Abstract
On December 4, 2009, the American Nurses Association (ANA) issued a call for public comment on a revised position statement, “Registered Nurses' Roles and Responsibilities in Providing Expert Care and Counseling at the End of Life.” The intent of this new statement is to replace the 1994 position statements on assisted suicide and active euthanasia, which clearly prohibit nurse participation in those activities. The revised position statement subtly endorses assisted suicide. Four main problems in the revised statement are addressed in this essay: a misunderstanding of the principle of double effect, the misuse of sole intent in the ANA Code of Ethics for Nurses, confusion about the meaning of conscience, and failure to recognize the primacy of human dignity. To date, the ANA's final decision on the revised statement has not been released.
On December 4, 2009, the American Nurses Association (ANA) issued a call for public comment on a revised position statement, “Registered Nurses' Roles and Responsibilities in Providing Expert Care and Counseling at the End of Life.” The intent of this new statement is to replace the 1994 ANA position statements on assisted suicide and active euthanasia, which clearly prohibit nurse participation in these activities. The purpose of the revised statement is said to be to provide information that would guide nurses when advocating for patients as they consider end-of-life choices, and to discuss personal ethical dilemmas that can occur for nurses when they care for the dying. 1
This revised statement, rather than guiding nurses in genuinely advocating for their patients and legitimately resolving ethical dilemmas, unfortunately misguides them and creates more ethical problems by subtly endorsing assisted suicide and encouraging nurses to support patients in those decisions. My comments here address four main problems in the revised statement that contribute to this misguidance: a) misunderstanding the principle of double effect; b) misusing the term “sole intent” in the ANA Code of Ethics; c) confusing conscience with mere subjective personal preference; and d) failing to adequately consider the fundamental principle that underlies all nursing practice, respect for the dignity that is inherent to all human beings.
The Principle of Double Effect
In the revised position statement, the ANA refers to a definition of the principle of double effect from the Hospice and Palliative Nurses Association. As cited in the revised statement, double effect is defined as,
A bioethical concept that provides moral justification for an action that has two foreseen effects: one good and one bad. The key factor is the intent of the person performing the act. If the intent is good (e.g., relief of pain and suffering), then the act is morally justifiable even if it causes a foreseeable but unintended result (e.g., hastening of death). 2
This definition is not accurate. While intention is important in the principle of double effect, it is not the key factor, nor does a good intention make an evil act into a good one.
For an accurate understanding of the principle of double effect, it is necessary to look to the foundation of the principle in natural law and to its grounding in the three determinants of a good act. 3 The goodness of a particular act is determined by the object of the act, the intention, and the circumstances. For an act to be morally good, there must be an integration of the goodness of the object, intention, and circumstances, and a defect in any one of these can render an act immoral. 4 However, and most importantly, “the morality of the human act depends primarily and fundamentally on the ‘object’ rationally chosen by the deliberate will.” 5 Thus, while the intention of the person performing the act is a factor, it is not the key factor.
It is also necessary to bear in mind that there are five conditions of the principle of double effect (some combine them to make four conditions) and that, for an action with both a good and bad effect, all of the conditions must be met in order for the principle to apply. Peter Cataldo is instructive in explaining how object, intention, and circumstances apply to the five conditions:
With respect to the Object of the act:
the act is in itself good or at least morally indifferent
With respect to the Intention of the act:
2) the good effect is directly intended and the bad effect is foreseen but unintended
With respect to the due measure of the Circumstances touching upon the effects and the act itself,
3) the good effect is not achieved by means of the bad effect
4) the good effect is proportionate to the bad effect
5) the good effect can only be achieved concomitant with, but not by means of, the bad effect. 6
In the case of assisted suicide, the object of the act (killing) is morally wrong. Because assisted suicide does not meet even the first condition, the principle of double effect cannot be said to support it. It is possible for the principle to support the use of pain medication in the care of patients at the end of life; however, all of the conditions must be met and do so with respect to the goodness of the object, intention, and circumstances, and their integration.
Sole Intent
The revised position states the following:
The ethical framework of the profession as articulated through the Code (2001) explicitly prohibits deliberately terminating the life of any human being. This new position statement reframes the language to state that nurses do not participate in actions with the sole intent of causing death, but do participate in actions with the sole intent of responding to suffering and providing comfort care in the last stage of life. 7
This “reframing” of language produces confusion about intention and the proper relationship of means to ends and, as a result, opens the door to allow support of assisted suicide. Provision 1.3 of the ANA Code of Ethics, to which the new position statement refers, states the following:
The nurse should provide interventions to relieve pain and other symptoms in the dying patient even when those interventions entail risks of hastening death. However, nurses may not act with the sole intent of ending a patient's life even though such action may be motivated by compassion, respect for patient autonomy and quality of life considerations. 8
By focusing on the word “sole,” one may find it possible to allow support of assisted suicide in which the intent of the nurse is not solely to end the patient's life but also to relieve suffering and to comfort the patient, or even to simply respect the patient's autonomy. Furthermore, the good effect (relief of suffering) is achieved by means of the bad effect (assisting suicide). This is a utilitarian line of thinking in which the end justifies the means. However, this violates the third condition of the principle of double effect in that the good effect must never be achieved by means of the bad effect, and as previously explained, a good intention does not change an evil act into a good one.
There are morally acceptable means to relieve suffering, comfort patients, and respect autonomy. Assisting suicide is not one of them. Ending the patient's life must never be the intent of the nurse, sole or otherwise, even if the will is moved by a desire to relieve suffering, comfort the patient, respect autonomy, or whatever.
Confusion of Conscience
The revised document includes confusing statements that suggest that conscience is merely a matter of subjective preference of personal values and beliefs rather than something deep-seated and informed by objective moral norms. Understood this way, it may be possible to set aside one's conscience so as to accommodate patient requests and to uphold the nurse's professional responsibility to advocate for and respect the patient's “fullest autonomy,” even if the patient's preference is assisted suicide. According to the revised document:
Nurses support, advocate, and value patient autonomy in decision-making in a health-care environment that frequently disregards personal preferences. Requests for assistance in dying pose challenges for nurses in terms of their own values and beliefs as well as their sense of professional responsibility and the values the profession of nursing serves to uphold…. Though there is a profound commitment both by the profession and the individual nurse to the patient's right to self-determination, limits to this commitment do exist. In order to preserve the moral mandates of the profession and the integrity of the individual nurse, nurses are not obligated to comply with all patient and family requests. 9
Although it is reassuring to read that nurses are not duty-bound to comply with all patient and family requests, the position statement goes on to imply that the nurse is duty-bound to discuss and support all end-of-life options with patients (including assisted suicide where legal), or at least find someone who will, and that doing so is “best practice,” implying that this is what the good nurse should do. 10
In reference to discussions of end-of-life options to include assisted suicide, the revised document states:
Nurses have an obligation to step forward as a profession to open this dialogue. Provision 1.4 of the Code of Ethics for Nursing notes that the right to self-determination “is the philosophical basis for informed consent in health care.”… In order to make informed decisions, invoking their moral and legal right to determine what is done to their own person, patients need “to be given accurate, complete, and understandable information.” …
[Furthermore] the withholding or withdrawal of life-sustaining treatment such as mechanical ventilation, cardiopulmonary resuscitation, dialysis, chemotherapy, antibiotics, and artificially provided nutrition and hydration, as well as the decision to forego life-sustaining treatment, are ethically acceptable. 11
This statement is misleading. While the withholding or withdrawal of treatment can be ethically acceptable, it is not automatically so, as the statement implies. The right to informed consent and the responsibility to provide information as part of the consent process only relate to morally legitimate options, not to information on how to kill. Nurses should never be required to inform patients that killing is an option, or made to believe providing such information is a requirement of nurses. Discussing the option of assisted suicide may seem permissible for a conscience understood as mere subjective preference. However, for a conscience grounded in objective moral norms that recognizes the moral impermissibility of assisted suicide, this would constitute complicity in moral wrongdoing. It may be that the confusion regarding conscience as something wholly subjective and deaf to objective moral norms is a contributing factor to the relentless problem of moral distress and compromised moral integrity that plagues nursing.
Human Dignity
Human dignity is one of the core values of nursing. 12 According to the first provision of the ANA Code of Ethics, the fundamental principle that underlies all nursing practice is respect for the inherent worth, dignity, and human rights of every individual. 13 Nursing correctly recognizes that dignity is inherent to human beings, not assigned to them by others or restricted by subjective considerations of social or economic status, personal attributes, or the nature of health problems. 14 Dignity is inherent by virtue of the fact that human beings are created in the image of God.
Given all this, it is odd that the position statement rarely mentions respect for human dignity but instead seems to focus primarily on “honoring the expression of the patient's fullest autonomy” and refers to end-of-life choices as “a quality-of-life issue.” 15 Along with human dignity, the core values of nursing are said to be altruism, social justice, integrity, and autonomy. 16 An overemphasis on autonomy seems to give it a primacy over the other values when, in fact, it is human dignity which has primacy, as it is the value from which all the other values are derived. Focusing on human dignity would assist nurses to recognize the divine image that is present in every human being, to respect the capacity to reason towards and understand the order of things established by the Creator, and to recognize the voice of conscience urging one to do good and avoid evil and directing the free will toward what is true and good. 17 With such an understanding of the human person, assisted suicide would be unthinkable.
Conclusion and Recommendations
By reframing language and misinterpreting principles and values, this revised position statement unfortunately endorses assisted suicide and, thus, contradicts the long-standing tradition of primum non nocere upon which both medicine and nursing are founded. Such activity is contrary to the ethical norm that a good end does not justify an evil means and that good intentions do not change an evil act into a good one. Nursing prides itself on being a caring profession, but killing is never an act of caring. Assisted suicide has never been legitimate nursing practice and should never be misconstrued as such.
This revised position statement should be rejected, or at least revised such that a position that clearly opposes assisted suicide and euthanasia is firmly upheld. Nursing could be of greater service to individuals and society by focusing on discovering ways to provide better care to patients who are approaching death, rather than including assisted suicide as if it were a legitimate moral option. As a result, patients might be less tempted to request assisted suicide and nurses might be less tempted to support it. Nursing education should include the study of ethics, including natural law and the Catholic tradition, which would help to clarify important principles, such as double effect, and other difficult issues in the care for the dying. Like medical schools, 18 nursing schools need to be schools of virtue and assist in the formation of conscience according to objective moral standards that will help to ensure decisions which are not only certain subjectively but also correct objectively. 19 This is vital given the work that nurses do and the trust that patients place in them.
The practice of nursing is a ministry of humble service to the sick and suffering, in whom we find his Holy Face. May the care and counseling of all our patients, especially those approaching the end of life, be guided by the wisdom of the Divine Physician and directed to the Good we desire.