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Ethical considerations and implications for euthanasia and assisted suicide in New Zealand

Amie Wright

Introduction

Over the last few years, thanks to media coverage of cases advocating the need for a change to the laws and legislation surrounding euthanasia I have become aware of the changing perceptions towards euthanasia and assisted suicide. For this reason, the clinical issue and setting I have chosen to explore is that of euthanasia in end-of-life care including the ethical reasoning behind legislation and potential changes to the status quo which Woods and Bickley (2015) predict will occur in coming years as public and parliamentary opinions continue to change.

Euthanasia can be defined as the intentional termination of one’s life resulting from the administration of a lethal dose of medication (Woods & Bickley, 2015). Non-voluntary euthanasia is a result of the same process, however, the patient suffering from disease or illness has not requested action (Woods & Bickley, 2015). Additionally, physician assisted suicide occurs when a doctor provides the means (medications) that the patient can self-administer and end his or her life (Woods & Bickley, 2015). In New Zealand, under current legislation (The Crimes Act 1961) euthanasia and assisted suicide are illegal – under Sections 63 and 179 respectively. The Crimes Act (1961) does not directly address the issue of euthanasia but section 63 states that “no one has a right to consent to the infliction of death upon himself or herself; …such consent shall not affect the criminal responsibility of any person who is a party to the killing”. Furthermore, section 179 says that anyone who aids or abets suicide is liable for imprisonment (Crimes Act, 1961). There have been attempts to change this law, the most recent being Maryan Street’s End of Life Choice Bill (2015) which sought to prevent criminal convictions when an individual suffering from the effects of a terminal or irreversible illness requested a medically assisted death. Also in 2015, Lecretia Seales, a terminally ill woman, filed a statement of claim to the High Court of New Zealand requesting that her doctor would not be prosecuted, should he assist her in dying (Seales v Attorney General, 2015).

From an undergraduate perspective, we, as student nurses, are educated on ethics from year one–we learn about beneficence, non-maleficence, and autonomy, and the importance of practicing nursing according to these principles (New Zealand Nurses Organisation, 2010). All three of these principles are implicated in the debate surrounding euthanasia and assisted suicide, consequently, the progression of legislation to enable euthanasia and/or assisted suicide would impact on the day-to-day practice of nurses (Woods & Bickley, 2015). It is for this reason that I have chosen to explore the issue of euthanasia, the ethical debate and the implications that the legalisation of euthanasia/physician assisted suicide would have for registered nurses.

PICOT – formulation of a research question

PICO/T is a research framework that allows the researcher to form a question that can be used to address a clinical issue (Whitehead, 2013). This is the framework that I used to refine my initial question - should euthanasia be legalised in New Zealand, to -

Ethically, does the End of Life Choice Bill  and associated views on euthanasia have a place in end of life care in New Zealand? If so, what implications would it have for Nurses?

Table 1:

Discussion/literature review

Woods and Bickley (2015) report that worldwide, controversy and concern surround the issue of euthanasia and acts of assisted suicide–both of which are illegal in New Zealand currently, but opinions and perceptions appear to be changing. The End of Life Choice Bill (Street, 2015) was submitted for consultation in 2015 by Maryan Street who said that, the purpose of the Bill was to ensure that under certain circumstances, individuals whom are suffering from a terminal or irreversible condition should be able to decide to end their lives and receive medical assistance to do so. The Bill would like to prevent convictions from occurring when the person suffering expresses their wish for a medically assisted death (Street, 2015). Whilst promoting compassion and the need to maintain human dignity, it also highlights the importance of upholding the individual’s ability to be as self-determining and autonomous at the end of their life as they were when they were not suffering (Street, 2015).

An issue with this Bill, is that nurses are not referred to (Woods & Bickley, 2015); The medical practitioner (for the purposes of this Bill is defined as an individual registered with the Medical Council of New Zealand and whom holds a current practising certificate) responsible for the overall care of the individual seeking assistance could delegate aspects of the procedure to others, meaning that nurses could potentially be asked to play a part in assisting the acts that would result in death (Woods & Bickley, 2015). Furthermore, Woods & Bickley (2015) highlight that the draft bill included a provision which protected the medical practitioners from liability but there was no mention of an exemption for nurses.

Ritchie (2016) weighed in on this aspect of the Bill, by acknowledging that a universal nursing position on euthanasia needs to be established and that legislation would need to be initiated in order to protect nurses from prosecution if they were involved in these acts. Ritchie (2016) also recommends the establishment of a set of guidelines that would include the health practitioner’s right to choose if they participated in the act that would end a life.

A subsequent issue with this Bill is that it lacks a clear definition of what constitutes a terminal illness – it can be interpreted to mean any illness that is life-threatening or life shortening (Suicide Inquiry, n.d.) for example, asthma is not necessarily a terminal illness but it can become life-shortening in a matter of minutes. Moreover, it is difficult for doctors to apply a timeline to terminal illness – it is impossible for them to predict exactly how long a person is going to live, they could have months or years left (Suicide Inquiry,n.d.).

Position of the New Zealand Nurses Organisation

The NZNO currently supports a palliative care approach to care for people who are dying, the belief is that “nurses should advocate for safe, compassionate, competent and ethical end of life care and equitable access to specialist palliative care services” (NZNO, 2016, p.6). Palliative care can be defined as: an approach that is designed to improve the quality of life for individuals suffering from illness by providing relief from pain, addressing psychological and spiritual needs and having supports in place to enhance quality of life as much as possible until death (World Health Organisation, n.d).

In spite of this, the NZNO acknowledges that euthanasia may be legalised in New Zealand and as a result, the NZNO supports an investigation into euthanasia and implications for nurses (NZNO, 2016). Also, in 2016, the NZNO made a submission to the Health Select Committee that outlined their position regarding end-of-life decisions and care stating that: 1) they have concerns focused around how legislative changes would affect the practice of nurses working with dying people on a day-to-day basis; 2) nurses will need to be protected from prosecution, and best practice standards for nurses will need to be outlined and implemented and; 3) Te Whare Tapa Wha should be used as the basis for discussions about such an ethical issue – they highlight that the Maori model allows a holistic look at ethical issues and will provide a better platform than a biomedical model (NZNO, 2016).

Global perspective

Euthanasia and/or assisted suicide is currently legal in a select few places; Switzerland allows assisted suicide but prohibits euthanasia; In Oregon, physician assisted suicide is legal but not euthanasia; both the Neverland’s and Belgium have legislation in place that legalises assisted suicide and euthanasia (The Life Resources Charitable Trust, n.d). Additionally, Luxembourg decriminalised euthanasia and physician assisted suicide in 2008 (Thill, 2015). The legislation that was formed stated that the person seeking euthanasia/physician assisted suicide had to be conscious and competent (Thill, 2015). The legislation also established the National Commission for control and assessment which is responsible for assessing and auditing if euthanasia and assisted suicide are carried out legally (Thill, 2015).

Ethical Considerations

Begley (2008) voices that ethics in nursing do not appear sporadically when a decision regarding a law needs to be made, they are the ever-present guide to nursing practice. Every interaction with people, be they patients or colleagues is guided by ethics – therefore they have an important place in the euthanasia debate (Begley, 2008). The four main ethical principles involved in the ethical debate on euthanasia are autonomy, non-maleficence, beneficence and justice (NZNO, 2010).

Research conducted by Gordon, Rauprich and Vollmann (2011) found that the first step towards dealing with an ethical issue is identifying the moral (ethical) conflict. In the case of euthanasia, one ethical conflict is that between the principles of autonomy – the right of the ill individual to practice self-determination and take action that he or she deems best for him or herself – and non-maleficence, the act of doing no harm (Gordon, Rauprich &Vollmann, 2011; NZNO, 2010). An individual suffering from a terminal or incurable illness may wish to act autonomously and request euthanasia but, Quaghebeur, Dierckx de Casterle & Gastmans (2009) propose that the sacredness of our existence does not allow the act of euthanasia to be presented as ethical nursing practice. However, Gordon, Rauprich and Vollmann (2011) argue that the answer is not so clear; they say that if the individual is deemed medically competent and is fully aware of the proposed consequences then their autonomy should be respected.

A second ethical conflict that Gordon, Rauprich and Vollmann (2011) explored was that between non-maleficence and beneficence. They expressed the thought that it is difficult to determine the extent of someone’s suffering; non-maleficence requires a nurse to do no harm  and beneficence is the act of doing good – a ‘good’ act such as one that would sustain life could in fact, inflict more harm upon the patient (Gordon, Rauprich &Vollmann, 2011). In addition, Ersek (2004) questions the professional integrity aspect of upholding the non-maleficence principle –for this too, there are two sides to the argument. Those who are pro-euthanasia may view the refusal to relieve patient suffering as something that destroys the trust and therapeutic nurse-patient relationship; those who are anti-euthanasia may believe that by assisting a patient to die, the nurse has violated the ethical nature of healthcare (Ersek, 2004). Brzostek et al (2008) elaborate a little more on this issue and say that the art of caring is integral to nursing practice, a request for euthanasia from a patient will likely change the therapeutic relationship and associated dynamics between the nurse and patient.

Findings / Implications for practice

As mentioned earlier, research suggests that there is an increasing awareness of euthanasia and a noticeable shift towards legislation changes in New Zealand (NZNO, 2016; Street, 2015; Woods & Bickley, 2015). The process of dying is fluid, it changes depending on the nature and complexity of illness and the death and dying experiences. Consequently, a number of ethical, legal and practical issues may arise and nurses will need to be able to address them whilst maintaining their practice competently (NZNO, 2016b).

• Registered nurses in New Zealand and their practice are governed by a number of legislative and ethical frameworks including:
• The Health Practitioners Competence Assurance Act 2003
• The Health and Disability Commissioner Act 1994
• The Code of Health and Disability Services Consumers Rights 1996
• Code of Ethics 2010
• Code of Conduct 2012

(NZNO, 2016b).

So, ethically, does the End of Life Choice Bill and associated views on euthanasia have a place in end of life care in New Zealand? If so, what implications would it have for Nurses?

Through conducting a review of the literature, it can be said that each side of the ethical debate regarding end-of-life care contributes a valid argument on perspectives both for and against euthanasia. The principles of autonomy, non-maleficence, and beneficence are all highlighted, manipulated and interpreted differently to persuade arguments both for and against euthanasia (Quaghebeur, Dierckx de Casterle & Gastmans, 2009). At this stage, it is difficult to establish a black and white answer on the place of euthanasia in end-of-life care however, it is clear from the research that changes potentially will occur as public and parliamentary opinions develop and gain traction (Woods & Bickley, 2015). It is for this reason that evidence-based recommendations need to be established before the issue and/or Bill/potential Bill’s progress further.

Recommendations and rationale

Firstly, if euthanasia was found to be ethically substantiated in the New Zealand environment then nurses would need to be familiar with and adhere to, legislative requirements. The legislative guidelines already established for nurses would need to be updated with any proposed changes to the status of euthanasia/assisted dying (Woods & Bickley, 2015); In order to carry out their practice competently, nurses would have to ensure they uphold their professional responsibility by staying informed about the clinical nursing implications that would result from legislation changes (NZNO, 2016b).

Secondly, if euthanasia is legalised in any form, nurses will require protection from prosecution; this could be achieved through the establishment of regulations and clear guidelines for best practice (Woods & Bickley, 2015; NZNO, 2016b). This is essential because nurses should be fully informed about proposed changes and due to their expertise in the care of people throughout their life, they should be prepared to contribute to and influence law, policy and nursing practice (Woods & Bickley, 2015).

Thirdly, legislative changes should contain guidelines for best practice which include a clause for nurses who wish to participate in euthanasia /assisted suicide and those who do not (NZNO, 2016b). Nurses should not feel obligated or pressured into participating in euthanasia if they have conflicting ethical or religious viewpoints (Sullivan, 1999).

Finally, nurses involved in such a sensitive issue should be provided with the means to access resources that will help them cope with being involved in an act that will deliberately end human life (Bannaszak, 1999). Ideally, an investigation would need to be conducted into how nurses involved in end-of-life care can reflect upon and address their feelings associated with euthanasia (Bannaszak, 1999; NZNO, 2016).

Conclusion

As literature suggests, perceptions about euthanasia and the place it holds in end-of-life care are changing. Euthanasia and assisted suicide remain illegal under New Zealand legislation but thanks to recent cases involving terminally ill people and the submission of the End of Life Choice Bill, both public and parliamentary opinions are changing. Ethics and human morals provide the basis of the argument both for and against a change in the legislation and ethical principles can be manipulated and interpreted differently for both sides. Furthermore, by conducting a thorough literature review, it can be said that the changes to legislation would need to provide clear guidelines for health practitioners – both doctors and nurses – so as to protect them from prosecution and to assist them in ensuring their practice is safe and ethical.

Reference list

Banaszak, A. (1999). The prospects for nursing if euthanasia is legalized. Nursing Standard, 13(45), 38-40.

Begley, A.M. (2008).Guilty but good: Defending voluntary active euthanasia from a virtue perspective. Nursing Ethics, 15(4), 434-445.

Brzostek, T., Dekkers, W., Zalewski, Z., Januszewska, A., & Gorkiewicz, M. (2008).Perception of palliative care and euthanasia among recently graduated and experienced nurses. Nursing Ethics 2008, 15(6), 761-776.

Crimes Act. (1961). Retrieved from http://www.legislation.govt.nz/act/public/1961/0043/latest/DLM327382.html

Ersk, M. (2004). The continuing challenge of assisted death. Journal of Hospice and Palliative Nursing, 6(1), 46 61.

Gordon, J., Rauprich, O., & Vollman, J. (2011). Applying the four-principle approach. Bioethics, 25(6), 293-300.

New Zealand Nurses Organisation. (2010). Code of ethics. Wellington, New Zealand: Author

New Zealand Nurses Organisation. (2016). Position statement: The role of the nurse in end of-life decisions and care for adults. Retrieved from   http://www.nzno.org.nz/Portals/0/publications/Position%20statement%20%20The%20role%20of%20the%20nurse%20in%20end-oflife%20decisions%20and%20care%20for%20adults,%2020161.pdf

New Zealand Nurses Organisation. (2016b). The Maryan Street petition to investigate fully public attitudes towards the introduction of legislation which would permit  medically assisted dying in the event of a terminal illness or an irreversible condition which makes life unbearable. Retrieved from http://www.nzno.org.nz/Portals/0/Files/Documents/Activities/Submissions/21602%20Medically%20Assisted%20Dying%20Final.pdf

Quaghebeur, T., Dierckx de Casterlé, B., & Gastmans, C. (2009). Nursing and euthanasia: A  review of argument-based ethics literature. Nursing Ethics 2009,16(4), 466-486.

Ritchie, L. (2016). Debating euthanasia. Kai Tiaki Nursing New Zealand, 22(4), 33.

Seales v Attorney general. (2015). Retrieved from http://www.lecretia.org/youcanhelp/seales-v-attorney-general/

Street, M. (2015). End of life choice bill. Draft for consultation. Retrieved from http://www.parliament.nz/resource/0000197305

Suicide Inquiry. (n.d.). End of life choice bill. Retrieved from http://suicideinquiry.nz/end-of-life-choice-bill/

Sullivan, M. (1999). Ethics of assisted suicide and euthanasia. Are we prolonging life or extending dying? Nursing Management, 31-33.

The Life Resources Charitable Trust (nd).Global euthanasia laws. Retrieved from http://www.life.org.nz/euthanasia/euthanasialegalkeyissues/global-euthanasialaws/Default.htm

Thill, B. (2015). Euthanasia and assisted suicide in Luxembourg – the personal views of a palliative care physician. European Journal of Palliative care, 22(1), 22-25.

Whitehead, D. (2013). Searching and reviewing the research literature. In Z. Schneider, D.Whitehead,G. LoBiondo-Wood, & J. Haber (Eds), Nursing and Midwifery Research methods and appraisal for evidence-based practice (4th ed.). Chatswood, Australia: Mosby Elsevier

Woods, M., & Bickley, J. A. (2015). Nurses and the euthanasia debate: Reflections from  New Zealand. International Nursing Review, 62, 13-20.

World Health Organisation. (nd). WHO definition of palliative care. Retrieved from http://www.who.int/cancer/palliative/definition/en/