The Thin Line Between Compassion and Crime: RI physicians navigate an ethical and legal landscape

Proponents of the physician-assisted Suicide, or “Death with Dignity,” movement seek to legalize a terminally ill patient’s wish to end life with a doctor’s help. The controversial topic is the subject of a recent bill introduced in the Rhode Island legislature (see The Lila Manfield Sapinsley Compassionate Care Act, H5572 deathwithdignity.org/states/rhode-island/). The bill provides certain safeguard requirements, including a terminal illness, patient competency, informed consent, two requests for death by the patient, two witnesses, and the patient (not physician) self-administering the final dose. The bill is very similar to that which legalized physician-assisted suicide in Vermont in 2013.  

In RI, the line between a physician helping a terminally ill patient end their life and committing a felony is so narrow that practicing medicine in this sphere puts professionals at constant risk of criminal liability. To better illustrate the ethical and legal landscape physicians face, consider the following scenarios: 

Scenario 1: 

Terminally ill patient: “The suffering is too great. I wish to die.” 

Physician: “I can increase your morphine, but it may stop your breathing.” 

Patient: “I understand and consent.” 

The doctor administers morphine to the patient with the intent to relieve pain, and the patient dies after the morphine is administered. 

This situation, referred to as the “double effect,” is legal under Rhode Island General Law §11-60-4 (webserver.rilin.state.ri.us/Statutes/TITLE11/11-60/11-60-4.HTM). The “double effect” is generally accepted by the medical profession, according to Miriam Hospital ethicist Dr. Herbert Rakatansky, clinical professor of medicine, emeritus, at Brown University. 

The physician’s intent is the crux of the action’s legality. Since the intent is to relieve suffering rather than deliberately end life, the fact that the fatal dose is physician-administered is not relevant. 

This same Rhode Island statute recognizes the right to refuse medical care, which is related to, but different than what is being discussed in this article. For more information on the right to refuse care, see Cruzan v. Director, Missouri Dept. of Health (pubmed.ncbi.nlm.nih.gov/12041283). The Cruzan case paved the way for modern advanced directives, which are legal documents indicating a person’s wishes to not be connected to life support indefinitely should there be no meaningful recovery or quality of life. When people mention “pulling the plug,” they are referring to the advanced directive. 

Scenario 2: 

Terminally ill patient: “The suffering is too great. I wish to die.” 

Physician: “I can give you a dose of morphine to end your life.” 

Patient: “I understand and consent.” 

Doctor prescribes and patient self-administers the fatal dose. The doctor’s intent is to end the patient’s life per the patient’s wishes, and the patient dies after the morphine is administered. 

This is the scenario sought to be legalized under the recent Lila Manfield Sapinsley/Death with Dignity bill. The doctor’s intent changes here from pain relief to ending life, and the dose is self-administered by the patient.  

There are myriad ethical considerations regarding the physician’s role as healer versus assistant to the patient’s requested demise. The American Medical Association (AMA) in the past few years consistently has not supported physician-assisted suicide practices, yet their website provides thoughtful guidance for those who do support it. The AMA Ethics Code Chapter 5.7 provides: “Instead of engaging in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life. Physicians: (a) Should not abandon a patient once it is determined that cure is impossible. (b) Must respect patient autonomy. (c) Must provide good communication and emotional support. (d) Must provide appropriate comfort care and adequate pain control. AMA Principles of Medical Ethics: I, IV.” 

Scenario 3: 

Terminally ill patient: “The suffering is too great. I wish to die.” 

Physician: “I can increase your morphine to end your life.” 

Patient: “Ok. I understand and consent.” 

Doctor prescribes and administers a lethal injection to the patient. The doctor’s intent is to end the patient’s life per the patient’s wishes, and the patient dies after the morphine is administered. 

This situation is typically referred to as euthanasia and in the United States, it’s a crime. Doctors (eg, Jack Kevorkian in the 1990s) have been tried and convicted of murder for doing just this. Despite its criminal consequences in the US, euthanasia is legal and is in fact the model in a few other countries such as the Netherlands and Belgium. The critical piece to differentiate with the Death with Dignity scenario is the lack of patient autonomy in the euthanasia model. In a situation where the final dose is self-administered by the patient, that patient is in full control and can change their mind up to the last moment, which would not be available if the administration was done by a physician.