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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advocator66ronpiesBrad FPeterWilliam Palmer MD Recent comment authors
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advocator66
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advocator66

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,… Read more »

Peter
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Peter

Thank you for this reply.

ronpies
Member

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

Ronald Pies MD

ronpies
Member

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… Read more »

ronpies
Member

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… Read more »

Peter
Member
Peter

“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.

BobbyGvegas
Member

“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.

Brad F
Member
Brad F

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… Read more »

Peter
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Peter

“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?

William Palmer MD
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William Palmer MD

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,… Read more »

Peter
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Peter

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.

William Palmer MD
Member
William Palmer MD

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… Read more »

William Palmer MD
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William Palmer MD

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… Read more »

BobbyGvegas
Member

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… Read more »

William Palmer MD
Member
William Palmer MD

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… Read more »

BobbyGvegas
Member

Ann Neumann covers the gamut of end-of-life issues (including death-with-dignity and PAS) with deft nuance in her excellent book ‘The Good Death.” I reviewed it here: http://regionalextensioncenter.blogspot.com/2016/07/a-billion-tons-of-human-bones.html

“radically undermines the traditional role of the physician as trusted teacher and healer”

How about the equally traditional function of alleviating suffering?