Merciful Assistance or Physician-Assisted Killing?
Imagine that your father, age 85, has been diagnosed with a terminal illness and given only three months to live.
Fortunately, he is still well enough to walk, and finds himself one night near a tall bridge. Having contemplated the suffering he believes will attend his final days, he decides to end his life by jumping off the bridge. However, he is too weak to hoist himself up atop the protective railing.
Suddenly, he sees his very own physician, Dr. Jones, walking by. He begs Dr. Jones to help him climb atop the railing, adding, “Don’t worry, Doc, it will be my decision to jump.” The doctor is taken aback, but quickly determines that his patient is not psychotic or severely depressed, and is capable of making a rational decision regarding suicide. The doctor tries to persuade your dad that pain and suffering can usually be well-controlled during the final days, but the patient is insistent: he wants to end his life.
Would you agree that Dr. Jones is fulfilling his obligations as a physician by assisting your father in jumping off the bridge?
If not, would you support the doctor’s providing your father with a lethal dose of medication?
From the standpoint of medical ethics, I see no fundamental moral difference in a doctor’s assisting a patient to jump off a bridge — without, of course, pushing him off — and a doctor’s prescribing a lethal dose of medication to “assist” in the patient’s suicide. The main difference is that, whereas anybody can assist a suicidal patient in climbing over a bridge railing, only physicians and a few other health care professionals are authorized by law to prescribe medication — and, in Oregon and Washington state, to prescribe lethal medication for “physician-assisted suicide” (PAS).
Of course, there are important procedural differences between my bridge scenario and the way PAS is handled in these states. There are numerous procedural safeguards in place to ensure that dying patients are thoroughly evaluated, and not pressured or coerced into requesting lethal medication — though the evidence is mixed as to how effective these safeguards have been. One study of physician-assisted suicide in Oregon and the Netherlands found no evidence that disadvantaged groups (such as the elderly or disabled) are being disproportionately affected by the laws (Battin et al). On the other hand, another study (Finlay and George) concluded that, “…there is reason to believe 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.”
From a strictly ethical perspective, I believe physicians have no more business helping patients kill themselves with lethal drugs than they do helping patients jump off bridges — regardless of how “voluntary” the patient’s decision may be. Clearly, neither action is compatible with the traditional role of the physician as healer. Indeed, psychiatrist and ethicist Dr. Thomas Szasz has argued that “physician-assisted suicide” is merely a euphemism for “medical killing.” For these reasons, I am opposed to the November ballot initiative in Massachusetts for a measure that would allow terminally ill patients to be prescribed lethal drugs.
And yet, as always, there are two sides to the story. When my 89-year-old mother was in her final days, she was in a good deal of discomfort much of the time. Despite having first-rate home hospice care, and the availability of powerful pain relievers — which my mother often refused to take — her dying was not an easy or peaceful process, for her or for our family.
There were times when I wondered if I could ever bring myself to provide her with the Oregon “solution.” Fortunately, my mother never requested this, and overall, I believe my family made her final days as dignified and comfortable as she would permit.
The debate over PAS often is clouded by a mistaken understanding of the dying process. Some advocates of the Oregon and Washington approach argue that the dying patient who wants to end her life has no recourse but to take a lethal drug prescribed by her physician. But in truth, competent, dying patients may end their lives by simply refusing food and drink. Indeed, medical ethicist Cynthia Geppert MD, PhD informs me that voluntary refusal of food and drink is now considered an accepted approach to dying, in palliative care medicine.
Many readers will instinctively recoil from this claim. “How could you let your loved one die of hunger and thirst?” they will understandably ask. But we usually ask this based on our own unpleasant experiences of hunger and thirst, as healthy, active persons. For the dying patient, voluntary refusal of food and fluids does not result in an agonizing or painful death, as a report in the July 24, 2003 New England Journal of Medicine concluded. According to the 307 hospice nurses surveyed in this study, most patients will die a “good” death within two weeks after voluntarily stopping food and fluids.
We may agree, as a society, that competent adults ought to be at liberty to end their own lives. But this is not the same as asserting their “right” to commit suicide, much less insisting that physicians should be complicit in fulfilling such a right. Unlike liberties, rights impose reciprocal obligations on others. And, in my view, the physician’s obligation during a patient’s final days is to do everything medically possible to relieve pain and suffering — not to relieve the patient of his life.
Acknowledgement: Thanks to Bret Stetka MD and Medscape for permitting use of some material contained in my essay, “Do We Need ‘Thanaticians’ for the Terminally Ill?”, available at: http://www.medscape.com/viewarticle/771274.
Battin MP, van der Heide A, Ganzini L, van der Wal G, Onwuteaka-Philipsen BD: Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impact on patients in “vulnerable” groups. J Med Ethics. 2007 Oct;33(10):591-7.
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 Mar;37(3):171-4. Epub 2010 Nov 11.
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 Accessed at: http://www.nejm.org/doi/full/
- Death with Dignity: Why I Don’t Want to Have to Starve Myself to Death – Dr. John Grohol
- The proposed Death with Dignity Act in Massachusetts (PDF)
- Pies R: End-of-life care and contingent vs. non-contingent duties: contributions from WD Ross’s ethics and the Judaic tradition. Accessed at: www.hektoeninternational.org/End-of-life-care-and-contingent.html
- Szasz T. Fatal freedom: the ethics and politics of suicide. Syracuse: Syracuse University Press; 1999.
- Arehart-Treichel J: A Few Psychiatrists Choose Path Strewn With ‘Heartbreaking Work.’ Psychiatric News, 2012;47:8-25. Accessed at: http://psychnews.psychiatryonline.org/newsArticle.aspx?articleid=1217914
Pies, R. (2012). Merciful Assistance or Physician-Assisted Killing?. Psych Central. Retrieved on April 29, 2016, from http://psychcentral.com/blog/archives/2012/09/30/merciful-assistance-or-physician-assisted-killing/