Physician-Assisted Suicide: An Egregious Boundary Violation

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I thank Joshua Pagano, DO, for his very thoughtful and nuanced response, “Medical Aid in Dying Allows for a Focus on Living,” to my article, “Is ‘Death with Dignity’ Really Possible?”¹ In essence, the response argues that physician-assisted suicide (PAS) is “…the preference of many patients with terminal illness [who wish]…to pass away peacefully while surrounded by family and friends,” and that this option provides them with “peace of mind” and “enormous comfort,” even if the patient never actually takes the lethal drug. It further asserts that “medical aid in dying has gained momentum…as many patients find it necessary to fight for the option to end their suffering…” and points to polls showing that most Americans support “medical aid in dying” or “doctor-assisted suicide.” The piece notes “…there is something distinctly different about the terminally ill person who is staring at the last 6 months of their life”—and who may be making a “rational” or “reality-based” decision to die—versus “someone suffering with mental illness.” Finally, employing a version of the Golden Rule, Pagano concludes that he could not, “…in good conscience deny someone a choice that I myself would want as an option under the same grim circumstances.”

While I appreciate Dr Pagano’s heartfelt comments, my colleagues and I reach very different conclusions on these matters, as summarized in the following paragraphs.

Voluntary Stopping of Eating and Drinking

Only a small minority of persons with a terminal disease seek a physician’s prescription for a lethal drug. Furthermore, there is no reason to believe that the only way terminally ill patients can “pass away peacefully while surrounded by family and friends” is to ingest a lethal dose of barbiturates. For thousands of years, dying human beings have managed to die peacefully in the embrace of family and friends without recourse to “Death with Dignity” legislation. And, as I noted in my article, terminally ill patients may choose voluntary stopping of eating and drinking (VSED), which, according to a study involving hospice nurses, results in a more satisfactory death than seen with PAS. In fact, “…as compared with patients who died by PAS, those who stopped eating and drinking were rated by hospice nurses as suffering less and being more at peace in the last 2 weeks of life.”²

Potential for Adverse Outcomes

The gentle, pastoral scene evoked in the response is far from assured, given current US procedures for PAS. One of the myths surrounding PAS is that it invariably provides a rapid, uncomplicated, and peaceful death. On the contrary, PAS is sometimes messy, prolonged, and uncomfortable. The person who ingests the lethal drug does not always “gently fall asleep.” Indeed, “Physicians who support [PAS] need to consider…the potential for adverse outcomes, including longer time to death than expected (up to 24 hours or more), awakening from unconsciousness, nausea, vomiting, and gasping.”³

Medical Ethics and Polls

Leaving aside methodological problems with the type of polls cited (for example, the 72% figure cited in the Gallup poll dropped to 65% when the question included the words, “commit suicide”), the central question is whether medical ethics ought to be governed by polls and plebiscites—or whether there are enduring and inalienable values that guide medical practice. I would ask the following: If 65% of the American public supported the euthanization of babies born with severe birth defects, would that justify the practice? Most major medical organizations—including the American Medical Association, the American College of Physicians,⁴ and the World Medical Association—have consistently opposed PAS on essentially ethical grounds. Recently, the College of Psychiatrists of Ireland also registered its firm opposition to PAS.⁵

Common Reasons for Medical Aid in Dying

Most requests for medical aid in dying are not made by patients experiencing untreatable pain or unbearable suffering, as data from Oregon have shown. Rather, the most common reasons for requesting medical aid in dying were loss of autonomy (97.2%), inability to engage in enjoyable activities (88.9%), and loss of dignity (75.0%).⁶

Psychological Vulnerability

It is not clear how genuinely rational or reality-based PAS decisions are, as Cynthia Geppert, MD, MA, MPH, MSBE, DPS, and I have discussed in our article, “Two Misleading Myths Regarding ‘Medical Aid in Dying.’”⁷ Indeed, research has shown that some cancer patients requesting assisted suicide have subtle cognitive distortions, such as “Nobody can help me,” that are clouding their judgment.⁸ Thus, people who are dying may be psychologically vulnerable to coercion in ways that are not readily detected under current PAS protocols. As the College of Psychiatrists of Ireland noted, “Perceived pressures in favor of induced death can be subtle. These cannot be excluded by tests of mental capacity, such as those used in psychiatric practice.”⁵

Avoiding Suffering

The issue is not, as was argued, whether it is rational to avoid foreseeable and inevitable suffering—I believe it clearly is. Rather, the issues are 1) whether physicians are morally justified in helping patients kill themselves weeks or even months before patients would otherwise die of their underlying illness; and 2) whether PAS is the only way of avoiding suffering at the end of life. VSED is clearly an alternative to PAS that does not raise grave ethical questions for physicians, and which may result in a more peaceful death than does PAS, as noted above.² And, contrary to a popular misconception, VSED is not starvation, since “…The body of a person who has a life-limiting illness is in the process of shutting down. They no longer require a great deal of nutrients or calories…and [do] not experience hunger or thirst in the way a healthy person does.”⁹

Ethical Comfort

Although we always aim to comfort our patients, this must be done within the constraints of sound medical practice and medical ethics. Comfort alone is not sufficient grounds for an action that may, in some important sense, be injurious to the patient—such as inducing or contributing to the patient’s death (think PAS). For example, suppose a depressed patient with chronic pain and a history of frequent substance abuse tells his doctor that he would find “enormous comfort” in having a large supply of oxycodone on hand “just in case I need it for pain.” This sense of comfort would hardly justify such a prescription under those conditions.

Legislation

PAS does not merely allow a single individual—the patient—a choice. By legislative fiat, it entangles the physician in a bureaucratized system of assisted killing. It is true that no physician is compelled to participate directly or actually carry out PAS; however, most PAS legislation is crafted so that the refusing doctor must provide medical records to a physician who provides PAS [Annette Hanson MD, personal communication, 12/30/21]. In my view, this vitiates the first physician’s conscientious opposition to PAS and forces him or her to collude with an unethical practice.

Subtypes of Suicide

The response states that, “Further stigmatizing those suffering with suicidal ideation in the context of mental illness in order to positively differentiate those with a terminal illness who desire medical aid in dying is not the way forward.” I am in complete agreement on this point. This is why my colleagues and I oppose the position of the American Association of Suicidology (AAS), which has tried to draw a sharp distinction between “conventional” suicide (eg, in the context of a mental illness) and what they call “physician aid in dying.”¹⁰ It is certainly true that we can discern subtypes of suicide; eg, impulsive vs planned; underlying psychiatric disorder vs reactive/situational, etc. But suicide (self-killing) is suicide regardless of the subtype.¹¹ Even the AAS acknowledges that there is an “undetermined amount of overlap” between the 2 categories they propose.¹⁰ We do not need a 2-tiered classification, in which there are good and bad, approved and unapproved, methods of taking one’s own life—leaving harried physicians to sort out which is which.

The Golden Rule

Finally, the closing invocation of the Golden Rule—one version of it, at least—seems a very decent and compassionate response. But the Golden Rule is not necessarily the best guide to medical ethics. For example, suppose we are considering the question, “Should psychiatrists be allowed to have sexual relations with their current patients?” Some might say, “Well, as a competent, consenting adult, I would want the choice of having or not having sexual relations with my psychiatrist. How, then, in good conscience, could I deny that right to someone else?” The problem, of course, is that it is a clear violation of long-established medical ethics for psychiatrists to have sexual relations with their patients—Golden Rule or not. It is a forbidden boundary violation.

Concluding Thoughts

In my view, PAS is an infinitely more egregious boundary violation, whether or not one might wish that option for oneself—and whether or not the dying patient consents to it. Indeed, a patient’s consenting to be killed does not mean a physician is ethically justified in acceding to the request.¹²

Rather than focusing on ways to assist suicide, physicians should rededicate themselves to securing state-of-the-art palliative care and supportive counseling for terminally ill patients. In closing, I thank Dr Pagano for reflecting on these difficult issues with me, and I hope he will reconsider his position in light of this response.

Dr Pies is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and editor in chief emeritus of Psychiatric Times^TM (2007-2010).

References

1. Pies R. Is “death with dignity” really possible? Psychiatric Times. November 30, 2021. https://www.psychiatrictimes.com/view/is-death-with-dignity-really-possible-

2. 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;349(4):359-365.

3. Lo B. Beyond legalization - dilemmas physicians confront regarding aid in dying. N Engl J Med. 2018;378(22):2060-2062.

4. Snyder Sulmasy L, Mueller PS; Ethics, Professionalism and Human Rights Committee of the American College of P. Ethics and the legalization of physician-assisted suicide: an American College of Physicians position paper. Ann Intern Med. 2017;167(8):576-578.

5. Baker N. Psychiatrists issue stark warning over assisted dying legislation. Irish Examiner. December 20, 2021. Accessed Janaury 6, 2022. https://www.irishexaminer.com/news/arid-40769343.html

6. Loggers ET, Starks H, Shannon-Dudley M, et al. Implementing a Death with Dignity program at a comprehensive cancer center. N Engl J Med. 2013;368(15):1417-1424.

7. Geppert CM, Pies RW. Two misleading myths regarding “medical aid in dying.” Psychiatric Times. 2018;35(8).

8. Levin TT, Applebaum AJ. Acute cancer cognitive therapy. Cogn Behav Pract. 2014;21(4):404-415.

9. Hospice care guidance: nutrition at the end of life. Crossroads Hospice & Palliative Care. Accessed January 6, 2022. https://www.crossroadshospice.com/hospice-resources/nutrition-hydration/

10. Creighton C, Cerel J, Battin MP. Statement of the American Association of Suicidology: “suicide” is not the same as “physician aid in dying.” October 30, 2017. Accessed January 6, 2022. https://suicidology.org/wp-content/uploads/2019/07/AAS-PAD-Statement-Approved-10.30.17-ed-10-30-17.pdf

11. Dworkin G. Suicide, strictly speaking. 3 Quarks Daily. July 22, 2019. Accessed January 6, 2022. https://3quarksdaily.com/3quarksdaily/2019/07/suicide-strictly-speaking.html

12.Yang YT, Curlin FA. Why physicians should oppose assisted suicide. JAMA. 2016;315(3):247-248.

For Further Reading

-Pies RW, Geppert CMA. Physician-assisted suicide and the autonomy myth. Psychiatric Times. October 27, 2021.

-Briscoe J. Is death a goal of care? Notes from a Family Meeting. 2021;2(4).

-Komrad MS, Pies RW, Hanson AL, Geppert CMA. Assessing competency for physician-assisted suicide is unethical. J Clin Psychiatry. 2018;79(6).