Now, as regards voluntary refusal of food and drink: Dr. Grohol is, of course, correct that we have little in the way of direct reports from dying patients, for obvious reasons; nor are most dying patients suitable candidates for research studies. The best available data comes from those whose job it is to detect and relieve pain and suffering—namely, hospice nurses. Having witnessed the skills of hospice nurses firsthand—in the case of both my mother and my father-in-law—I can attest to their keen ability to detect and empathize with any pain or discomfort in the patient. The admittedly limited data from Ganzini et al (9) argue against the notion that VSED [voluntarily stopping eating and drinking] per se leads to a painful or uncomfortable death (9).
This is not to say that dying under such circumstances is simple, painless or “easy.” Nevertheless, Ganzini et al. found that, on a scale from 0 (a very bad death) to 9 (a very good death), the median score for the quality of VSED deaths, as rated by the hospice nurses, was 8. That said, the natural, human impulse to “feed” our loved ones is very hard to overcome, and without emotional support for the patient’s family, a dying loved one’s decision to decline food and drink can be very stressful.
Summarizing and commenting on the hospice nurse study, Judith Schwartz, PhD, RN—who has had extensive experience with this approach (personal communication, 10/2/12)—concluded as follows:
“When compared to the deaths of patients who died by physician-provided lethal medication, the nurses rated those who died by VSED [voluntarily stopping eating and drinking ] as suffering less and being more at peace in the last 2 weeks of life. Although this was a small study that may not be generalizable outside of Oregon, Ganzini’s findings suggest that clinicians can feel reassured that recommending VSED as an end-of-life option to terminally ill persons affords a gentle and humane death, providing the patient has made a well-considered and informed decision to hasten their dying and is surrounded by others who provide emotional support and palliative care during the dying process.” (10, italics added)
This conclusion is consistent with the February, 2007 position statement by the American Academy of Hospice and Palliative Medicine (AAHPM), which states that VSED may be considered as “…an acceptable strategy for the patient, family, and treating practitioners.” (11). Another advantage of VSED compared with PAS is that, once the patient has ingested a lethal dose of barbiturates, it is extremely difficult to reverse the impending death, if the patient suddenly has second thoughts. In contrast, for the first few days of VSED, the conscious patient can have a change of heart and simply resume food and drink—and this outcome has in fact been reported (10).
Dr. Grohol wonders how physicians could accept VSED in dying patients when they would not accept similar behavior in, say, a patient with anorexia nervosa. But to compare refusal of food and drink in the case of a mentally competent, dying patient to a similar refusal on the part of an otherwise healthy patient with anorexia nervosa is to conflate two entirely different psychiatric–and ethical–situations. (For example, many patients with anorexia nervosa have a near-delusional belief about their weight and body image). There is nothing contradictory or paradoxical in a physician’s cooperating with the first (dying patient/VSED) scenario, but not with the “anorectic” scenario.
Furthermore—as Dr. Grohol and I agree—a patient’s voluntary refusal of food and drink is not a “free pass” that allows the physician to abandon the patient (which, indeed, would constitute malpractice). On the contrary, if the patient consents to continued care by the physician or by hospice nurses, palliative sedation is generally used concomitantly with VSED, to manage disease-related pain or discomfort. Sadly, Oregon PAS data for 2011 show that a physician was present at the time of the patient’s suicide in only 11.3 percent (8 of 71) of cases—hardly a comforting thought for patients or their families—making it hard to assess the frequency of complications from PAS (12). These may include vomiting after drug ingestion, and even (albeit rarely) failure of the drug to produce death. Thus, in 2011, two Oregon patients ingesting supposedly lethal medication doses awoke and ultimately died of their underlying illness (12).
Dr. Grohol argues that the proposed Massachusetts law does not compel or coerce physicians to prescribe fatal doses of medication for their patients, and I agree. But this point is entirely irrelevant to the ethical problems already noted by Dr. Rockett and Dr. Lehmann. If legislators in some perverse American state decided to legalize corporal punishment of noncompliant patients, it would still be inherently wrong for physicians to beat their patients, regardless of whether the law “coerced” them to do so!
Dr. Grohol raises the important issue of who has access to medications in the U.S., and here he makes a very good point; i.e., “If my liberty to purchase and administer such drugs wasn’t restricted in the first place, we wouldn’t need such laws. But since my liberty has been restricted, a law [permitting physician-assisted dying] is needed.” (1) The late Dr. Thomas Szasz—famously libertarian in his views regarding access to drugs—makes a similar point, in his book, Fatal Freedom:
“I do not believe in a “right” to physician-assisted suicide, partly because I believe that if people could access drugs without obstruction by physicians and the law, PAS would be a nonissue, and partly because the concept of right implies reciprocal obligations.” (13, p.74).
But even if we accept the proposition that people ought to have access to lethal drugs without the approval or prescription of a physician—and I am not at all sure I do–then the ethically responsible action is to change our laws regarding obtaining medication, not to involve physicians in killing their patients. In this regard, one interesting proposal was recently put forward by Prokopetz and Lehmann. They propose a system that would remove the physician from direct involvement in the process of ending a terminally ill patient’s life:
“…if a physician certifies that [the patient is terminally ill] in writing, patients could conceivably go to an independent authority to obtain the prescription. We envision the development of a central state or federal mechanism to confirm the authenticity and eligibility of patients’ requests, dispense medication, and monitor demand and use.” (14)
This proposal has its own practical and ethical drawbacks, particularly the risk that it would lead to a breach in the doctor-patient relationship, or even outright abandonment of the patient at a time when compassionate care is urgently needed. Still, the Prokopetz-Lehmann proposal is worthy of further consideration and does not violate the ethical tenets of medical care.
Finally, it is striking that Thomas Szasz—an avowed libertarian–opposed PAS laws, and affirmed that most dying patients have an acceptable alternative:
“Actually, regardless of how disabled a person may be, as long as he is conscious he can kill himself, without (active) assistance, by refusing to eat. Everyone possesses this ultimate reservoir of autonomy, and virtually everyone recoils from acknowledging it.” (13, p. 113)
I have spent many of the past 30 years opposing the central claims of Dr. Szasz, but on this point, I believe he was correct. He was also right that the term “physician-assisted suicide” is a comforting euphemism, designed to secure the cooperation of legislators and to disguise the undeniable fact that physicians who follow the PAS guidelines are—let us be clear–assisting in killing their patients. I don’t doubt the compassionate and honorable motives of these doctors, nor do I condemn patients who choose PAS; but in my view, PAS is misguided—both as medical practice and as public policy.
At the same time, we owe it to our terminally ill patients to redouble our efforts at alleviating pain and suffering, by every means available to advanced palliative care. Unless physicians persuade the public that we are doing so, many dying patients will continue to ask of us what ethical practice cannot countenance. Physicians since Hippocrates have entered into a social covenant not to harm patients, but to heal, cure and comfort them. When we violate that covenant, we are no longer trustworthy healers. Physician-assisted suicide fails to honor that covenant.
2. Geppert CMA, Roberts LW: The Book of Ethics. Center City, Hazelden, 2008.
3. Dr. Barbara Rockett: Physician-assisted suicide “in direct conflict” with doctor’s role. Boston Globe, 7/31/12.
4. Assisted dying, without the doctor? Ethicist says physicians can help without prescribing lethal dose. Boston Globe, 07/12/2012.
6. Emanuel EJ, Fairclough D, Clarridge BC, et al. Attitudes and practices of U.S. oncologists regarding euthanasia and physician-assisted suicide. Ann Intern Med. 2000;133:527-532. Note: Dr. Judith Schwartz points out (personal communication, 10/4/12) that most requests for PAS in Oregon and Washington experience relate to “existential distress,” rather than inadequately managed pain. This points to the need for comprehensive, supportive psychological care during the dying process—not merely relief of pain.
7. Marker RL, Hamlon K: Patients Rights Council.
8. Rosner F. Biomedical Ethics and Jewish Law. Hoboken, NJ: Ktav; 2001.
9. 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;394:359–365.
10. Schwartz J: Exploring the option of voluntarily stopping eating and drinking within the context of a suffering patient’s request for a hastened death. J Palliat Med. 2007 Dec;10(6):1288-97.
11. American Academy of Hospice and Palliative Medicine. Physician-assisted death. Position statement, 2/14/07.
12. Oregon’s Death With Dignity Act, 2011.
13. Szasz T. Fatal Freedom: The Ethics and Politics of Suicide. Syracuse, NY: Syracuse University Press; 1999.
14. Prokopetz JJ, Lehmann LS: Redefining physicians’ role in assisted dying. N Engl J Med. 2012;367:97-99.
15. Personal communication, 10/3/12
Acknowledgments: I thank Dr. John Grohol for providing a forum for these views. I also thank Dr. Cynthia Geppert and Dr. Judith Schwartz for providing valuable resources, references and perspectives. The views represented here, however, are solely my own.
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Last reviewed: By John M. Grohol, Psy.D. on 7 Oct 2012
Published on PsychCentral.com. All rights reserved.
Pies, R. (2012). Physician-Assisted Suicide: Why Medical Ethics Must Sometimes Trump the Patient’s Choice. Psych Central. Retrieved on March 8, 2014, from http://psychcentral.com/blog/archives/2012/10/07/physician-assisted-suicide-why-medical-ethics-must-sometimes-trump-the-patients-choice/