Physician-Assisted Suicide, Euthanasia, and Counseling Ethics

Physician-assisted suicide and euthanasia are distinguished and discussed in the context of the counselor's role in helping terminal clients. An aging population coupled with the proposed legislation in many states to legalize physicianassisted suicide could mean these issues will become more paramount to the counseling profession. Potential ethical dilemmas are discussed using the biopsychosocial model, five pillars of ethics, and an existing health-care model as guidance. Physician-assisted suicide, euthanasia, and end-of-life issues represent a point of convergence for medical and counseling ethics. Health care professionals work directly with terminal patients, some of whom make requests to physicians for help in ending their lives. The counselor’s involvement with end-of-life issues is indirect, but vital nonetheless. Counselors may see clients diagnosed with a terminal illness. Counselors play an important role in these cases, with a primary goal to help the client enhance their quality of life (Shallcross, 2012). With end-of-life issues, the ethical implications and potential for dilemmas are numerous. The 2014 American Counseling Association Code of Ethics address end-oflife issues in the context of preventing foreseeable harm, legal mandates, and confidentiality considerations (American Counseling Association, 2014). Although not explicitly addressed in the ethics code, physician-assisted suicide and euthanasia raise unique, if not extreme, ethical questions. As more states legalize or have proposed legislation for legalization, counselors may encounter more clients dealing with these issues in particular (Biller-Andorno, 2013). This article addresses the ethics of physicianassisted suicide, euthanasia, and related concepts from a counseling ethics perspective. Physician-Assisted Suicide and Euthanasia, Distinctions Any discussion of related actions should start with a clarification of said terms to elucidate as clearly as possible the meaning of each term. The term euthanasia implies active voluntary euthanasia. This requires a patient requesting death and a physician Ideas and Research You Can Use: VISTAS 2014 2 complying with the patient’request. In another form, involuntary active euthanasia, patients oppose the procedure. The closest examples of involuntary active euthanasia are death penalty cases. State-sanctioned instances of licensed-physicians assisting statesanctioned inmate deaths,, presuming the prisoner opposes the death sentence, qualify as involuntary active euthanasia. A third form is non-voluntary active euthanasia, wherein a person who lacks decision-making capacity and cannot express a preference is the recipient of euthanasia. A comatose patient who is not only taken off all life-sustaining devices but subsequently given a lethal dosage of medication is an example of nonvoluntary active euthanasia. Apart from the death penalty in some states, active euthanasia is illegal in all fifty states (Lo, 2009). Distinct from active euthanasia is passive euthanasia, which stands for the withdrawal or withholding of life saving intervention. Passive euthanasia does not involve actively inducing death, but rather not saving a life, or not initiating a procedure that could prolong life. Declining life support or abiding by a do-not-resuscitate order are both examples of passive euthanasia. Although ethically controversial like active euthanasia, passive euthanasia is legal in all fifty states (Orfali, 2011). The major ethical distinction between passive and active euthanasia is the presumed agent of death. Passive euthanasia is commonly thought of as allowing-to-die, rather than killing, with the patient’s disease tagged as the culprit. With active euthanasia, the physician is inferred to be the agent of death. Physician-assisted suicide (PAS) differentiates itself from both types of euthanasia. With PAS, a physician provides the means for death with the patient bringing about the act itself. In cases of PAS, patients are the direct agents of their own demise. Physicians are part of the means to the end. Some ethicists believe that the moral responsibility of the physician is lessoned by the direct action of the patient in PAS as opposed to euthanasia (Beauchamp & Childress, 2008). The Biopsychosocial Model Counselors and other qualified mental health professionals enter the PAS process by way of helping to alleviate mental illnesses that may be driving a patient’s request to end his or her life. Of the states where PAS is legal, Oregon, Washington, and Vermont, with aid-in-dying provisions in New Mexico and a legal precedent for defense in Montana, it is common to have provisions stating that patients must obtain counseling to ensure that their free choice and not depression is the motivating force behind the request (Manning, 2014). This collaborative effort between medical doctors and mental health professions showcases the biopsychosocial model in action. Legally, ethically, and clinically, the whole person is being addressed. Physicians make medical diagnoses and identify the terminal disease responsible for impending death. Nevertheless, even pernicious biological disease does not exist in a vacuum. Patients with cancer, for instance, will make decisions about their prognosis according to their psychological state in the context of their culture. Psychologically, depression is associated with suicidality (American Psychiatric Association, 2013). The question is then begged, are thoughts pertaining to the cancer or depression responsible for a person requesting PAS? States require patients who request PAS to seek counseling mainly to attend to this question. Counselors, trained Ideas and Research You Can Use: VISTAS 2014 3 in the arts of empathy and diagnosis, are equipped to help clients and physicians alike by ensuring their clients are in satisfactory mental health and possess decision-making capacity (Shallcross, 2012). In this process, counselors are guided by their ethical code, which is an applied form of principle-based ethics. The Five Pillars of Ethics Counseling ethics are a form of applied ethics. Other disciplines have applied ethical codes, such as business and medicine. Applied ethics are the most practical version of ethics, but in principle should be extensions of normative and meta-ethics (Huemer, 2008). Correspondingly, the substance of most ethical domains, especially applied ethics, are five prima facie pillars. Prima facie alludes to principles whom at first sight carry with them merit and authority. In essence, a prima facie principle should be followed and clinicians should conduct their behavior in alignment with each principle. For end-of-life questions such as physician-assisted suicide (PAS) and euthanasia, ethicists usually draw from an ethical code and the five pillars of ethics in order to make a decision on what to do about addressing the question. Not having a standard or ethical theory for guidance can muddy the ethical waters in these emotional issues. Each pillar offers a directive speaking to the ethical validity of an issue and advocates likewise (Page, 2012). 1. Autonomy, or self-rule, or self-governance, is the right of individuals to make their own mental health and health care decisions. Autonomy would endorse both PAS and euthanasia presuming the person is an adult with decision-making capacity. Autonomy would not oppose collaboration of client, counselor, and physician in making decisions, but would stress that ultimately it is the client who has the right to decide yes or no, and the counselor and physician also have the right to decide whether to participate in the process. 2. Non-maleficence offers the dictum do no harm. The prime ethical imperative is to, above all else, do not hurt or further harm a client. Depending on perspective, non-maleficence would endorse or deny PAS and euthanasia. The result of PAS and euthanasia is client death, which seems the ultimate in harm. However, requiring a client in extreme physical pain to continue in agony may be construed as harm as well. Non-maleficence creates a dilemma within itself in this case. 3. Beneficence, or the promotion of goodness, likewise is an ethical-pillar dependent on perspective. Does promoting well-being presuppose life at all costs? Or, does beneficence recommend alleviating suffering and hence insinuate the ending of life? Beneficence illustrates how seemingly straightforward guidelines like do good are relative to frame of reference and personal value systems. 4. Fidelity is a principle that advocates for promise-keeping and loyalty. A counselor following the fidelity directive is obliged to keep his or her promises to clients. Thus, if a counselor promises to help clients locate a physician willing to help end their life with PAS, then the counselor is ethically compelled under fidelity to do so. In this sense, fidelity is a second-tier principle regarding PAS and euthanasia that comes into play predominately once a decision has already been made. 5. Justice is the fifth pillar and speaks of equality, obeying the law, and properly allocating social resources. The first definition, equality, would suggest that all Ideas and Research You Can Use: VISTAS 2014 4 clients have equal access to PAS and euthanasia if they are available and legal. This leads to the second meaning, obeying the law, which tells counselors to follow the legal statutes of their jurisdiction. A proper allocation of social resources implies that finite resources, such as time, be allocated in a fair manner. A counselor who devotes more time than usual to a terminal client while shortening their normal time with other clients would not be acting just, as this action violates both the first and third definitions of the principle.