The Case for Medical Aid in Dying: Part 1

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COMMENTARY

As more states consider legislation permitting medical aid in dying (MAID), the controversy around this practice within our profession continues to swirl. Articles in opposition have appeared frequently in this publication.^1-14 As someone in support of MAID as a reasonable and merciful option for some patients, I have struggled to make sense of the basis for opposition.

In this culture, which highly values individual freedom, we generally hold that persons should be free to choose how they want to live their lives, unless they violate the rights of others. Choosing how to die in the face of a terminal illness is certainly an important life choice—one increasingly supported by the majority of our citizens.¹⁵ Thus, the burden is on opponents to show why this option should be prohibited.

Arguments are of 2 general types: arguments from fundamental principles held categorically by opponents, and arguments that undesirable practical consequences are likely to follow—or have followed—MAID implementation. In this and 2 subsequent articles, I will challenge these arguments as unconvincing. Here I examine arguments from fundamental principles. In subsequent articles, I will consider arguments based on consequentialist concerns.

The Primary Principles of the Opposition

Two primary principles are involved: (P1) It is categorically wrong to take one’s own life under any circumstances, and (P2) it is categorically wrong for a physician to help anyone take their own life.¹⁰ Such allegedly self-evident first principles typically derive from religious or other transcendent beliefs, cultural traditions, or appeals to the universal dictates of reason in the spirit of Immanuel Kant. The last is suspect, as rational individuals clearly do not come to the same conclusions about what reason dictates. Transcendent beliefs are only compelling to those who accept that religious or metaphysical system. Even respected traditions may become less relevant or rejected as circumstances and other cultural values change. In short, appealing to principles does not in itself clinch the argument.

For (P1), there is typically an appeal to transcendent beliefs, directly or indirectly religious, hence there is not much room for logical arguments that might persuade someone who operates from different premises. Weekly churchgoers are the only group where the majority do not support MAID.¹⁵ The question is whether one’s personal ethical intuitions, religiously derived or not, should be imposed on everyone else. Our cultural tradition and legal system have generally said no to that.

The Hippocratic Oath

The argument that MAID intrinsically does violence to the physician’s role (P2) appears to have 2 components. The first is that it violates the Hippocratic Oath and the tradition surrounding it, with its commitment to respect the value of life.^3,5 In its original form, the Hippocratic Oath explicitly forbids the administration of lethal medicine for the purpose of killing the patient. It should also be noted that the original Hippocratic Oath involves swearing in front of Apollo as well as the promise to take care of our teachers and their children as if they were our own.

Traditions are not fixed in time but evolve as the needs and values of society changes. Due to its many anachronisms, the oath has largely been replaced in medical schools around the country by alternative oaths thought to better reflect modern realities and values. It is noteworthy that in a content analysis of medical school oaths administered in 2000, only 6 of the 122 allopathic medical schools surveyed had oaths that contained a stipulation against MAID or euthanasia.¹⁶ We still embrace our commitment as physicians for the valuing of life. But should this reflect the quality or the quantity of life? For many of us, respecting the life of the patient has as much or more to do with supporting their dignity, autonomy, and relief of suffering as it does with simply maximizing the number of days they keep breathing.

One of the developments over time that has changed the balance, certainly from the time of Hippocrates, is that we have largely eliminated bacterial aid in dying (BAID). I think it can be argued that with the discovery and development of antibiotics—overall a tremendously wonderful thing—there has come 1 harmful and unintended consequence: The frequency and duration for which individuals had to face protracted deterioration with extensive suffering and dignity-reducing loss of function before dying was greatly lower in pre-antibiotic times. Patients with such conditions would typically rather quickly contract life-ending infections, such as pneumonia. Having curtailed nature’s most common way of alleviating such suffering, I would suggest the least we can do is to provide some merciful alternative.

The Valuable Role of Physicians

A second component of this argument put forward by opponents of MAID is that if an individual wants to die, why involve the physician?¹⁰ This strikes me as a profoundly insensitive attitude. If any of you, like me, has had and loved multiple pets, you have undoubtedly had the difficult experience of being present as one was euthanized by a veterinarian. Beyond the unavoidable sadness of losing a beloved member of the family, I have always found this a peaceful and comforting process made possible by the supportive presence of the veterinarian who cared for my animal over many years, or if that is not possible, by another caring veterinarian. How should I have felt if the veterinarian had said, “As a doctor to animals, I am here to preserve and value their lives, not to end them. Besides, you can do this yourself or ask someone else to help you. If you do not have a gun, a sledgehammer will work”? I would argue that we have a valuable role to play, as physicians, in providing not simply technical assistance but emotional support and understanding to patients if they have reached the difficult decision to end their life.

The example of the veterinarian raises an interesting question. I have never heard anyone say that a veterinarian is violating their professional integrity by euthanizing their patients—rather, it is looked upon as a kind and humane option. It seems to me that the burden is on those who oppose MAID to demonstrate why we should be less kind and humane to our fellow humans than we are to the nonhuman members of our families. It seems to me that once one removes any theological or metaphysical beliefs that humans are categorically different by virtue of our soul or some special plan God has for us, the basic principles of kindness in the face of suffering should apply to humans as well. Besides, humans—unlike our beloved pets—can tell us what they want.

Opponents to MAID argue that it is a whimsical jettisoning of a 2500-year tradition of how physicians should act based on a brief contemporary moment in which autonomy is excessively valued over the other cornerstones of medical ethics—beneficence, non-malfeasance, and justice—as an expression of a consumer-based culture in which physicians have become mere providers.^1,11 Although I agree that long-standing traditions should not be abandoned thoughtlessly, there are times when the tradition needs to be modified in light of changes in conditions or the evolution of other values in society. Slavery is a tradition with a much longer history and more universal acceptance than the Hippocratic tradition, and it is only relatively recently that modern societies have rejected it—yet I doubt any of us would argue that the rejection was unwarranted. Aspects of a tradition need to be judged on their own merits after careful consideration as to whether we should continue, modify, or abandon them.

In the same spirit, opponents of MAID accuse supporters of simply following public opinion based on polls showing that the majority of the public support MAID, as if they engage in less thoughtful ethical reflection than opponents.6 It is true that no one, including physicians, should blindly or reflexively change their position based on the latest poll. However, when our own guild becomes seriously out of step with the values of the larger culture, it may be time for a serious self-examination as to whether we have become ossified and out of touch.

“Noble” Deaths

Opponents of MAID frequently cite in heroic terms cases of individuals bravely facing their gradual deterioration and death, and even fighting it until the end, with courage and dignity.^7,8 And it is certainly fine for individuals to do so, if that is how they choose to end their life. However, there is the implication that this is a nobler way to die than MAID. I see no reason why an individual cannot approach MAID with courage and dignity as well. Just as there is more than one good way to live, there is more than one good way to die.

The flip side of this rhetorical maneuver is to describe the empathic and spiritually edifying experience for the doctor and loved ones of being there and sharing the dying experience with the patient. I suspect that this experience is often more satisfying for the participants other than the suffering patient. Furthermore, it has been a long time since physicians typically spent much time at the deathbed communing with the dying person. That role, if it occurs at all, has long since been abdicated to other health care professionals. But most basically, I see no reason why the same empathy and caring cannot be provided in the context of MAID as well as, if not better than, with a protracted unaided death.

Physician-Assisted Suicide

Opponents of MAID prefer the label of physician-assisted suicide (PAS). Although I think MAID is a less emotionally biasing term, I do not see this as an important argument. What I do think is important is their stress that there should be no fundamental distinction between this practice and any other kind of suicide.¹⁵ Killing oneself is killing oneself. They then go on to argue that MAID should not be allowed because of the devastating effects that suicide has on surviving family, citing either anecdotes or data supporting this.¹³ But there is little reason to think that reactions to an unexpected self-inflicted death by a troubled individual would resemble reactions to a planned death in the context of MAID, whether we call that suicide or not. I believe there is quite a difference in these 2 kinds of suicide. If I am taking a family history of a depressed patient and the patient tells me that their parents committed suicide in midlife while depressed, it has very different implications than if the patient tells me that their parents with terminal illnesses chose to end their lives rather than continue to suffer.

Voluntary Stopping of Eating and Drinking

Opponents of MAID insist on making a fundamental distinction where I believe there is none—namely between electing MAID or hastening one’s death by other means, such as refusing further treatment or the voluntary stopping of eating and drinking (VSED).^6,7 The latter is viewed as a totally acceptable and even admirable removal of the impediments to death, while the former is ethically wrong. Frankly, this seems like a hairsplitting distinction based on a bit of medieval casuistry. If VSED is acceptable because it is simply refusing essential nutrients rather than actively consuming a lethal substance, I would assume that opponents of MAID have no problem with a person sealing themselves in a small, airtight box and dying of suffocation. After all, they are simply depriving themselves of oxygen rather than actively consuming a lethal substance. I would argue that this is a distinction with no ethical or moral importance—a difference of means, not of ends. If there is no difference between MAID and any other suicide, is there a difference between VSED in the context of a terminal illness and dying from severe anorexia nervosa? Starving to death is starving to death. Whether or not this distinction exists or is significant has important implications for many of the consequentialist arguments that will be addressed in subsequent articles.

Dr Heinrichs is a psychiatrist in Ellicott City, Maryland.

The opinions expressed are those of the author and do not necessarily reflect the opinions of Psychiatric Times™.

What are your thoughts on MAID? Share your questions, concerns, and potential solutions via PTEditor@mmhgroup.com.

References

1. Geppert CMA, Komrad MS, Pies RW, Hanson AL. Psychiatrists must prevent suicide, not provide it. Psychiatric Times. November 18, 2019. https://www.psychiatrictimes.com/view/psychiatrists-must-prevent-suicide-not-provide-it

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

3. Komrad MS. Are psychiatrists who assist in suicide betraying their professional values? Psychiatric Times. June 15, 2021. https://www.psychiatrictimes.com/view/psychiatrists-suicide-betraying-values

4. Komrad MS. First, do no harm: new Canadian law allows for assisted suicide for patients with psychiatric disorders.Psychiatric Times. 2021;38(6).

5. Pies R. Hippocratic medicine is hallowed ground. Psychiatric Times. January 24, 2022. https://www.psychiatrictimes.com/view/hippocratic-medicine-is-hallowed-ground

6. Pies R. Physician-assisted suicide: an egregious boundary violation. Psychiatric Times. January 11, 2022. https://www.psychiatrictimes.com/view/physician-assisted-suicide-an-egregious-boundary-violation

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

8. Pies RW. Life with dignity: a tribute to Hilary Lister. Psychiatric Times. 2018;35(10).

9. Pies R. Will the AMA heed its own ethics council regarding assisted suicide? Psychiatric Times. 2018;35(7).

10. Pies RW. Deferring to the mastery of death: Hippocrates, Judge Gorsuch, and the autonomy fallacy. Psychiatric Times. 2017;34(4).

11. Pies RW. Physician-assisted suicide and the rise of the consumer movement. Psychiatric Times. 2016;33(8).

12. Pies R. Physician-assisted dying for adolescents with intractable mental illness? Psychiatric Times. 2016;33(5).

13. Pies R. Is suicide immoral? Psychiatric Times. 2014;31(2).

14. Pies RW, Geppert CMA. Physician-assisted suicide and the autonomy myth. Psychiatric Times. October 27, 2021. https://www.psychiatrictimes.com/view/physician-assisted-suicide-and-the-autonomy-myth

15. Brenan M. Americans’ strong support for euthanasia persists. May 31, 2018. Accessed August 13, 2022. https://news.gallup.com/poll/235145/americans-strong-support-euthanasia-persists.aspx

16. Kao AC, Parsi KP. Content analyses of oaths administered at U.S. medical schools in 2000. Acad Med. 2004;79(9)882-887.