and endurance are highly regarded and highly rewarded values in Islam. “Those who patiently persevere will truly receive a reward without measure” (Qur’an 39:10). “And bear in patience whatever ill maybe fall you: this, behold, is something to set one’s heart upon” (Qur’an 31:17). When means of preventing or alleviating pain fall short, this spiritual dimension can be very effectively called upon to support the patient who believes that accepting and standing unavoidable pain will be to his/her credit in the hereafter, the real and enduring life.

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[1]  “Declaration on Euthanasia”, The Sacred Congregation for the Doctrine of the Faith, May 5, 1980 http://www.usccb.org/prolife/tdocs/euthanasia.shtml (accessed March 14, 2011)

 [1]  “Religion and Spirituality” The Death with Dignity National Center (DDNC), Oct. 13, 2009 http://euthanasia.procon.org/view.answers.php?questionID=000154 (accessed March 14, 2011)

Physician-Assisted Suicide generally refers to a practice in which the physician gives a patient a prescription for a lethal dose of medication, which the patient intends to use to end his/her life. The physician provides the means for death but it is the patient who must make the conscious decision to use the drug to effect death. For those who take the drug, the physician’s writing a prescription is a necessary step in the process that leads to the patient’s death, but it is not the determinative or even the final step.

 

Euthanasia, on the other hand, generally means that the physician acts directly, for instance by giving a lethal injection, to end a patient’s life. The physician, at the patient’s request, not only provides the means for death but also is the agent of death.

 

 

Why Do Patients Request Physician-Assisted Suicide?

 

•         Severe physical and emotional suffering

•         Not wanting to live in pain

•         Not wanting to be a burden

•         Not wanting to be dependent on others for personal care

•         Depression

•         Hopelessness

•         Being tired of life

•         Loss of ability to maintain personal relationships

•         Problems in interpersonal relationships

•         Feelings of isolation and separation

•         Financial pressures

 

Some studies suggest that issues of dignity, control and independence motivate requests for PAS more often than unrelieved pain or other symptoms. Patients want to be in control by having a lethal dose of medication on hand in case suffering should become intolerable in the future.

 

Is Physician Assisted Suicide Legal?

As of January 2011, physician-assisted suicide is legal in 3 states (Oregon, Washington and Montana). Other states are considering PAS legislation. The Oregon Death with Dignity Act typically serves as a template for the other states.

To request a prescription for lethal medications, the Oregon Death with Dignity Act requires that a patient must be:

 

·        An adult (18 years of age or older).

·        A resident of Oregon.

·        Capable (defined as able to make and communicate health care decisions), and

·        Diagnosed with a terminal illness that will lead to death within six months.

 

To receive a prescription for lethal medication, according to the Oregon Death with Dignity Act, the following steps must be fulfilled:

 

·        Two oral requests to physician, separated by at least 15 days.

·        Written request, signed in the presence of two witnesses.

·        Confirmation of diagnosis & prognosis by a consulting physician.

·        Confirmation of competency by both prescribing and consulting physician.

·        If either physician believes the patient’s judgment is impaired by a psychiatric or psychological disorder, the patient must be referred for a psychological examination.

·        The prescribing physician must inform the patient of feasible alternatives to assisted suicide, including comfort care, hospice care, and pain control.

·        The prescribing physician must request, but may not require, the patient to notify his or her next-of-kin of the prescription request.

 

 

Is Physician-Assisted Suicide Ethical?

 

Arguments against Physician-Assisted Suicide

1.      Sanctity of Life: Physician-assisted suicide is morally wrong because it contradicts strong religious and secular traditions against taking human life.

 

2.      Passive vs. Active Distinction: There is an important moral difference between passively “letting die” and actively “killing.” Treatment refusal or withholding treatment equates to letting die (passive) and is justifiable, whereas physician-assisted suicide equates to killing (active) and is not justifiable.

 

3.      Potential for Abuse: Here the argument is that certain groups of people, lacking access to care and support, may be pushed into assisted death. Furthermore, assisted death may become a cost-containment strategy. Burdened family members and health care providers may encourage option of assisted death. To protect against these abuses, it is argued, physician-assisted suicide should remain illegal.

 

4.      Integrity of the Medical Profession: The Hippocratic Oath states, “I will not administer poison to anyone where asked,” and “Be of benefit, or at least do no harm.” Furthermore, major professional groups (AMA, AGS) oppose assisted death. The overall concern is that linking physician-assisted suicide to the practice of medicine could harm the public’s image of the profession.

 

5.      Physicians Make Mistakes: These may include:  errors in diagnosis and prognosis, failure to diagnosis depression, inadequate treatment of pain, etc. Since these types of mistakes may result in unnecessary death, the State has an obligation to protect human lives from these inevitable mistakes.

 

 

Arguments in support of Physician-Assisted Suicide

 

·        Respect for Autonomy: Death with Dignity legislation fulfills the 4 criteria for making autonomous choices: knowledge of the intended procedure, ability to weigh various alternatives, mental competence and lack of coercion. Decisions about time and circumstances of death are very personal. Competent person should have right to choose death.

 

·        Justice: Justice requires that we “treat like cases alike.” Competent, terminally ill patients are allowed to hasten death by refusal of burdensome life-sustaining treatments. For some patients, treatment refusal will not suffice to hasten death; their only option is suicide. Justice requires that we should allow assisted death for such patients.

 

·        Compassion: Some physical and psychological burdens are so severe they cause unbearable suffering that goes beyond pain. It is not always possible to relieve this kind of suffering. Thus physician-assisted suicide may be a compassionate response to unbearable suffering.

 

·        Individual liberty vs. state interest: Though society has strong interest in preserving life, that interest lessens when person is terminally ill and has strong desire to end life. A complete prohibition on assisted death excessively limits personal liberty. Therefore physician-assisted suicide should be allowed in certain cases.

 

·        Openness of discussion: Some would argue that assisted death already occurs, albeit in secret. For example, morphine drips ostensibly used for pain relief may be a covert form of assisted death or euthanasia. That physician-assisted suicide is illegal prevents open discussion, in which patients and physicians could engage. Legalization would promote open discussion.

 

 

The Following Conditions May Justify Physician-Assisted Suicide

 

•         Voluntary request by competent patient

 

•         Ongoing patient-physician relationship

 

•         Mutual and informed decision making by patient and physician

 

•         Supportive yet critical and probing environment of decision making

 

•         Considered rejection of alternatives

 

•         Structured consultation with other parties in medicine

 

•         Patient’s expression of a durable preference for death

 

•         Unacceptable suffering by the patient

 

Use of a means that is as painless and comfortable as possible