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.
Governed by the principle of nonmalfeasance, the physician will wisely decline the patient’s request, and explain why that is necessary. So, too, in my view, with a dying patient’s request for lethal medication or “assisted suicide.” As Dr. Barbara Rockett, President of American Medical Association’s Foundation, cogently noted:
Centuries ago the physician Hippocrates wrote the Hippocratic Oath, which many of us took when we became physicians and guides us in the ethical practice of medicine. It states that when treating patients, physicians will “First do no harm.” It goes on to state that “I will give no deadly medicine to anyone if asked nor suggest any such counsel.” Physician-assisted suicide is in direct conflict with this statement which, when followed, has protected the patient, physician, society and the family, and at the same time has committed doctors to compassion and human dignity. (3)
Similarly, Dr. Lisa S. Lehmann, director of the Center for Bioethics at Brigham and Women’s Hospital, commented that, “Writing a prescription that allows a patient to acquire a lethal dose of a medication with the explicit intention of ending their own life really goes beyond the accepted norms of what physicians do…” (4) Proponents of so-called “death with dignity” laws need to ask themselves why only two states in the U.S. have adopted such laws; and why the American Medical Association, the Massachusetts Medical Society, the American Nursing Association, and the Massachusetts Academy of Family Physicians (5) all oppose physician-assisted suicide.1 A partial answer is likely to be found in the foregoing statements by Dr. Rockett and Dr. Lehmann.
As regards “human dignity,” reasonable and compassionate people will differ on what, exactly, constitutes “dignity” and a “dignified death.” For some, a “dignified” death is one in which pain is endured with stoic resignation. My late mother, for example—a strong-willed and very independent-minded psychiatric social worker—frequently refused pain-relieving medication during her final days, much to the consternation of her physician son. But that was her idea of a “dignified” death. For other terminally ill patients, death with “dignity” may involve refusing any further food or drink. Indeed, as my medical ethicist (and theologian) colleague, Dr. Cynthia Geppert points out (personal communication, 10/3/12), refusing food and drink during the final days of life has long been considered a dignified way of dying in virtually all the world’s major religious faiths. (Importantly, declining appetite is a natural, bodily process during the final days of the dying process). I will return to this much misunderstood (and frequently misrepresented) option later. For now, I’ll simply say that I am not persuaded that ending one’s life with a prescribed medication is more “dignified” than declining further sustenance—which requires nobody’s authorization or prescription, and has been considered a morally acceptable way to end one’s life for many centuries.
That said, Dr. Grohol and I stand shoulder to shoulder as regards the physician’s absolute responsibility to alleviate the suffering associated with a terminal illness. And, it must be acknowledged that physicians — until very recently in medical history — have fallen woefully short in their willingness to alleviate the suffering that often attends a terminal illness. Unfortunately, this failure has helped fuel the understandable fear, on the part of the general public, that they will endure great suffering during their final days and therefore ought to be allowed to take a lethal overdose to end their lives. (Loss of autonomy and being a “burden” on others are also very common fears).
Probably every psychiatrist who has consulted in terminal illness cases has a horror story about the attending physician who was afraid to use adequate doses of pain medication in treating the patient nearing death, for fear of “addicting” the individual! But I believe that with the emergence of palliative care medicine as a subspecialty, this picture is beginning to change, and that expert palliative care represents a better and more ethical alternative to so-called “physician-assisted suicide” or “physician-assisted dying.” Indeed, Dr. Ezekiel Emanuel and colleagues concluded that “Requests for euthanasia and physician-assisted suicide are likely to decrease as training in end-of-life care improves and the ability of physicians to provide this care to their patients is enhanced.” (6)
Contrary to Dr. Grohol’s impression, no conscientious physician—and certainly, not this writer—feels it is “…perfectly okay for a physician to let his or her patient die of willful starvation and dehydration.” (1). For me, as for most physicians, any decision to end one’s life, or hasten one’s death, requires scrupulous examination and represents an occasion of profound sadness and loss—hardly an event to feel “perfectly okay” about.
But it is not a question of “letting” a competent patient refuse food or drink during the dying process. It is not a physician’s prerogative to “let” or not “let” a patient choose that route, assuming the patient is mentally competent (i.e., not psychotic, delirious, severely depressed, and also apprised of the risks and benefits of all available options). No physician’s order is required to allow a competent patient to refuse food and drink, nor can a physician countermand a competent patient’s decision to do so. While there is no recognized “right” to commit suicide in this country, competent, terminally ill patients are at liberty to stop eating and drinking.2
This is not necessarily what I or many other physicians would counsel or recommend; indeed, I would consider it my duty to explore with the patient every appropriate palliative care option. But it is not in the physician’s purview to prevent a competent, dying patient from refusing sustenance.
More broadly, in the U.S., competent patients have a legal right to decline intrusive or “heroic” measures that artificially prolong the dying process. Indeed,
“…the law already permits patients or their surrogates to withhold or withdraw unwanted medical treatment even if that increases the likelihood that the patient will die. Thus, no one needs to be hooked up to machines against their will. Neither the law nor medical ethics requires that “everything be done” to keep a person alive. Insistence, against the patient’s wishes, that death be postponed by every means available is contrary to law and practice. It is also cruel and inhumane.” (7)
Just so. As physician and ethicist Dr. Fred Rosner has observed, for the physician, “To prolong life is a [commandment], to prolong dying is not.” (8)
- In 1997, the AMA was joined by the American Psychiatric Association, the American Nurses Association, and nearly 50 other health care-related organizations when it filed an amicus curiae (“friend of the court”) brief with the U.S. Supreme Court opposing PAS. [Nair S. Virtual Mentor Ethics. Journal of the American Medical Association December 2005, Volume 7, Number 12] [↩]
- It is important to distinguish “rights” from “liberties,” as well as “reciprocal obligation” from “compulsion.” As Szasz notes (Fatal Freedom, p. 113), rights require an “obligor” who must fulfill the right; a liberty is exercised without any other party’s direct, active involvement. It is also crucial to understand that neither rights nor obligations are absolute; they are always balanced against competing rights and obligations. People in this country have a right to free speech, and, in general, government has an obligation to protect it. But people do not have a right to yell “Fire!” in a crowded theater, nor is the government obligated to protect such behavior. There is no recognized “right” to kill oneself in the U.S., but mentally competent people, in my view, ought to be at liberty to end their own lives, even though I would almost always counsel against it.
Most recognized obligations in this country have “opt out” provisions; e.g., in general, there is a recognized “right” to abortion, and physicians are, in general, “obligated” to respect and fulfill that right—but they are not compelled by law to do so. Similarly, if we make PAS a “right,” as the Massachusetts bill would effectively do, we would confer a generalized reciprocal obligation on physicians to respect and fulfill that putative right, all other things being equal. This is not the same as compelling physicians to carry out a PAS request; however, it might well open the door to frivolous litigation against physicians who “denied me my right to a PAS prescription”—even though such lawsuits would almost certainly be dismissed. [↩]