Physician-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.
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.