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)
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.
- 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. [↩]