The Abandonment of Professional Ethics, Individual Nurses, and the Patient

The American Nurses Association (ANA) Center for Ethics and Human Rights Advisory Board’s draft position statement, “The Nurse’s Role When a Patient Requests Aid In Dying” is a deeply flawed document. It betrays not only the essence of nursing in particular but also that of medicine in general. It further betrays the nurses who would be subject to it, and the patients who request assistance in committing suicide.

The document’s authors have asked for public comment. We are happy to oblige.

The authors are eager to distinguish between euthanasia, which is “inconsistent with the core commitments of the nursing profession,” and assisted suicide, a distinction they make by using the misleading term “aid in dying” [line 15]. But this is a deliberate misnomer. What we are talking about is not “dying,” a process in which one is passive in the face of some disease or bodily condition. We are talking about causing death. This is properly called “killing” or, when the killing is self-inflicted, “suicide.”

They will, of course, insist that there is a morally relevant distinction between the direct “administration” of a death-causing drug in euthanasia, and the “self-administration” characteristic of suicide. But even if we were to accept a distinction between “supplying” and “putting the drugs in the patient’s body,” if the person delivering the drugs does so for the purpose of allowing the person to commit suicide, then it is a distinction without a substantive difference.

The authors write that “nurses should be comfortable supporting patients with end-of-life conversations” including discussion about assisted suicide. Furthermore, “nurses should reflect on personal values related to aid in dying and be aware of how those inform one’s ability to provide nonjudgmental information in response to a patient’s request” [lines 23; 72–83].

These sentences clearly demonstrate the internal contradictions of the ANA statement. On the one hand, nurses are prohibited from active participation in a patient’s death. Yet on the other, nurses are told they must “be comfortable” with helping patients who wish to end their own lives; they must offer information, support, and even their presence at the event [see line 112]. It is an impossible line for nurses to walk.

The authors write that nurses who experience “significant moral and ethical conflict” and therefore do not wish to participate in assisted suicide “should ensure the ongoing care of the patient by identifying nurse colleagues willing to do so” [line 47]. But this is an ambiguous claim. Who would deny that the nurse must not give up on the patient simply because the patient is asking for suicide, or has already obtained the means to commit suicide? However, if the claim is that the nurse must provide for the patient’s request, or else pass the ball to another willing nurse, then what is being proposed is a threat to nurses’ conscience rights.

Note that it is the individual nurse who is responsible for identifying a willing colleague. Why should any medical professional be forced to refer for something one considers inherently at odds with the practice of medicine? That would betray one’s profession, and one’s own integrity. Worst of all, it would betray the patient, for the thing the patient requires is care, and acquiescing in this request brings care to a screeching halt.

Proponents will argue that patients will be denied care if nurses can opt out, but the thing being refused here is not patient care. So-called “medical aid in dying” is, ironically, the only way to ensure that no one else may take up the task of caring for the patient.

The authors argue, “When nurses care for those whose health condition, attributes, lifestyles, or situations are stigmatized, or encounter a conflict with their own personal beliefs, nurses must render compassionate, respectful and competent care” [line 60].  It is not always easy for nurses to support patients whom they dislike, or whose lifestyle choices made the patient unwell, or whose religious beliefs they do not share, or even whose particular treatment choices they would not have chosen. None of those circumstances, however, is inconsistent with the proper practice of nursing, which is why the nurse is called upon to continue faithful support for the patient.

But assisted suicide is inconsistent with nursing. It is not a legitimate treatment option. How can nurses “render compassionate care” by participating in something they consider to be the opposite of care? What could it possibly mean to look out for a patient’s safety by providing him or her with the information—or worse, the means—to carry out the ultimate self-harm?

Care is not acquiescing to the patient’s every request. Care means looking out for the patient’s interest, even when the patient does not. In the case of a dying patient, truly compassionate care means offering real aid in dying—that is, helping him or her to live better while dying, and standing firmly with him or her throughout, not abandoning him or her in the hour of greatest need.

If death, not care, is what the person wants, anyone can provide that competently. Why involve the medical professional?

The authors insist, as do all advocates of assisted suicide, that it is a compassionate response to pain and suffering [see line 84]. Indeed, fear, pain and suffering (including existential suffering) are often part of the end of life, sometimes overwhelmingly so. Yet data from Oregon, Washington, and other states is clear that it is not actual pain but fear of pain that usually motivates the decision to end one’s own life. And if fear of suffering drives people to consider suicide, the compassionate act is to alleviate the suffering or the fear, not to eliminate the person.

If pain and suffering are the reasons for bringing someone’s life to an end, there are no logical grounds to keep suffering patients from choosing assisted suicide, whether they are terminal or not. But the real driver behind suicide is not pain. The real man behind the curtain is the desire for radical autonomy. Once suicide is an accepted outcome, the logic of autonomy demands that people should not even need to be in pain to commit suicide if they so choose.

The authors warn against nurses making value judgments about assisted suicide: “At no time should the nurse advocate for or against the patient’s decision” [line 118] and “The nurse’s decision to be present should not be negatively evaluated” [line 121]. Here, the writers have shown their hand. It is clear that the purpose of this document is to communicate to nurses that they are expected to accept assisted suicide as simply one more healthcare option.

This becomes even more clear when one considers that arguments against suicide assisted by medical professionals are not at all addressed in this document. They are alluded to, but not described or even rebutted; they are simply ignored. There is only one place in the document where the authors admit that there might be an inherent ethical problem with assisted suicide [see line 29].

The conclusions of this unfortunate document do not even ask whether any state should legalize assisted suicide to begin with, whether the practice is moral, or whether it is consistent with the practice of nursing. It simply assumes that, since assisted suicide is legal somewhere, that it is therefore moral and consistent with the values of the profession.

The nurse who believes it is morally wrong and professionally disastrous—and who has, until this point, been supported by the ethical principles of the nursing profession—has suddenly been left out to dry. The message is clear: get on board, or get out.

The ANA draft position statement, “The Nurse’s Role When a Patient Requests Aid in Dying,” is an exercise in begging the question. It engages in rhetorical sleight-of-hand, using terminology with familiar meanings and then eliding those meanings into other, less benign notions. It blurs distinctions, most notably between morality, professional ethics, and law. In short, it is an exercise in the very bias which, according to the document itself (lines 67, 108), cannot be any part of the nurse’s relationship with the patient. It is precisely this bias that the document demands that we all share.

We reject these conclusions, and this document. We call for all nurses to do the same.

Stephen J. Heaney
Associate Professor of Philosophy
University of Saint Thomas
Saint Paul, MN

Dianne Johnson, RN, OCN, MA
(44 years in nursing)
Founder and Mission Director, Curatio (Catholic Apostolate to Healthcare Workers)

Sarah Spangenberg
Graduate student, Theology
Saint Paul Seminary School of Divinity
University of Saint Thomas (Saint Paul)
Outreach Director, Minnesota Alliance for Ethical Healthcare

Patrick G. Spencer, MSN, FNP-C, RN
(34 years in nursing)