OP-ED

The American Medical Association Goes Wobbly on Physician-Assisted Suicide

flying cadeuciiPhysician-assisted suicide. Physician-assisted dying. Physician Aid in Dying. All these terms have been used to describe a terminally ill patient’s use of a lethal, prescribed medication. Sometimes the medication is used to end the patient’s life; sometimes, it is held “in reserve” to provide a sense of control over the timing of death. Historically, the American Medical Association has stood squarely against physician-assisted suicide (PAS). But recently, in approving “Resolution 015”, the organization has resolved to study the issue of “aid in dying”, with an eye toward reconsidering the AMA’s longstanding policy. As a medical ethicist, I find this resolution deeply troubling.

Consider this scenario from an ethical perspective. Your loved one is facing a terminal illness, and is expected to live only another month or two. He is sitting in his doctor’s office, and knows that the doctor owns a gun, which she keeps locked up and loaded in her office. The patient, who is mentally competent, requests use of the physician’s gun, in order to end his life. Would it be ethical for the physician to grant the patient’s request? I suspect most of us would be horrified at the thought. Indeed, most U.S. states have laws that prohibit someone from “knowingly and willfully assisting” another person in the commission of suicide.

Yet four states (California, Vermont, Washington and Oregon) have passed legislation that allows physicians to prescribe a lethal drug to terminally ill patients who wish to end their lives. (In Montana, the state’s Supreme Court ruled, in 2009, that terminally ill patients may avail themselves of a physician’s aid in ending their lives, without deciding the constitutionality of that practice).

From the ethicist’s point of view, the question is: what is the ethical and moral difference between handing a terminally ill, suicidal patient a loaded gun, and handing him a lethal prescription? In both instances, the physician acts with the knowledge that, if “correctly” used, the lethal means will almost certainly kill the patient. Indeed, I believe the apparent differences between the scenarios are mostly cosmetic and psychological: we associate physicians with writing out prescriptions, not with handing out loaded guns.

I don’t mean to argue that the procedures and safeguards in place for PAS are ethically equivalent to handing the patient a loaded gun. In all four states where PAS is legal, there are safeguards to ensure that the patient is acting voluntarily and not, for example, suffering from a psychiatric disorder that impairs judgment. However, there continues to be controversy regarding the adequacy of these supposed safeguards, and research studies have yielded mixed results. My point is simply that the mere act of prescribing a lethal drug to one’s own patient is comparable, in ethical terms, to handing the patient a loaded gun.

To be sure, guns are widely available to almost anyone in the U.S., whereas medication is dispensed almost entirely under the aegis of a physician or other health care professional. This has led some to argue that, if PAS is prohibited, there ought to be some legally approved mechanism for terminally ill patients to acquire lethal medication, without involving physicians. This is certainly an issue worthy of debate and discussion, and I might conceivably support such a mechanism. But, in my view, the absence of this option does not legitimize the use of physicians as indirect agents of the patient’s death. Indeed, beneath the comforting euphemisms of “death with dignity” and “physician assisted dying”, we find a stark truth: in states where PAS is legal, some physicians—albeit with humane intentions– are deliberately facilitating the self-induced death of their patients. I do not condemn the benign motives of these physicians, but neither do I condone their actions.

To be clear: the U.S. Supreme Court, in its 1990 Cruzan case, supported a mentally competent patient’s right to refuse medical treatment or to stop intrusive medical care, even if that decision is expected to be life-ending. However, in two 1997 cases (Washington v. Glucksberg and Vacco v. Quill), the U.S. Supreme Court essentially rejected a constitutional “right to assisted suicide.” Even the famously libertarian psychiatrist, the late Dr. Thomas Szasz, did not recognize a “right to suicide”–much less to physician-assisted suicide–though he believed that persons ought to be “at liberty” to end their own lives. This is a crucial distinction: a right ordinarily imposes obligations on others to ensure that the right can be exercised–a liberty does not. But even if we posit a “right” to use another person’s assistance in committing suicide—e.g., a friend or family member–it does not follow that physicians ought to be among the permitted agents of the patient’s self-inflicted death.

Finally, it must be said that orthodox medicine has not adequately addressed the physical and emotional needs of terminally ill patients–especially with respect to providing adequate relief of pain. The medical profession needs to do much more to ensure that dying patients receive the best available palliative care, including emotional support for patients and their families. But “assisting” patients to kill themselves is simply a bridge too far—and radically undermines the traditional role of the physician as trusted teacher and healer.

Acknowledgment : The author thanks James L. Knoll IV, MD, for his comments on an earlier draft of this piece; however, the views presented here are my own.

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For further reading:

Pies R: http://psychcentral.com/blog/archives/2012/10/07/physician-assisted-suicide-why-medical-ethics-must-sometimes-trump-the-patients-choice/

Pies R: Physician-Assisted Suicide and the Rise of the Consumer Movement. http://www.psychiatrictimes.com/blogs/couch-crisis/physician-assisted-suicide-and-rise-consumer-movement

Starks H, Dudzinski D, White N. Physician aid-in-dying. Ethics in Medicine. https://depts.washington.edu/bioethx/topics/pad.html. Accessed June 28, 2016.

Lewis P. Assisted dying: what does the law in different countries say? BBC. http://www.bbc.com/news/world-34445715. Accessed June 28, 2016.

Harper T. Call for assisted dying for our young will prove most emotional, contentious. The star.com. https://www.thestar.com/news/canada/2016/02/26/call-for-assisted-dying-for-our-young-will-prove-most-emotional-contentious-tim-harper.html. Accessed June 28, 2016.

Massachusetts Medical Society. Physicians reaffirm opposition to physician-assisted suicide. December 3, 2011. http://www.massmed.org/News-and-Publications/MMS-News-Releases/MMS-Physicians-Reaffirm-Opposition-to-Physician-Assisted-Suicide. Accessed June 28, 2016.

Battin MP, van der Heide A, Ganzini L, et al. Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impact on patients in “vulnerable” groups. J Med Ethics. 2007;33:591-597.

Finlay IG, George R. Legal physician-assisted suicide in Oregon and The Netherlands: evidence concerning the impact on patients in vulnerable groups—another perspective on Oregon’s data. J Med Ethics. 2011;37:171-174.

Ganzini L, Goy ER, Miller LL, et al. Nurses’ experiences with hospice patients who refuse food and fluids to hasten death. N Engl J Med. 2003;349:359-365.

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16 replies »

  1. I respect Prof. Strauss’s experience and perspective, but firmly disagree with his comments on my essay.

    First, Prof. Strauss calls my loaded gun vignette (it is not an analogy) “specious” and finds it “incomprehensible.” Alas, he presents no logical or ethical argument to explain why he reaches these conclusions, making it nearly impossible for me to respond. However, I’ll give it a try.

    First, I present no analogy in the strict sense (“A is to B, as C is to D”). Rather, I analyze the “deep structure” of two actions—(a) providing a lethal weapon or (b) providing a lethal prescription—and find no substantive ethical differences between them. The self-comforting illusion that they differ ethically at a deep, structural level is created by our familiarity with doctors writing out prescriptions–not handing out guns. Prof. Strauss’s spurious counter-example of “telling the dying patient to drive her automobile over a cliff” represents an action of an entirely different ethical character—“telling” (urging, advising) a patient to do X is most certainly not the same as providing her with a means to carry out an action without urging her to do so. And so, I stand by my loaded gun/lethal prescription comparison without reservation.

    Prof. Strauss evidently believes that the figures he cites re: how often PAS is used (“…only….003 of 1%…”) somehow nullify or mitigate the “controversy” I alluded to, with respect to the adequacy of safeguards in states that permit PAS. They do not. One can’t draw inferences regarding the adequacy of safeguards from number-crunching of the sort Prof. Strauss offers. Specifically, the relatively rare use of “terminal medication” in Oregon or other PAS states in no way demonstrates the adequacy of existing safeguards in Oregon or other PAS-favorable states. This issue must be analyzed on a case-by-case basis, according to criteria grounded in medical ethics.

    For example, Finlay & George evaluated legal physician-assisted suicide in Oregon and The Netherlands. ( J Med Ethics. 2011 Mar;37(3):171-4). On the basis of official reports from the Oregon Health Department on the working of the Oregon Death with Dignity Act since 2008, the authors concluded that, “…some terminally ill patients in Oregon are taking their own lives with lethal drugs supplied by doctors despite having had depression at the time when they were assessed and cleared for PAS” –contrary to the intent of the law. Similarly, Pereira (Curr Oncol. 2011 Apr;18(2):e38-45) concluded that in all PAS-friendly jurisdictions, “…laws and safeguards are regularly ignored and transgressed in all the jurisdictions and… transgressions are not prosecuted.”

    Finally, the topic of “terminal sedation” raised by Prof. Strauss is tangential, and beyond the scope of my essay. More to the point: “terminal” (or palliative) sedation is in a wholly different ethical category than deliberately participating in the killing of one’s patients; i.e., PAS. Specifically: “In contrast to euthanasia and physician-assisted suicide, the intent of palliative sedation is not to cause death, but to relieve suffering. Palliative sedation is only given to relieve severe, unrelieved suffering, and it is only utilized when a patient is already close to death.” (see: Morrow A, https://www.verywell.com/does-palliative-sedation-cause-death-1132043). None of this is true of PAS as carried out in many jurisdictions, particularly in Europe.
    Moreover, the absence of statutory guidelines for terminal sedation—however regrettable—is in no sense an argument in support of PAS, if that is what Prof. Strauss intended to suggest. The same is true with respect to the absence of statutory guidelines in the case of patients who voluntarily forego life-sustaining treatment—which is a right upheld by the U.S. Supreme Court in the 1990 Cruzan case. The absence of statutory guidelines in these instances—and I will accept this claim on Prof. Strauss’s authority—is surely not an argument in favor of PAS.

    In sum, as nearly all medical and nursing organizations agree, physicians should not be involved in helping to kill their patients. Period.

    Respectfully,
    Ronald W. Pies MD
    Professor of Psychiatry and Lecturer on Bioethics & Humanities, SUNY Upstate Medical University;
    Clinical Professor of Psychiatry,
    Tufts University School of Medicine

  2. I appreciate Prof. Strauss’s comments, and I will reply substantively in short order.

    Ronald Pies MD

  3. Dr. Pies’ article on August 18th and his supplemental piece are deeply distressing, not because opposition to aid in dying does not merit respect, but his reasoning does not for several reasons. I will address but 2 points. First, the gun analogy is simply specious. A physician even making such an analogy is incomprehensible, just as telling the dying patient to drive her automobile over a cliff would be. Second Dr.Pies, in referring to the guidelines incorporated in the existing statutes in Oregon, Washington, Vermont and California, states “there continues to be controversy regarding the adequacy of these supposed safeguards, and recent studies have yielded mixed results.” Examination of the Oregon Department of Health’s report shows that under the Oregon Death with Dignity Act from 1998 through 2015 1,545 prescriptions for terminal medication were written and 991 persons actually ingested the medication. These numbers prove that the statutory guidelines are effective and relatively few Oregonians utilize the right to obtain terminal medication. Out of a 2015 population of over 4 million just 218 persons – .006 of 1% – obtained prescriptions and only 132 – or .003 of 1% – actually took the medication.

    Dr. Pies will, I assume, acknowledge that the medical profession widely recognizes the practice of terminal sedation, providing a dying patient with such large doses of morphine or other medications that they will be essentially comatose and without pain. There are no statutory guidelines for terminal sedation. Perhaps some hospitals do have policies as to when this is allowed, but one could certainly question the appropriateness of such guidelines which leave will leave enormous discretion in the hands of the treating medical team. The “adequacy” of such guidelines can surely be questioned. Further, with respect to patients who choose (or do so through their surrogates if they lack capacity) to forgo or stop life sustaining treatment there are no statutory guidelines. If those patients request withholding or withdrawal of treatment, are they to be denied their rights because of the absence of “adequate guidelines” or because one of their reasons may be concern for the effect of their illness on their families?

    Peter J. Strauss
    Distinguished Adjunct Professor of Law, New York Law School
    Of Counsel, Drinker Biddle & Reath, New York, New York

  4. “Just to let readers know: my standing policy for online exchanges is to reply only to fully signed comments. Ideally, if you are a health care professional, please indicate your title or position.”
    __

    That’s pretty weird.

  5. “but because they fear becoming a burden, fear loss of autonomy, feel depressed, or for other non-pain related reasons.”

    Why are these inconsequential reasons? Certainly for families with limited means the financial burden of “hanging on” can be of great worry to the patient. Independence, autonomy and mobility are certainly things I think about and what makes life enjoyable. Sitting in a chair looking out the window with the inability to wipe your own bum is not a life.

    Why do I think most doctors are not patient advocates – that duty seems left to nurses and family – and the patient.

  6. Peter, my problem with it is that it has to be done under supervision*–for the reasons I’ve given–yet no one that I know wants to watch someone drink enough nembutal (or whatever….the potion is left up to the doctor) to kill him or herself. Would you like to watch this? The solution has to be that the legislature do the job or some agent of theirs. They are the ones who vote for these policies and we need their skin in the game. It is not in the practice of medicine or a subset thereof. Besides, hospice is doing a fine job of ‘intense palliation’ if you know what I mean.

    *It is too late for effective supervision in California’s law, which went into effect in July and which only advises that the patient have supervision. Again, who wants to watch this? So that, in effect, the patient is home alone with a huge glass of poison.We can’t laugh now, but this will become a joke in a few years.

  7. Some further comments on Physician Assisted Suicide (PAS):

    Many thanks to those who have posted comments. I know this is a very emotional issue for doctors, patients, and families, and that there are no “quick and easy” answers to the complex issues that arise at “end of life.” I certainly struggle with these matters myself, and have so struggled in cases involving my own family.

    Just to let readers know: my standing policy for online exchanges is to reply only to fully signed comments. Ideally, if you are a health care professional, please indicate your title or position. I realize that some readers won’t be comfortable leaving their names, but as this is a professionally-oriented website, I respectfully encourage “signing in” as a gesture of taking personal responsibility for one’s views.

    I would like to thank Dr. Palmer for his comments, and fully agree with his comment that, “We have to have a few boundaries in medicine and writing out a prescription for a huge drink of poison for someone to drink at home is a little outside of what we do.”

    As for relieving suffering, yes, of course–doctors have a responsibility to use all available medical means to alleviate pain and suffering during the patient’s final days, and this can be accomplished with currently available methods of palliative care, palliative sedation, and intensive hospice care. Alleviating suffering, however, does not include helping the patient kill himself, in my view.

    It is also important to note that several research studies have shown that most patients who request PAS are not doing so in order to relieve intractable pain and suffering, but because they fear becoming a burden, fear loss of autonomy, feel depressed, or for other non-pain related reasons. These are in no sense “inconsequential” concerns for the patient, but there are many better approaches to these worries than helping the patient kill him/herself. For example, clinical depression can be successfully treated, and fears of becoming a “burden” are often not shared by the patient’s family, who do not want to see the patient kill himself and are willing to care for the dying patient–that is what loved ones and family do, and have done for centuries!

    The concern of many ethicists who fear the “slippery slope” of PAS is that some patients with chronic illness will feel pressured into taking their own lives, because they fear becoming a “burden” to their families–even when the family is more than willing to provide palliative care, love and support.

    With regard to “advocacy” for patients: physicians are far from the only ones who have traditionally opposed PAS. For example, the American Nurses Association code of ethics comes out firmly against nurses’ participation in assisted suicide and euthanasia.
    [see: http://www.nursingworld.org/MainMenuCategories/EthicsStandards/Ethics-Position-Statements/Euthanasia-Assisted-Suicide-and-Aid-in-Dying.pdf%5D.
    PAS is also opposed by many disability activists, who fear that the disabled will be especially pressured to end their lives [see: http://notdeadyet.org/assisted-suicide-talking-points%5D

    For more on some of the myths regarding PAS, please see Dr. Ezekiel J. Emanuel’s excellent piece : http://opinionator.blogs.nytimes.com/2012/10/27/four-myths-about-doctor-assisted-suicide/?_r=0

    Finally: I respect and understand that many persons of good will disagree with my position, which I present without any belief that there are perfect answers or final truths in this very difficult area.

    Respectfully,
    Ronald Pies MD

  8. I don’t think we’d have the do it yourself kit if docs would stand up for the wishes of suffering patients. It’s a shame people have to ask for a DIY method so docs can continue to wring their hands on getting the ethics perfect. Seems there are no such “ethics” when people cannot afford medical care.

  9. I think there is false equivalency between guns and pills. We have knives as well, and people don’t cut their wrists. For the same reason, people don’t wish to shoot themselves.

    It has a cultural stigma attached and it’s gruesome. Society can discuss the equivalency, but if you ask people, and I am sure investigators have, folks don’t wish to die that way. There are exceptions, however, and I am certain intentional street drug use, bridges, hanging, and others means will suffice when you have a plan. But most terminally ill people, my guess, don’t want that. They want their relatives to see them in repose and the patient’s themselves want to drift.

    Brad

  10. I’m not clear about your point, Peter.
    I don’t have any definite or guiding view about the ethics here. My problem is that the mechanics of this process seem filled with ugly, somewhat shocking difficulties. And the bill was passed without any input from physicians…the legislature just assuming that some docs would do this prescribing job…like they were amending the practice of medicine from the outside.

    An imaginative legislature might first have asked itself: “Who would like to witness this act of a patient drinking 50 grams of nembutal.”

    “No one” is the highly probably answer.

    Getting a zero here, an imaginative legislature would then ask itself “If the patient does this alone at home how can we make it safe and tolerable for others?” [ A patient completes the job and a child in the home is safe and pets do not lick it and the body doesn’t sit around for weeks rotting while animals eat its flesh, …and crimes are not committed….on and on we go here….]

    Getting a zero here, I would think, would cause attorneys drafting the bill to go back to the docs for long discussions. Alas, this did not happen.

  11. “But “assisting” patients to kill themselves is simply a bridge too far—and radically undermines the traditional role of the physician as trusted teacher and healer.”

    How come when doctors take their suffering terminal pets to the vet to get “assisted” death they think themselves humane, kind and understanding – even though the pet has no input in the decision. Why wouldn’t they take the same approach to a fully rational suffering and terminal humane being?

  12. Thanks Bobby, I’ll check out the book. My problem is mainly having the patient home alone with all this poison without some way to insure a real time supervision. You know the patient may fall asleep before taking the full lethal dose and you then have a half concsious patient with perhaps pets or children or visitors coming to the scene. Or someone decomposing for days before being discovered by family. Or crimes being committed with the remainng dose. You can’t have large amounts if lethal poison sitting around homes without some supervision. Dumb. Just have trained teams from the governors office monitor and observe the process. A simple solution. A physician ex officio could advise.

  13. I am not a physician, so you are much better informed here.

    From “The Good Death.”

    I had a 3 p.m. appointment with Mark Connell, the Missoula lawyer who had represented Baxter. Before I had gotten on the plane for Montana, I had watched a YouTube video of Connell arguing before the Montana Supreme Court. In it, Justice Jim Rice asks Connell how aid in dying would affect important laws intended to protect citizens.

    Connell’s voice is calm, almost buttery, authoritative without being too assertive. In the video, he’s wearing a dark suit and tie, the model of a small town lawyer. He answers,

    “Statutes in Montana, the Montana Rights of the Terminally Ill Act, cross that line over and over and over again. We’re not working on a blank canvas here. Montana law recognizes multiple situations where it’s all right for a doctor to hasten death. This happens every day in our hospitals. This double effect doctrine is when a doctor goes to a patient and his family and says, “You’re suffering, I’m gonna put you out of suffering. Here’s the extra morphine that will do the job.” This is done deliberately so. And so our law recognizes there are certain situations where, because of the paramount duty doctors have— and the state recognizes— to alleviate suffering, medicine can proceed to the point where death is hastened. Our contention, as you know, is that there’s not much difference between that and aid in dying. It takes a small step further.”

    “Double effect.” An action that has two outcomes. Connell was referring to the medical principle that a doctor may medicate a patient to alleviate pain and suffering, even to the point of death, so long as the doctor’s intention is to relieve suffering. In Principles of Biomedical Ethics, Tom L. Beauchamp and James Childress write, “This rule incorporates a very influential distinction between intended effects and merely foreseen effects.” The principle traces back to St. Thomas Aquinas, a Dominican friar and Catholic theologian who died in 1274. In Summa Theologica, his seminal, foundational work, Aquinas writes, “A single act may have two effects, of which one alone is intended, whilst the other is incidental to that intention.” Aquinas says that the nature of an act depends not on its outcome but on the “agent’s” intention, and he gives an example of how the double effect works. He says that when we protect ourselves from an attacker, our intent is self-protection. If we happen to kill the attacker, our action of self-defense is justified because “the agent intends to save his own life.” Double effect has been a principle in Catholic moral theology for more than a century; later, it was taken up by philosophy and applied ethics. The double effect was ultimately enshrined in medical ethics by Beauchamp and Childress in 1977 as medical technology was quickly complicating the dying process and clear ethical principles became necessary. But the double effect has always been accompanied by controversy. Some don’t place the same emphasis on intent that Aquinas did (or the Catholic Church continues to), particularly when the second outcome is foreseeable, even predictable. Even, perhaps, hoped for…

    Neumann, Ann (2016-02-16). The Good Death: An Exploration of Dying in America (pp. 61-62). Beacon Press. Kindle Edition.

    Beyond the issue of “physician-assist,” Neumann goes on to cite examples of the radical “pro-life/disability rights” position that terminally ill patients who express a wish exercise their personal moral agency to end their lives are in fact “clinically depressed” and should be subjected against their will to MORE “treatment.” Some of the most extreme disability rights partisans argue that “death with dignity” laws are the first (slippery slope) steps toward a new eugenics.

    It’s a good book.

  14. I can’t find this “alleviating suffering” role or duty or obligation or job in any of the usual definitions of the practice of medicine, Bobby. “Beneficence” doesn’t hack it.

    I don’t have any firm ethical opinions about this, but I do not feel it falls under the practice of medicine: giving patients large quantities of barbituates to take home with them*. I don’t see why the CA governor or the legislature can’t supervise and run this program if they want it. They (de facto) do it for capital prisoners.

    *A terminal cancer patient, 45, living alone with a 5 yr old daughter, divorced, she gets her 50 gram drink of nembutal from the pharmacy and is supposed to drink this at home in the presence of a witness. What if there is no witness? Are you going to punish or fine her! What if she feels pity for her daughter who will be orphaned and takes the daughter with her? What if she only takes part and falls in a stupor and the dog laps it up? What if she takes it alone but is not discovered for a week? by her relatives! What if she wants to off someone else?

    No one thought this bill through and it has ghastly aspects throughout the bill.

    Further, if it is deemed not the practice of medicine and something goes wrong, who is liable? E.g. if someone else is poisoned or dies?

    The governor or legislature should do it. They have the teams all set up in San Quentin and other prisons and they can do home visits and witness the process.

    We have to have a few boundaries in medicine and writing out a prescription for a huge drink of poison for someone to drink at home is a little outside of what we do.

    I don’t have a problem with vets or dentists or lawyers or movie-script writers doing it as long as they are licensed and as long as the law is not whacky. I only have a problem with medicine doing it.

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