I very much appreciate Dr. Grohol’s taking the time to comment on my essay about physician-assisted suicide. I have great respect for his wisdom, judgment and fairness, and I recognize that reasonable people will disagree on this hotly-contested and complex issue.
I certainly don’t pretend to have reached any final “truth” in the matter of physician-assisted suicide (PAS). At the same time, I believe that Dr. Grohol’s conclusions (1) rest on several misapprehensions regarding my own position; the ethical responsibilities of physicians; and the relevant medical facts pertaining to terminally ill patients.
Dr. Grohol argues that the debate is really “…about patient empowerment, human dignity and choice.”
I fully agree with Dr. Grohol that the patient’s autonomy is of great importance; indeed, autonomy is considered one of the four cardinal principles of medical ethics, along with benevolence, nonmalfeasance and justice (2).
But sometimes, medical ethics must set limits on a patient’s autonomous requests, even in the context of an understandable choice on the patient’s part. Thus, a patient may feel completely justified and “empowered” in requesting that the dose of her pain medication be doubled, even though that would be extremely dangerous to her health.
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Thank you for the interesting response you wrote, Dr. Pies.
The Hippocratic Oath is not an absolute, and I find it of little value in the discussion of modern medical ethical issues. The Hippocratic Oath also states that a physician will not give a woman “an abortive remedy” (e.g., doctors may not perform abortions). Yet abortions are legal and performed in the U.S. and Europe — reflecting the changing times of a society. In the past, the Hippocratic Oath has also been used by doctors as an argument as to why they shouldn’t share their medical knowledge and information with mere patients.
When it comes to arguments about dignity and such, I believe it is each person’s right to decide what dignity means to them. It is not for us to decide what constitutes “dignity,” since it comes in many forms, and one’s beliefs about one’s own dignity may change over time. So I would not be so brazen as to believe I know what “dignity” means for you in your life — or for a perfect stranger. For me, personally, dignity means leaving quietly, quickly and painlessly when I’ve been diagnosed with a terminal illness. That definition doesn’t fit in with any option available to me today.
The problem with sedatives and receiving enough pain medication in hospice is that practice still varies and nobody can guarantee you’re going to get a doctor who’s going to prescribe you everything you need. Indeed, the medical boards and government (via the DEA) continue to harass physicians who “overprescribe” such medications, and I see no significant change in that harassment in the past 5 or 10 years. If anything, it’s gotten worse for many of these doctors. This isn’t some hypothetical issue — this is a real, ongoing problem that hasn’t been yet adequately addressed (see, for example, http://www.health.com/health/condition-article/0,,20189399,00.html ).
I would never, ever want to take the chance that I or a loved one will be forced to suffer at the end of my life because of a doctor’s fear of the government. Yet this is the sad (and disturbing) reality that many patients and their families experience today.
I won’t comment on why only two states have gone down the road of giving their citizens the option to die with dignity, save to say it’s not a popularity contest. Most states don’t allow or recognize gay marriage either; does that say anything of value about gay marriage?
Finally, the only reason it needs to be a law is simply because it is illegal for doctors in most states to help a patient die a few days, weeks or months sooner than they would ordinarily. All this law does is help patients hasten their own inevitable death and make it a little less painful. I also don’t care if it’s a physician prescribing me the medications or if I can get them on my own.
The key factor for me, and I suspect many others, is simply being given a set of reasonable choices about how our life ends. Because how our life ends is just as important to most of us, if given the choice and options, as the kind of life we lead. Today, we have only two choices with a terminal, painful disease — die a painful death and hope the pain medications will help us experience less pain (and the doctor will be willing to actually prescribe them at the needed doses) or starve oneself to death. Neither of these options appear attractive to most of us. A third option — of ending our lives sooner through the use of a drug — appears to alleviate many of my concerns.
Agree with Mr Grohol. Great comment, thanks.
So after reading this rebuttal post, it still is about merciful assistance versus physician assisted killing, hmm? Seems like a polar position to me as I wrote prior.It is up to the individual patient and involved physician what is the best choice, and isn’t that the beauty of health care, choice and personability?
I very much appreciate Dr. Grohol’s willingness to provide so much space for the expression of my position, and I am content to leave the debate where it stands. Dr. Grohol does indeed make some very good points in his rejoinder.I do not see my position as “polarized”, and–as I stated in the beginning of this essay–I don’t claim to have arrived at any “final truth” in this vexing matter. Indeed, I am open to some “middle ground” position, so long as it is consistent with generally accepted medical ethics.As for Massachusetts, the voters will have the final word on Nov. 6–and therein lies the beauty of living in a democracy!Best regards,Ronald Pies MD
I have a couple of thoughts/reactions to this exchange.1.) I find it odd that Dr. Grohol asserts you can’t count on a doctor ‘giving you everything you need’ to die peacefully via palliative care. And yet, we should trust these same physicians to make wise choices about who gets ‘helped’ to commit suicide and who doesn’t.2.) Dr. Grohol should take his concerns about the discomfort and pain associated with VSED – ‘voluntary stopping eating and eating’ – with the organization Compassion & Choices (who are also promoting the assisted suicide ballot measure in Mass.). And not just for terminally ill people but as a means for “people in every state of safe, legal and peaceful means to end life when physical decline and suffering become pointless and unbearable.” (See: http://www.compassionandchoices.org/tag/vsed/)They’re currently getting hospice people on board to ‘help’ nonterminally ill people commit suicide this way.So Dr. Grohol probably shouldn’t be complaining to Dr. Pies, who is correct about VSED when it comes to people who are near death. It would be educational for Dr. Grohol to take his concerns to Compassion & Choices and report back with the results of the conversation.
It is not ethical to force any person to choose only between starving themselves to death or enduring whatever pain and indignity the medical profession wishes to inflict on them as the person waits for disease to stop their heart. That is only the illusion of choice, not actual choice.
If the patient has the right to end his or her life by not eating, then the patient has the right to end his or her own life.
The system you defend is cruel in practice; palliative care is not as universally applicable or as well practiced as you claim it is (I am surprised that your own experience and your reading of the literature has led you to those conclusions, since they are not based in fact), and many patients do not want more palliative care, they just want to end their life.
Not everyone has religious beliefs which make them feel they have to live until the last possible gasp, and they should not be forced to submit to their physician’s religious beliefs. The “doing no harm” excuse, while popular among physicians opposed to patient control of the end of life (often for religious reasons), is only true for a very narrow cellular definition of “harm”. Withholding help to end one’s life causes a prolongation of physical pain and emotional suffering, which feels like harm to the people going through it.
I am now getting old, and will be facing this soon myself.
When physicians and lawmakers withhold help to end a patient’s life, those of us who consider it our right and desire to end our life on our own terms are left with a bad choice. Either we end our lives early, while we are still mentally and physically capable of doing so by ourselves, or we wait, and risk a debilitating stroke or other mishap which could make us incapable of ending our own lives. That would deliver us into the cruel hands of ‘caring’ physicians, and the choice between often-ineffective palliative care (and it’s associated physical and emotional misery) or a long period of self-starvation, which is not always as pleasant as you claim it is.
Dr Pies, your position on this is for your own benefit and comfort. That is fine, but please don’t pretend that it is for the benefit of patients, or that it is ethically superior to a self-selected peaceful death.
It’s not.
Perhaps readers who come by hereon can read this link from Bill Keller at the New York Times and see how it relates to this discussion:
http://www.nytimes.com/2012/10/08/opinion/keller-how-to-die.html?pagewanted=all&_r=0&pagewanted=print
Thank you.
After reading Dr Pies’ lead story of this month’s Psychiatric Times, I have to forward this comment to ask sincerely what is the judgment call to allow a stranger into your home late at night and not risk serious consequences and how, to me at least, it raises my ongoing question of why, as a psychiatrist, you comment on societal issues like this post above and expect to be taken as an expert without challenges.
This comment probably won’t be kept on the thread, but really, twisting a questionable judgment call into a mini rabbinical type sermon of how people should work with others, well, careful to believe your choir. For what it is worth, one of my attendings I respected in med school taught me one thing that makes me comment at threads of yours is this: careful when you use your standing as a doctor in commentary of societal matters outside your expertise, it could diminish your respect by those in the community at least, and could alienate you with your peers even more. Hey, I know some of what I have said on the net and in rooms with colleagues has not endeared me with them, but I call it as I was trained.
Just my opinion, note I do not comment at every post you make here and other places.
The ballot question favoring physician-assisted suicide was defeated in Massachusetts, albeit by a very slender margin. Although many of my medical colleagues are gratified by this outcome–and believe it is in the best interests of ethical medical practice–I also believe the vote should serve as a “wake up call” to physicians all over the country.
We must redouble our efforts to relieve both emotional and physical suffering at the end of life, so that the public has confidence that their needs will be met, as death approaches. This will require a concerted effort on the part of physicians, both in becoming more skilled at palliative care, and in communicating more effectively with the public. I believe this must happen urgently, and I hope that the public will continue to be involved in the process.
Respectfully,
Ronald Pies MD