Deferring to the Mastery of Death: Hippocrates, Judge Gorsuch, and the Autonomy Fallacy

COMMENTARY

We must care for the dying, not make them dead.

Leon R. Kass, MD¹

Lately, I’ve been rummaging through 3 impressive books and thinking a great deal about the contentious issue of . . . —well, let’s just call it “end-of-life care” for now. The first book is classicist and philosopher Ludwig Edelstein’s collection of essays, Ancient Medicine, with its scholarly analysis of the Hippocratic Oath.² Next is physician-ethicist Steven H. Miles’s 2004 work, The Hippocratic Oath and the Ethics of Medicine,³ which challenges some of Edelstein’s conclusions. Finally—and particularly relevant to the moment—is Judge Neil Gorsuch’s book, The Future of Assisted Suicide and Euthanasia,⁴ which seems to have attracted little attention from medical ethicists, until Judge Gorsuch’s recent nomination to the US Supreme Court. This event gives us an opportunity to examine Judge Gorsuch’s scholarly writing—without in any way implying a political endorsement.

What do these 3 works have in common, and how do they touch on psychiatric practice? All deal with the thorny issues of suicide and assisted suicide, although from quite different perspectives.

Recently, my colleague, medical ethicist Dr. Cynthia Geppert, and I dealt with end-of-life issues in response to a thoughtful letter from a psychiatrist. I will not re-litigate all the arguments and counter-arguments in that exchange—including several impassioned comments by Psychiatric Times readers. Rather, I focus here on 3 related topics:

1. That part of the Hippocratic Oath that addresses the use of a “deadly drug”

2. The ethos of “Hippocratic medicine” and how it has shaped medical practice

3. The principle of respecting the patient’s autonomy, and how that principle has been misunderstood in the debate over end-of-life care. On this last topic, Judge Gorsuch has some important things to say.

The perils of terminology

I acknowledge that the term I will use in this essay, “physician-assisted suicide,” is both controversial and value-laden, albeit no more so than the alternative terms, “physician-assisted dying” and “assisted death.” I doubt we can discuss these matters using terminology that is completely “value-neutral.” Medical ethics is inherently concerned with values, and this is inevitably reflected in our language. Even if we used the most descriptively precise term, “Deliberate Prescription of a Lethal Drug,” we would still be making an implicit value judgment of sorts; ie, that we should avoid terms like “suicide” or “death” in our description of the act that now has legislative approval in 5 states. While acknowledging these complexities and controversies, I will use the term “physician-assisted suicide” in this essay, for reasons detailed in the Footnote at the end of this article. In brief, my view is that the terms “physician-assisted dying” and “aid in dying” function as comforting euphemisms that prevent legislators, physicians, and patients from seriously examining the moral implications of helping a patient commit suicide.

Finally, a few caveats: having witnessed the prolonged decline and death of several family members, I can see both sides of the physician-assisted suicide debate, and I do not presume that the problems surrounding “end-of-life care” admit simple solutions. While I am opposed to physician-assisted suicide, I recognize that many physicians—including several psychiatrists whom I respect—disagree with my stance. By the same token, I intend no condemnation or disparagement of terminally ill patients or their physicians—who, in good conscience, choose the path of physician-assisted suicide.

With these caveats in mind, let’s begin with the father of medicine, Hippocrates of Kos (ca. 450 - 380 BCE).