by Michelle Lau
June 29, 1998

Assisted suicide remains one of the most complex, controversial issues in the healthcare arena. Many nurses must not only confront their personal feelings on the issue, but also determine what their roles should be.

Nurses are constantly caught in the middle of the debate on assisted suicide, said Virginia Tilden, DNSc, RN, nurse ethicist and professor of nursing at Oregon Health Sciences University.

This is especially true since Oregon’s Death with Dignity Act—the first law allowing terminally ill patients to request a lethal dose of drugs from physicians—does not mention any of the other clinicians that may be involved.

For example, if nurses do not morally agree with assisted suicide, they must choose whether or not to remove themselves from the clinical team. "At that point the nurse has to decide, ‘Do I make sure I am not jeopardizing my employment, or do I honor my moral code? And how do I do one event or the other without jeopardizing my relationship with this patient?’ " said Tilden, associate director of the university’s Center for Ethics in Health Care.

In all states besides Oregon, assisted suicide is illegal. While it still happens in other states, nurses involved in assisted suicide could jeopardize their professional licenses.

What can you do?

Nurses and ethicists agree that it isn’t easy to respond to a patient who requests information on assisted suicide.

Some say that where assisted suicide is legal, caregivers should supply the information or refer the patient to someone willing to supply it. "This is not the time to abandon someone when they need to talk about this. I don’t think giving information to a patient is assisting in suicide," said Pat Murphy, PhD, RN, FAAN, clinical nurse specialist in ethics at Newark Beth Israel Medical Center in New Jersey. Murphy wrote the American Nurses Association position statement on assisted suicide, which says that assisted suicide violates the ethical traditions of the profession and nurses should not participate in it.

Others say providing the requested information is easier for the health professional, but not in the patient’s best interests. According to Alexander Morgan Capron, professor of law and medicine at the University of Southern California, nurses and physicians have a difficult time dealing with dying patients. Legalized assisted suicide would harm patients, because some health professionals would see it as an easy, quick, painless way out of dealing with disease. "It isn’t easy having to confront and try to help in some fashion someone who is dying where you cannot achieve cure," he said.

Carol Melvin, RN, president of California Nurses for Ethical Standards, thinks a nurse’s role is to always try to deter patients from assisted suicide. In fact, a patient who makes such a request should be referred to a psychiatrist or psychologist, she said.

"Many times terminally ill people are clinically depressed. I don’t believe it is a violation of a patient’s rights to refer that patient to someone that can give them psychiatric care and counseling to determine what it is that is driving them to seek assisted suicide," Melvin said.

Richard Wagner, PhD, founder and executive director of Paradigm Enhancing Life Near Death in San Francisco, a resource center for terminally ill patients with cancer or AIDS, doesn’t believe that terminally ill people who want to end their lives are acting out of desperation. Wagner, who has been present when several people have ended their lives, said their decisions weren’t rash. "They were thoughtful and reflective, and it was a difficult decision."

Managing pain

Good palliative care is important for terminally ill patients, according to Tilden. Marty Ayers, PhD, RN, executive director of the Hospice and Palliative Nurses’ Association, agrees.

"The majority of our nurses are not in favor of assisted suicide, because they feel with good palliative care, with good hospice care, people can live a fuller, comfortable life," she said.

Palliative care allows patients the opportunity to live out the remainder of their lives in comfort, provides them with the opportunity to resolve personal issues, and allows their family time to grieve, Ayers said.

"Most nurses have not been educated on what good end-of-life care is. They have been educated in the cure model, so death, then, is seen as defeat," she said.

Murphy adds, "I don’t believe people would beg us to kill them if we managed their pain."

Considering all options

But good palliative care won’t prevent some patients from thinking about assisted suicide. And nurses face tough decisions about whether to discuss it or to try to deter a patient. "I wouldn’t try to deter someone from doing something they felt was in their best interest—something that was rational and legal," said Barbara Coombs Lee, JD, FNP, executive director of Compassion in Dying Federation in Portland, Ore.

Melvin disagrees. It is a nurse’s responsibility to do no harm, she said. "Patients think it is their wish, but helping them commit suicide is doing them harm."

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Public Opinion

In 1977, 38 percent of Americans agreed "a person has a right to end his or her own life if this person has an incurable disease." In 1996, 61 percent agreed with the statement.

In 1997, three-fourths of Oregon voters thought assisted suicide should be available "when a person is terminally ill and in extreme suffering during the final stages preceding death."

SOURCE: The Oregonian Web site.