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.
See: Commentary on Deferring to the Mastery of Death, by Cynthia Geppert, MD, MA, MPH, MSBE, DPS, FAPM.
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).
Acknowledgments—All of the following colleagues contributed in some way to this essay: Drs. Leon Kass, Cynthia Geppert, James L. Knoll IV, Mark Komrad, Anne Hanson, Tony Yang, James Ellison; and Prof. Lars Johan Materstvedt. I am especially indebted to Farr Curlin, MD, for his helpful comments on my manuscript.
1. Kass LR. Dehumanization Triumphant. 1996. http://legacy.bishopireton.org/FACULTY/GAVINW/HomepageGavin_files/Euthanasia/Dehumanization%20Triumphant%20Leon%20Kass.htm. Accessed February 24, 2017.
2. Temkin O, Temkin CL, eds. Ancient Medicine: Selected Papers of Ludwig Edelstein. Baltimore, MD: Johns Hopkins University Press; 1967.
3. Miles SH. The Hippocratic Oath and the Ethics of Medicine. New York: Oxford University Press; 2004.
4. Gorsuch NM. The Future of Assisted Suicide and Euthanasia. Princeton, NJ: Princeton University Press; 2006.
5. Kass LR. A dignified death and its enemies: why doctors must not kill. In: A Worthy Life: Finding Meaning in America. New York: Encounter Books (in press for 2017).
6. Telushkin JA. Code of Jewish Ethics. Vol. 2. New York: Bell Tower; 2009.
7. Yang T, Curlin FA. Why physicians should oppose assisted suicide. JAMA. 2016;315:247-248.
8. Pies R. Physician-assisted suicide and the rise of the consumer movement. Psychiatric Times. August 2016;32:40-43.
9. Conaboy C. Assisted dying, without the doctor? Ethicist says physicians can help without prescribing lethal dose. http://archive.boston.com/whitecoatnotes/2012/07/12/assisted-dying-without-the-doctor/oXqQYicMqaazlG8THxTlpN/story.html. July 2012. Accessed February 27, 2017.
10. Lehmann LS, Prokopetz JJ. Redefining physicians’ role in assisted dying. N Engl J Med. 2013; 368:486.
11. American Nurses Association. Position Statements: Euthanasia, Assisted Suicide, and Aid in Dying. April 24, 2013. http://www.nursingworld.org/euthanasiaanddying. Accessed February 27, 2017.
12. White C. Bishops of England and Wales refresh the art of dying well. Crux. February 17, 2017. https://cruxnow.com/commentary/2017/02/17/bishops-england-wales-refresh-art-dying-well/. Accessed February 27, 2017.
13. Krugley R. Not just a matter of semantics. Psychiatric Times. January 2017. http://www.psychiatrictimes.com/blogs/not-just-matter-semantics. Accessed February 27, 2017. ❒