Why Physicians Should Oppose Assisted Suicide

Physician assisted suicide is fundamentally incon-

sistent with the physician’s professional role,” according to a long-standing position of the American Medical Association.1 That we are debating this question of whether physician-assisted suicide (or “physician- assisted death”) is ever justifiable shows how far medi- cine has shifted toward redefining the role of physician. If the medical profession accepts physician-assisted suicide, it will be declaring decisively that “physicians” are mere providers of services, to be guided only by the desires of the individual patient, the will of the state or other third parties, and what the law allows. The idea of medicine as a profession, which embodies a shared commitment to care for persons who are sick and debilitated so as to restore their health, will quickly fade into memory. Those made vulnerable by sickness and debility, to whom physicians owe their solidarity as physicians, will have much less reason to entrust them- selves to physicians’ care.

For centuries, physicians have worked to preserve the health of persons with terminal illness, respecting pa- tients’ authority to refuse any treatment recommended. Often, physicians can do no more than preserve only small measures of health—such as the patient’s capacity to rest, eat, or have a bowel movement—or relieve those insults to health caused by pain or other distress- ing symptoms. To patients who are concerned that

palliative measures might hasten their death, physicians promise to use only those medications and dosages pro- portionate to relieve the symptoms the patient experi- ences. While acknowledging that death may come sooner as a side effect of palliation, physicians pledge never to intentionally hasten the patients’ death. All this physi- cians do without controversy and under ethical norms that have guided medicine for centuries. Yet with physician- assisted suicide, the physician is to disregard what is per- haps the most universal moral injunction—do not kill— and write a lethal prescription with the express intent of helping patients kill themselves.

What has changed that would make physician- assisted suicide justifiable? Many say that physician- assisted suicide is justified on the basis of compassion and mercy toward those in “prolonged and excruciat- ing pain.”2 Evidence, nevertheless, indicates that calls for physician-assisted suicide are not mainly driven by the

experience of pain or other refractory symptoms.3 The case of Brittany Maynard illustrates a pattern. At the time she committed suicide, she was not experiencing symp- toms beyond the reach of proportionate palliation. Rather, she feared the prospect of possible pain and abject debility, in which she might “suffer personality changes and verbal, cognitive and motor loss of virtu- ally any kind.”4 This patient’s case is consistent with re- ports from Oregon3 that found patients requesting physician-assisted suicide reported being concerned about “losing autonomy” (91.5%), being “less able to engage in activities making life enjoyable” (88.7%), “loss of dignity” (79.3%), “losing control of bodily func- tions” (50.1%), and being a “burden on family, friends/ caregivers” (40%). Only 1 in 4 (24.7%) even reported “concern about” inadequate pain control.

These data imply that improving access to pallia- tive medicine will not satisfy those who seek physician- assisted suicide, because assisted suicide is driven primarily by the desire for self-determination and autonomy and the wish to avoid debility and depen- dence. Ms Maynard put the point clearly when she said, “I want to die on my own terms. I would not tell anyone else that he or she should choose death with dignity. My question is: Who has the right to tell me that I don’t deserve this choice?”4

Who indeed? Yet here a contradiction is displayed. Patients already have the right to refuse life-sustaining

treatment. They have the right to pro- portionate palliation, even if death is hastened as a side effect. They also have the liberty to end their lives by all man- ner of methods that do not involve physicians. With respect to physician- assisted suicide, the “right to die” is a eu- phemism for the putative “right to have a physician help me kill myself.” This

alleged right of self-determination, as Burt noted, is “radically incomplete as a justification for physician assisted suicide.” “[T]he confident assertion of the self- determination right,” he continued, “leaves unacknowl- edged and unanswered a crucial background question: who can be trusted to care for me when I am too vul- nerable and fearful to care for myself?”5

The question of trust brings into focus what pro- fessional medical organizations6 have long known but many seem ready to forget: “Physician assisted sui- cide is fundamentally inconsistent with the physician’s professional role.”1 If physicians were solely service providers who accommodated the self-determining choices of patients, then physician-assisted suicide would be logical if assisted suicide were justified. But the heart of the medical profession is not providing services. Rather, the physician’s constitutive profes- sional role is to attend to those who are sick and

…physicians have maintained solidarity with those who are sick and disabled, seeking only to heal and refusing to use their skills and powers to do harm.

VIEWPOINT

Y. Tony Yang, ScD, LLM, MPH Department of Health Administration and Policy, George Mason University, Fairfax, Virginia.

Farr A. Curlin, MD Trent Center for Bioethics, Humanities & History of Medicine, Duke University, Durham, North Carolina.

Counter Viewpoint page 245

Corresponding Author: Y. Tony Yang, ScD, LLM, MPH, Department of Health Administration and Policy, George Mason University, 4400 University Dr, MS: 1J3, Fairfax, VA 22030 (ytyang@gmu.edu).

Opinion

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debilitated, seeking to preserve the measure of health that can be preserved, and to help them bear the pain and progressive loss of autonomy and bodily function that illness often brings. There would be no profession of medicine but for human beings’ shared vulnerability to illness. There can be no practice of medicine if patients do not trust physicians to care for them when they can- not care for themselves.

And herein is the conflict. Insofar as physicians enjoy societal trust, it is because since Hippocrates, physicians have maintained solidarity with those who are sick and disabled, seeking only to heal and refusing to use their skills and powers to do harm. That is why Doctors Without Borders treats injured Taliban soldiers. It is why physicians have refused to participate in capital punishment, or to be active combatants, or to cooperate with torture. It is why physi- cians have refused to help patients commit suicide. Many patients with terminal illness fear unbearable pain or other symptoms. The physicians’ role is to care for them in their illness so as to relieve pain or otherwise help them bear up under the symptoms they endure. Many patients loath the prospect of abject debility. The physician’s role is to maintain solidarity with those whose health is diminished, not to imply that debility renders a patient’s life not worth living.

In a culture enthralled with self-determination, limits to free- dom of choice can appear as unwarranted obstacles. The boundary against intentionally causing the patient’s death, however, gives pa- tients a reason to trust physicians while also giving physicians the freedom needed to perform their duties and responsibilities. Phy-

sicians who care for patients with advanced illness know that both they and their patients will at times be tempted to do away with pain and other symptoms by ending the patients’ lives. This temptation is not new. To guard against it, for millennia many physicians have sworn in the Hippocratic Oath, “I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect.”7

Rather than posing an obstacle to compassionate care, this bound- ary creates a space in which physicians can act freely and decisively to palliate distressing symptoms. Without this commitment, pa- tients have good reasons to be concerned that the morphine that leads to sedation is dosed not in proportion to the pain but in an ef- fort to hasten death.

In sum, physician-assisted suicide is never justifiable. It is never justifiable because it always violates the injunction not to kill. It is never justifiable because it unjustly patronizes the desires of the few who request physician-assisted suicide over the needs of the much larger number who have already endured, or expect to endure, the debility and dependence that advocates for physician- assisted suicide desire to avoid. Physician-assisted suicide contra- dicts the physician’s professional role and undermines the distinc- tive solidarity with those whose health is diminished that makes the practice of medicine possible. Physicians who seek to sustain medicine as a healing profession will have to distinguish and dis- tance themselves, just as Hippocratic physicians did, from those practitioners who are willing to kill. In the meantime, physicians should oppose the legalization of physician-assisted suicide and steadfastly refuse to condone or participate in it.

ARTICLE INFORMATION

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Additional Contributions: We thank Daniel Sulmasy, MD, PhD (Department of Medicine and Divinity School, University of Chicago), Lauris Kaldjian, MD, PhD (University of Iowa Carver College of Medicine), and Lydia Dugdale, MD (Yale School of Medicine), for their helpful comments on an earlier draft of this commentary. None of these persons received any compensation for their contributions.

REFERENCES

1. American Medical Association (AMA). American Medical Association Policy H-140.952: Physician Assisted Suicide. AMA website. https://www.ama -assn.org/ssl3/ecomm/PolicyFinderForm.pl?site =www.ama-assn.org&uri=/resources/html /PolicyFinder/policyfiles/HnE/H-140.952.HTM. Accessed October 28, 2015.

2. Botelho G. California governor signs “Right to Die” bill. CNN. October 6, 2015. http://www.cnn .com/2015/10/05/us/california-assisted-dying -legislation/. Accessed October 28, 2015.

3. Oregon Public Health Division. Oregon’s Death With Dignity Act—2014. Oregon Public Health Division website. https://public.health.oregon.gov /ProviderPartnerResources/EvaluationResearch /DeathwithDignityAct/Documents/year17.pdf. Accessed October 28, 2015.

4. Maynard B. My right to death with dignity at 29. CNN. November 2, 2014. http://www.cnn.com/2014 /10/07/opinion/maynard-assisted-suicide-cancer -dignity/. Accessed October 28, 2015.

5. Burt RA. The suppressed legacy of Nuremberg. Hastings Cent Rep. 1996;26(5):30-33.

6. Snyder L, Sulmasy DP; Ethics and Human Rights Committee, American College of Physicians- American Society of Internal Medicine. Physician-assisted suicide. Ann Intern Med. 2001; 135(3):209-216.

7. Edelstein L. The Hippocratic Oath: Text, Translation and Interpretation. Baltimore, MD: Johns Hopkins University Press; 1943. http://guides .library.jhu.edu/c.php?g=202502&p=1335752. Accessed October 28, 2015.

Opinion Viewpoint

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