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?
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Your examples and conclusions are illogical, and disturbing.1. Your initial bridge example assumes that these are comparable situations, but patients contemplating PAS are rarely in a position to have a nice stroll along a bridge. Not comparable, in any way.2. In your bridge example, the patient decides in the moment, on the bridge, to end his life. How is that comparable to a decision made over time, while suffering and contemplating every possible outcome, and making a decision based on multiple inputs?3. Why exactly is the word “voluntary” put in quotes in your bridge example? Because, intentional or not (I believe intentional), this gives the impression that the person requesting death to end suffering that will only end with death anyway has been somehow coerced and lacks free will.4. Ah yes, just refuse food and drink….because that’s dignified and quick. And oh so easy. Why don’t you go ahead and stop breathing or blinking, while you’re at it? Try fasting for even a 24 hour period, and come back and tell me how easy that would be to do for the WEEKS it would take to die. Go talk to malnourished children around the world and ask them how it feels to starve to death. An ill patient, already in enough pain to consider ending their lives, is now supposed to add additional pain??5. “Misunderstanding of the dying process” – this is quite possibly the most offensive part of this “article”. Your quote an article where a small sample healthy nurses are interviewed regarding the pain and discomfort levels of other people. In what way is this a scientific study on which to base your conclusion that someone dying from thirst would have no discomfort or pain??? These nurses aren’t experiencing it, and they are a grossly biased sample. Again, I challenge you to drink NOTHING for even 2-3 days and tell me how you feel.You’re welcome to your opinion, but please provide some logical arguments, not this manufactured crap.Your arguments are based on pure, unadulterated selfishness – YOUR discomfort with death and dying, perhaps due to religious beliefs or who knows what. But how is it ANY of your business what someone else does with their body? You have zero ownership of that person.This article is disgusting and disturbing.
This article makes perfect sense. Doctors should assist in relieving pain and suffering during the end of life, not relieve the patient of his/life. Thank you so much for this clarification of a very fine line in patient care. Just assist and let nature take its course. If I’m dying, please don’t MAKE me eat or drink. Ughhh…. my body is too tired to digest….just rub my back and be with me.
There is no indication in this article that anyone is MAKING anyone eat. What it’s saying is that starving oneself is the only OPTION available.
I think you misread.
“voluntary refusal of food and drink is now considered an accepted approach to dying, in palliative care medicine.”
Correction~~~~Making someone eat or drink…. by artificial means….
Comfort measures including pain medication are used to keep patients comfortable in palliative care medicine.
Dr Pies,
The proposed law in Massachusetts would not impel you to help someone end their life. No one could force you to prescribe a life ending prescription to someone who requested it. Consequently, your opinion that it it wrong is noted.
So what? It is your opinion.
However, it is not your life.
And this is the beauty of choice. If and when I make the choice that I want to end my life rather than go through weeks of starvation and deprivation of life sustaining liquids, I want that choice. And you have the choice to say, “no.” But, my choice is still rational. You see, I watched my own mother die for 3 1/2 years. And the last 2 1/2 weeks were wretched!
My parents had seven children, Dr. Pies. After watching what happened to my mother, ALL SEVEN CHILDREN have decided that we will not go through what she experienced! No animal in the USA has to endure what she did! And, yes, this was in a hospital…Newport Hospital, to be exact.
Let me be clear; we do not live in Massachusetts. We live in RI, with one in FL. So, we have no stake in the upcoming election results. However, every one of the seven of our parents’ children have decided that we will end our own lives, or help out our siblings, (regardless of any possible result), if necessary, rather than endure the outrage our mother had to go through. Why? Because this is a matter of a fundamental right — it is our body; it is our life.
It is no one’s choice but our own.
So, you are free to make your choice to say “no,” Dr Pies.
We will demand, and we will take our own freedom to make our choices, too. It is *our* choice, after all.
Shalom, Salaam, Pax!
As a board certified psychiatrist now practicing over twenty years including the work I did the last 2 years of residency, this suicide issue is again as gray as the bereavement issue argued here and other sites in the past; while probably not best served with a law written by politicians alone, I just want to ask, why is it doctors in general, psychiatrists specifically, react to suicide and end of life issues in such a polar manner of all wrong to die/all right to live? Fortunately got the chance to learn something very gray about the issue in my fourth year of residency working C/L work at a community hospital, out of the politics and stifling control of the teaching hospital I had to endure those first 3 years
For the sake of space, to summarize a convoluted story of terminal pain and anguish, asked to consult on a 70+ woman with stage 4 breast CA with too many mets to attack, and she was on the med service for complications of chemo and needed a stat psych consult because, per the consult statement, “patient wants a lethal dose of opiates to die, needs to be transferred to psych unit.” I really wish I could tell this story fully to give the impact, but, it’s a thread, so the conclusion she and I came to was this: she didn’t need to go to a psych unit, she couldn’t ask a health care provider to compromise their oath and willingly take the life of a person, and it was ok to be at peace to want to move on after a full life with a terrible end stage illness like metastatic breast cancer. So after the attending doctor caring for her medically had his Intermittent Explosive Disorder outburst at the nursing station, my attending respectfully contained said colleague and got the patient transferred to another provider who embraced sympathy and options, and I got to meet her adult children who wanted to understand why someone wanted to die with dignity and as pain free as able, we got her discharged with appropriate follow up set and she thanked me for the understanding time to talk and problem solve.
Oh, and she died at home about a week later, and the terms sounded like she overdosed on meds, but, family was at peace with her choice.
It is a shame we need yet another law to practice common sense and problem solve what each individual problem presents to us. But, we as a collective society have just relented and expect someone else to care for us, just as long as we have screens and toys to play with when not allegedly doing our jobs. I am not a pure Libertarian in my nature, but it is a better political ideology than what either end of politics as usual spews on us these days as Republicans or Democrats.
Intolerance or overtolerance to choose on November 6. Wow, can’t wait to participate!
I thank those who have commented thus far, and I realize this is a very heated and emotional issue–one that continues to divide the medical community itself, in many cases.
Dr. Hassman asks, rhetorically, “why is it doctors in general, psychiatrists specifically, react to suicide and end of life issues in such a polar manner of all wrong to die/all right to live?”
While I think a “polar” attitude does describe some physicians, including some psychiatrists, I am not sure that’s true of most. I believe that most MDs (as well as nurses, social workers and other professionals
confronting end-of-life dilemmas) realize that these are complex and nuanced issues, with no easy answers, as his case vignette demonstrates.
That’s why I used a question as the title of my
article, and why I observed that “there are two sides to the story.” And I think that if Dr. Hassman reads my paper in Hektoen International, he will see that
I do not have a polarized view of ending one’s life under certain dire and irreversible circumstances.
But I also want to emphasize that my article was not about the “rightness” or “wrongness” of ending one’s life, which is an enormously complex issue in its own right. My article was about the ethics of a physician
becoming involved–albeit indirectly–in the killing of patients, however benign and noble the intention.
For underneath the comforting euphemism of “death with dignity”, killing patients with prescribed medication is what we are really discussing.
And, to foreshadow my reply to Dr. Grohol–whose wisdom and balance I have come to respect greatly–
I am not at all convinced that there is much “dignity”
in a terminally ill patient deliberately poisoning herself, compared to one who voluntarily decides
to turn away from food and drink, as dying people did for centuries before doctors had formal prescriptive powers.
[For more on this voluntary refusal of food and liquids, and why it is often a humane option, I recommend the excellent paper by Dr. Judith Schwartz, "Exploring the Option of Voluntarily Stopping Eating and Drinking within the Context of a Suffering Patient’s Request for a Hastened Death", JOURNAL OF PALLIATIVE MEDICINE Volume 10, Number 6, 2007]
Declining to write a prescription for lethal medication is not about restricting a dying patient’s “freedom of choice”; there are, after all, hundreds of ways of ending one’s life. It is about the limits of what is medically ethical, and whether a patient’s
“choice” of taking a lethal drug is one which ought to involve the physician’s complicity.
No, I do not believe that doctors who participate in Oregon-type “death with dignity” laws are being “impelled” or “compelled” to do so, but that is beside the point. If the action of prescribing a lethal dose of medication is not medically ethical–as many of us in the field believe–it doesn’t matter whether the doctor acts voluntarily or not: the action would still be wrong.
That said, I do not condemn mentally competent, terminally ill patients for choosing to end their lives, so long as they have been carefully informed of all the available alternatives. Neither do I condemn the doctors in Oregon and Washington who, in good conscience, participate in the “death with dignity” option–though I disagree in principle with the statute that makes their actions “legal.”
These are complex matters, and I acknowledge there are no simple, cut-and-dried answers to end-of-life issues. Yet physicians must always keep in mind the
ancient dictum of “doing no harm.”
Respectfully,
Ronald Pies MD
Hi Dr. Pies, I do look forward to your reply.
In the meantime, I might say that when there’s question within the actual profession about whether something is ethical or not, it’s something the profession should sort out among themselves first. By bringing it into the public arena for debate, physicians are pitting their interests and varying ethics against a patient’s choice.
In fact, it’s directly interfering with the patient-doctor relationship, and the choices of the patient to end their life with dignity (which, in my opinion, is certainly a more dignified way to die than through wasting and being prescribed a sedative).
If wasting were really as painless and a simple way to die as you and other physicians suggest, I see little reason for the use of a sedative. The fact that a sedative is routinely prescribed in these situations is evidence that perhaps it is far from a painless, simple or dignified way to die.
Patients simply want a painless way to die when their death has already been foretold. Unfortunately, the only people who can provide this are physicians. If government would give prescriptive power of these medications to another type of professional, then we could take this issue out of the hands of physicians and put into a profession’s hands that doesn’t have the ethical dilemma.
Best,
John
PS – Physicians do harm all the time. Some of it is unintentional, leading to the 50,000-100,000 deaths per year in hospitals. But some of it is intentional, in order to fix the underlying problem. For instance, physicians harm patients with chemotherapy — which causes all sorts of additional health problems in patients. But they do so in order to treat the underlying cancer, after talking about these options with the patient.
So the “do no harm” dictum in modern medicine is not — nor has it ever been — an absolute. The relief of suffering is just as important a dictum, and I think the one that is most relevant in this discussion.
Respectfully, having worked with scores of psychiatrists in my travels, I would easily bet $20 that if 5 different psychiatrists saw this patient I met with above, 4 would have put her in an inpt unit.Sure, not 100% of physicians take a fixed/rigid approach to an issue like this. But if 80% do, and I really believe that is a fair interpretation, what is the take home message for patients with those odds?Am I missing something in this post here, you are arguing that this legislation should not be passed, correct? That is the perspective stated by Dr Grohol in his separate post.Legislation is black and white. Making a statement supporting or rejecting pending legislation is a black and white stance. As I said above earlier in the thread, do we really need laws to treat individuals who are coming to their doctor for not only care, but empathy and compassion?Just wait for it folks, as PPACA gets more settled as the standards of care for this country, we will see more care mandated by politicians. Frightening, no, an understatement to me. Truly the end of responsible and ethical care as we as doctors were trained to know it.
So I come home tonight and peruse through the September issue of Clinical Psychiatry News, and first read on page 1 about how the DSM-5 is nearing completion and where the article continues on an inside page, read in a boxed piece about recent proposal changes, the bottom one labeled Suicidal Behavioral Disorder really threw me for a loop. Then I read further inside an Opinion piece by Dr Michael Brodsky, the Medical Director of a program in California exactly about what could be possible ramifications should this diagnosis pass our esteemed DSM-5 drafters muster and be used in usual clinical settings, an example used I can only defer interested readers to read the whole piece in going to the site and finding Dr Brodsky’s piece at http://www.clinicalpsychiatrynews.com .In it, you will read the following, when he presented the patient to the attending in the ER and had concluded the patient could be discharged after contacting the patient’s outpatient psychiatrist and planning for close outpatient follow up, for a 3 tablet ‘overdose’ of 20mg Paxil tablets (for interested readers, you have to read the whole vignette, sorry I am making some conclusions on my own here), the attending disagreed completely and advised a “brief” psychiatric admission as it would be the safer course of action than a discharge home. Really, safer for whom? Just the patient? And what does the outpatient psychiatrist have to say about the disposition plan? No mention such doctor had any input here.I relate this here to reinforce my point: colleagues cannot handle gray presentations as illustrated in this article, and will just turf such situations to an inpatient unit, who by the way in my last 11 years practicing in the same basic area, such inpatient colleagues have called me about 5% of the time a patient of mine was admitted and treated. That is random chance for statistics readers, true?So why do I drag this literature into this thread? Think about it here with chronically ill, terminally ill people who may not have any psychiatric history and are now dealing with dwindling quality of life issues due to medical illness, who if having suicidal thoughts can look forward to being labeled as a psychiatric diagnosis of Suicidal Behavior Disorder, which the author above has no idea how it would play out with insurers and further clinical involvements. Again, it is rather pathetic to me we need to create legislation to allow patients to confer with physicians who have a comfort zone consulting with patients and invested family members/significant others to support tough but responsible choices about their future, but, the gray will lead to one possible choice concluding death by patient pursuit has viable consideration.But, and this is a reach here on my part by inferring Dr Pies’ prior support of ending the Bereavement Exclusion as proposed in DSM-5 means he supports this new diagnosis above (SBD) as well, who reading here wants to disagree this diagnosis will not be used by colleagues put in ER or curbside hospital consultation situations? And, know this readers, Dr David Kupfer, chair of the DSM-5 task force and pictured inside with the cover DSM-5 to pass article, has under the picture ” Dr Kupfer says the APA plans a version of the DSM-5 that can be used in primary care settings.”Wonderful, now our somatic colleagues who already write more than 75% of antidepressant prescriptions in this country can have their own version of DSM-5 to accurately start making diagnoses like SBD. Really will encourage thoughtful and considerate dialogue with their somatic patients who are struggling with illnesses that may not be effectively controlled nor minimizing disruptive consequences.Really Dr Pies, do you see where this is going? Yes, I suspect you think me to be one of the most jaded and cynical colleagues you have dialogued over the net these past couple of years, but, what if I have some merit to my concerns and interpretations? Do you want to risk further harm to such patients by letting alleged noble intent and supposed commitment to “do no harm” in fact cause more harm, as Dr Grohol gave some examples above in his last comment?Readers need to know both sides of this issue, and I hope you will give pause to this in both allowing my comment printed and a possible reply by you if worth your time and energy.Personally, I know the adage “the road to hell is paved with good intentions” was made for doctors. Do you have one you have used as motivation or direction in your career?
Re: PAS (Physician-assisted suicide)
I appreciate the points made by Dr. Grohol and Dr. Hassman. This topic is too complex to deal with in a short space, and I plan to send Dr. Grohol a rather long response to his posting, soon.
For now, just two brief points: 1. I do not say, nor do I believe, that voluntary cessation of food and drink is a “painless” or “simple” way of dying, nor do I believe it should be separated from ongoing medical monitoring and palliative care. I merely argue that it is a reasonable, tolerable, and ethical alternative to that of doctors prescribing medication that will kill their patients. As I will note in my long piece, this is also the 2007 position of the American Academy of Hospice and Palliative Medicine. 2.That physicians have legal control over prescribing in this country is an issue that may require legislative remedies– see, in this regard, the interesting proposal by Prokopetz and Lehmann, N Engl J Med. 2012 Jul 12;367(2):97-9–but physician-assisted suicide cannot be justified on this basis, in my view.
2. Re: “Physicians do harm all the time…some of it is intentional, in order to fix the underlying problem.” Here, I believe Dr. Grohol confuses “intentionality” with “awareness of possible outcome.” No decent, conscientious physician intentionally inflicts bodily or emotional harm upon his or her patient–that is the moral basis of “Do no harm.” Rather, we understand that our intention to treat or cure disease will sometimes result in a “cost” to the patient, in the form of potentially serious side effects (e.g., from cancer chemotherapy). This is not the intentional inflicting of “harm”; rather, after a process of informed consent with the patient, it is a trade-off that both patient and physician agree to.
In contrast, knowingly and intentionally writing a prescription for a drug that will almost certainly kill the patient is inflicting irreversible “harm” of an entirely different order and magnitude–even if the patient agrees to it, and even if the physician’s intention is to relieve suffering. But, to be sure, these are thorny philosophical issues, often termed the “Double Effect” doctrine, usually attributed to Thomas Aquinas. I would refer Dr. Grohol to Szasz’s discussion of this in his book, “Fatal Freedom”, pp. 6-7.
The late Dr. Szasz–a famously “libertarian” thinker–was opposed to physician-assisted suicide, and considered it a mendacious euphemism for “medical killing.” Szasz and I disagreed on many things, but on this point, I think Szasz was nearer the truth (if there is a single “truth”!) than those who defend PAS.
Re: some of Dr. Hassman’s points: I share with him some deep misgivings about legislators “micro-managing” the practice and prerogatives of physicians. Unfortunately, in Massachusetts, the ballot initiative must be voted “up” or “down”, and
I believe that defeating it (i.e., opposing PAS) is the better alternative–as does the Mass. Medical Society, the American Medical Association, and the Massachusetts Academy of Family Physicians.
Re: “suicidal behavior disorder”, I have not investigated this proposed diagnosis and do not have a fixed view of it at this time. I have never advocated adding such a diagnosis to the DSM-5, however, and in general, I favor fewer and
simpler diagnostic categories [you can find a long discussion of this, Dr. Hassman, by going to: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3403926/
Best regards,
Ron Pies MD
Ok…while I lack such eloquence from the above contributors, let me start here: As a Hospice R.N. I was told by my supervisor that starving to death and dying from dehydration was not painful; but rather, it was a natural part of the dying process. I call BS. Not the fact that it is part of the process, but that it is painless. Any rational, NOT terminally ill client will tell you to starve is far from painless. Until there is a study showing me the part of the brain’s pain cycle shuts down during the dying process (that was a joke) then one can not say with certainty.
The goal of any hospice provider is to make the process dignified and as physically painless as possible. Why NOT be able to end the true physical suffering BEFORE it truly starts? Think of it as preventative medicine, if you will. We know the end result…death. How do we make it physically painless? Don’t let it start!
Also, isn’t it more ethical to LISTEN to your client than completely ignore their wishes? It may be against the law to assist in suicide, but how was it said? Oh yes, “everything they did in Nazi Germany was legal.” Meaning: sometimes doing the right thing isn’t doing the right thing.
“Also, isn’t it more ethical to LISTEN to your client than completely ignore their wishes? It may be against the law to assist in suicide, but how was it said? Oh yes, “everything they did in Nazi Germany was legal.” Meaning: sometimes doing the right thing isn’t doing the right thing.”Very well said. I know Dr Pies will not be pleased to read this reply, but I still believe that a sizeable percentage of my colleagues do not listen to patients, just focus on check list symptom identification to fit DSM criteria that do not simply fit the person in front of them, allegedly noted by a new patient I saw today. And this “thing” known as DSM 5 coming out next year will only sell this further not only to mental health care providers, but to primary care providers too if Dr Kupfer’s comment in CPN noted by me above is true.I am getting ready to start my own blog soon, because I am so tired of watching my own profession sabotage my efforts beyond what other professions in mental health have already done to hurt the process of care. I know Dr Pies has no overt agenda to do anything negative for our field, but, I do not get what I interpret as blind loyalty to those I see entrenched in positions of power and opinion making. Again, really doctor, what is wrong with some of us accepting that death is an option before nature seems the outcome?You have written about “being the mensch”, well, sometimes a mensch has to do what is right, not popular nor convenient. Bet your Rabbi would agree.
Please see my follow-up article for a further discussion of these difficult and controversial issues.
Physician-Assisted Suicide: Why Medical Ethics Must Sometimes Trump the Patient’s Choice
Ronald Pies MD