Academic journal article Social Work

Historical and Contemporary Issues in End-of-Life Decisions: Implications for Social Work

Academic journal article Social Work

Historical and Contemporary Issues in End-of-Life Decisions: Implications for Social Work

Article excerpt

In 1997 the state of Oregon legalized physician-assisted suicide in which physicians can prescribe a lethal dose of medication at the request of terminally ill individuals who want to end their lives. By implementing the Death with Dignity Act (Oregon Health Division, 2001), Oregon became the first jurisdiction to implement a statute sanctioning medical interventions that directly lead to a person's death. Subsequently, in 2002 the Netherlands enacted the Termination of Life on Request and Assisted Suicide Act (Netherlands Ministry of Foreign Affairs, 2002), formally legalizing both assisted suicide and euthanasia that had been practiced in the country for decades. Shortly thereafter, Belgium passed a similar law (Vollmer, 2002), making these the only two jurisdictions with explicit laws legalizing physician-facilitated euthanasia. These laws are indicative of a new era in which end-of-life (EOL) decisions and policies have become increasingly complicated. With medical advances in the past half century, decisions about whether to begin treatments, to terminate life-sustaining measures, and to intentionally end life are commonplace.


Since the time of Descartes (1598-1650) Western medicine has separated the mind from the body, dividing sickness into two categories: (1) disease, which is concerned with physical dysfunction and treatment, and (2) illness, which includes the entire human experience with sickness, including beliefs and culture (Brown, Barrett, & Padilla, 1998). U.S. medicine's disease-oriented approach has produced superior technology with less attention to the personal and sociocultural implications of illness. Thus, the United States has the most technologically advanced sickness care in the world, but 43 million people in the United States are uninsured. By contrast, other developed countries provide universal access to health care but rely less on technology to treat sick people than the United States does.

Circumstances and demographics surrounding death also have changed dramatically in the past century. Increases in the number of health care providers, revolutionary expansion in health care technology, improvements in environmental and public health, and the promulgation of health care institutions have contributed to greatly increased life expectancy in the United States. At the turn of the 20th century, the average life expectancy in the United States was 47.3 years. It rose to 62.9 years by 1940, and to 76.7 years by 1998, a 62 percent increase in one century (National Center for Health Statistics, 2002). However, the presence of physicians and hospitals at the end of people's lives has also led to the intrusion of medical professionals and health care systems into the natural process of dying. In the 1940s most deaths were the consequence of single factors such as acute disease and accident. Today, chronic illness is the leading cause of death and the greatest source of health expenditures in the United States.

Although people are living longer, they are more likely to have multiple health problems and to die in institutions than ever before (Hoffman, 2000). For some people, especially as they age, chronic illness compromises quality of life. For example, Hendin (1999) found that medical illness was a factor in half the suicides of people ages 50 and older and 70 percent of those 70 years and older. Increased life expectancy, chronic illness, technological advances, and expanded treatment options have all complicated EOL and the process of dying.


As EOL care has become formalized and institutionalized over the past half century, treatment choices have expanded greatly and decisions have become much more complicated. For this discussion, EOL treatment is conceptualized on a four-level continuum: (1) palliative, (2) active, (3) aggressive, and (4) invasive. …

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