Not Just a Matter of Semantics
Not Just a Matter of Semantics
LETTER TO THE EDITOR
As a practicing psychiatrist for 40 years (if residency training is included) with experience in both end-of-life care and the assessment of suicide behaviors, I have always objected to the use of the term “assisted suicide” when applied to terminally ill patients. A physician’s efforts to help terminally ill people bring their lives to a dignified conclusion should be referred to as “assisted dying.” This is not a minor semantic point. As both Drs. Ronald Pies and Cynthia Geppert have pointed out, there are 4 European countries that allow physicians to assist people who are not terminally ill in ending their lives (“Physician-Assisted Dying for Adolescents With Intractable Mental Illness?” Psychiatric Times, May 2016, pp 1,27-31).
Canada recently passed a yet-to-be-implemented federal law that will also allow this practice. It appears from the experience in Europe that all cases of non-terminally ill people who pursue this assisted dying path have a major psychiatric disorder from which they are seeking relief. Unlike efforts to help terminally ill people, this activity when applied to non-terminally ill people can legitimately be called “assisted suicide” and should be strongly condemned by all physicians and the health care establishment at large.
My point is that there is a clear reason to distinguish the terms “assisted dying” and “assisted suicide.” Language and terminology matter. The ethical, moral, and public policy implications of this distinction should make this a high priority for the Psychiatric Times editorial staff.
Richard Krugley, MD, DABPN, LFAPA
Interim Chair, Department of Psychiatry
St. John’s Episcopal Hospital
Far Rockaway, NY
Drs. Pies and Geppert Reply
We thank Dr. Krugley for his thoughtful comments on physician-assisted suicide (PAS) and “assisted dying.” Each of these designations expresses a value judgment about the nature and intentionality of the practice. Thus, those who believe PAS is ethically justifiable tend to use the term “assisted dying” to place this intervention squarely in the mainstream of end-of-life care. In contrast, those who question the ethical justifiability of providing patients with lethal prescriptions favor the use of “assisted suicide” as more truthfully naming the action.1
As Dr. Krugley rightly notes, our use of language is a critical issue when discussing end-of-life options. Whether our terminology is emotionally “loaded,” pejorative, or approving has important implications for how we conceptualize the ethical issues at stake. Indeed, euphemisms have been utilized in everything from advertising to fascism to desensitize the moral sense of the public. Some of these linguistic considerations are discussed elsewhere,1 and the general ethical issues involved in the PAS debate are nicely outlined in a paper by Starks and colleagues.2
We fully agree with Dr. Krugley that there are both medical and ethical reasons why “a physician’s efforts to help terminally ill people bring their lives to a dignified conclusion” differ radically from similar efforts in patients who do not have a terminal illness, whether physical or mental.3,4 Indeed, we further agree with Dr. Krugley that, “Unlike efforts to help terminally ill people, this [assistance] when applied to non-terminally ill people can legitimately be called ‘assisted suicide’ and should be strongly condemned by all physicians and the health care establishment at large.”
The importance of distinguishing medically validated terminal illness (such as end-stage pancreatic cancer) from non-terminal illness (such as schizophrenia or major depression) was recently affirmed by the Board of Trustees of the American Psychiatric Association (APA), whose statement reads:
The American Psychiatric Association, in concert with the American Medical Association’s position on Medical Euthanasia, holds that a psychiatrist should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death.5
Contrary to some misinterpretations of this statement, the APA was not tacitly condoning or endorsing interventions “for the purpose of causing death” in cases of terminal illness [personal communications, Mark S. Komrad, MD, Annette Hanson MD, 12/16/16].
We respect Dr. Krugley’s long experience with end-of-life care, and we acknowledge that both the linguistic and the ethical issues in this context are extremely complex and controversial. That said, we are troubled by the term “assisted dying” when it is applied —even in cases of terminal illness —to a physician’s prescribing a lethal medication to the patient. We believe that this goes beyond “assisting dying” as this term is understood in palliative and hospice medicine, and in the sense to which we would restrict this term, ie, to situations in which futile measures that merely prolong the dying process are discontinued.