Authentic autonomy cannot be assessed without an understanding of these psychodynamic issues. Specifically, as Hicks notes,
In any suicidal patient, including the terminally ill, the request to die can be a plea for help or an attempt to be given a reason to live. A request for PAS can be an entreaty for the doctor to take the terminally ill patient's situation or despair more seriously, or a test of the doctor's true feelings about the patient's value now that he is nearing death.15
Finally, it is important to recall that autonomy is only one of the four “cornerstones” of medical ethics; the others are beneficence, non-malfeasance, and justice.5 Many would argue that helping one’s patient kill herself is hardly beneficent—and, indeed, constitutes malfeasance.16 Furthermore, we must remember that the supremacy of autonomy is a relatively recent development in the history of ethical thought—one that many ethicists believe has become unduly preeminent.17-19 As Tauber has argued, “Complex social and economic forces have placed patient autonomy at the center of medical ethics, and thereby displaced an older ethic of physician beneficence.”18 Indeed, as Desai and Grossberg observe in their textbook on long-term care,
The preeminence of autonomy as an ethical principle in the United States can sometimes lead health care providers to disregard other moral considerations and common sense when making clinical decisions . . . we strongly feel that the role of the medical profession is to understand but not to support such wishes [for physician-assisted death]. Every person’s life is valuable, irrespective of one’s physical and mental state, even when that person has ceased to deem life valuable.20
Re-defining incurability and terminal illness
Most PAS legislation applies to an adult with a terminal illness or condition predicted to have fewer than six months to live. The common interpretation of this phrase would be, “six months to live even with treatment,” often with the assumption that there is no further or additional therapy capable of halting or reversing the disease process. Good law and sound public policy both depend upon clear and cogent definitions. Yet, incredibly, “terminal illness” is never defined at this level of detail in existing PAS statutes (ie, with respect to treatment vs no treatment). Nevertheless, in Oregon and Washington State, nearly identical criteria are interpreted to mean fewer than six months to live without treatment. Thus, an otherwise healthy 20-year-old with insulin-dependent diabetes could be deemed “terminal” for the purpose of Oregon’s “Death with Dignity Act,” since, without insulin, the patient would probably die within six months.
So, too, patients refusing appropriate treatment may be deemed “incurable” or “terminal” under current interpretation of the Oregon law.21 Thus, a patient with anorexia nervosa who refuses treatment could be eligible for PAS under Oregon law, even though she has never tried a course of intensive, evidence-based therapy. By this Orwellian logic, an individual with pneumonia who refuses to take antibiotics could be deemed “incurable” and qualify for physician-assisted suicide! As Swedish investigator Fabian Stahle dryly observes, “This is in fact an alteration of the traditional meaning of the concept of ‘incurable’ . . .”21
In a remarkable, notarized exchange with the Oregon Health Authority, Mr. Stahle posed the following questions:
In the [Oregon] law, “terminal disease” is defined as an incurable and irreversible disease that has been medically confirmed and will, within reasonable medical judgment (in the opinion of the patient’s attending physician and consulting physician), produce death within six months. Is this rule interpreted as “without administration of life-sustaining treatment”?
Craig New, Research Analyst, Oregon Health Authority, Center for Public Health Practice, Public Health Division, replied as “ . . . your interpretation is correct. The question is: should the disease be allowed to take its course, absent further treatment, is the patient likely to die within six months?” [emphasis added]
As Mr. Stahle rightly concluded, “So under Oregon’s assisted death law, one can achieve the status of being “incurably” sick even if the disease can be treated! Thus, all diseases which, without treatment, are expected to lead to death within six months are considered to be incurable and therefore qualify for assisted death.”1
Stahle then posed a follow-up question to Mr. New:
If a patient with a chronic disease (for instance, diabetes) by some reason decides to opt out from the life-sustaining medication/treatment and by doing so is likely to die within 6 months, thereby transforming the chronic disease to a terminal disease—does he/she then become eligible to take use of the act?
New replied that, yes, indeed—the patient would qualify for assisted suicide. In New’s words, the Death With Dignity Act “. . . does not compel patients to have exhausted all treatment options first, or to continue current treatment . . . [and] if patientS decide they don’t want treatment, that is their choice.”
There is certainly room for debate regarding the role of the physician in “end-of-life” care. Nonetheless, as psychiatrists and medical ethicists, we believe that so-called “medical aid in dying” (physician-assisted suicide) is a serious boundary violation and an unethical act. This is consistent with the historical positions of the American Medical Association, the American Psychiatric Association (based on the AMA Code of Ethics), the American College of Physicians, the World Medical Association, and the American Nurses Association.22,23
Whatever individual physicians decide with respect to MAID/PAS, it must be based on a clear-eyed understanding of current statutes and legislation. This means exposing the myths that surround these statutes.24 Among these are the commonly-received notions that patients choosing PAS act “autonomously” and have a demonstrably incurable condition. In truth, current PAS statutes produce a form of pseudo-autonomy that enshrines the supreme authority of the physician, and re-defines “incurable” to mean almost anyone who is seriously ill.
1. Pies R. Brittany Maynard and the Loose Language of Suicide. Medscape. November 19, 2014 https://www.medscape.com/viewarticle/835014. Accessed July 2018.
2. Pies R, Geppert CM. Not just a matter of semantics. Psychiatric Times. Feb. 2, 2017 http://www.psychiatrictimes.com/couch-crisis/not-just-matter-semantics. Accessed July 12, 2018.
3. Christakis NA, Lamont EB. Extent and determinants of error in physicians' prognoses in terminally ill patients prospective cohort study. West J Med. 2000;172: 310-313.
4. Starks H, Dudzinski D, White N, et al. Physician Aid-in-Dying. Ethics in Medicine. https://depts.washington.edu/bioethx/topics/pad.html. Accessed July 12, 2018.
5. Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 5th ed. New York: Oxford University Press; 2001: 58.
6. Lane M. Ancient political philosophy. Zalta EM, Ed. Stanford Encyclopedia of Philosophy. Stanford University: Metaphysics Research Lab; 2017.
7. Waimberg J. Does the constitution protect a “right to die”? https://constitutioncenter.org/blog/does-the-constitution-protect-a-right-to-die. Accessed July 12, 2018.
8. Oregon Health Authority. Death With Dignity Act: Revised Statute. https://www.oregon.gov/oha/ph/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Pages/ors.aspx. July 12, 2018.
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11. Szasz TS. Fatal Freedom: The Ethics and Politics of Suicide. Syracuse University Press, 2002.
12. Knoll JL. Suicide prohibition: shame, blame, or social aim? Haldipur C, Knoll JL, Luft E, Eds. Thomas Szasz: An Appraisal of His Legacy. NY: Oxford University Press (In press).
13. Statement of the American Association of Suicidology: Suicide Is Not the Same as Physician Aid in Dying. http://www.suicidology.org/Portals/14/docs/Press%20Release/AAS%20PAD%20Statement%20Approved%2010.30.17%20ed%2010-30-17.pdf. Accessed July 12, 2018.
14. Oregon Death With Dignity Act: Data Summary 2016. https://www.oregon.gov/oha/ph/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year19.pdf. Accessed July 12, 2018.
15. Hicks M. Physician-assisted suicide: a review of the literature concerning practical and clinical implications for UK doctors. BMC Fam Pract. 2006;7:39.
16. Hallowell B. Why so many doctors oppose euthanasia and assisted suicide. Deseret News. August 2016. https://www.deseretnews.com/article/865659304/Why-so-many-doctors-oppose-euthanasia-and-assisted-suicide.html. Accessed July 12, 2018.
17. Pies R. Physician-Assisted Suicide and the Rise of the Consumer Movement. Psychiatric Times. August 2916. http://www.psychiatrictimes.com/couch-crisis/physician-assisted-suicide-and-rise-consumer-movement. Accessed July 12, 2016.
18. Tauber AI. Sick autonomy. Perspect Biol Med. 2003;46:484-495.
19. Wardrope A. Autonomy as ideology: towards an autonomy worthy of respect. New Bioeth. 2015;21:56-70.
20. Desai AK, Grossberg GT. Psychiatric Consultation in Long-Term Care. Baltimore, MD: Johns Hopkins University Press; 2010: 262.
21 Stahle F. Oregon Health Authority Reveals Hidden Problems with the Oregon Assisted Suicide Model. January 2018. https://www.masscitizensforlife.org/oregon-health-authority-reveals-hidden-problems-with-the-oregon-assisted-suicide-model. Accessed July 12, 2018.
22 Marine JE. Physician-Assisted Suicide: Why Physicians Should Oppose It. February 2018. https://www.acponline.org/system/files/documents/about_acp/chapters/md/marine.pdf. Accessed July 12, 2018.
23. Komrad MS. APA position on medical euthanasia. Psychiatric Times. February 2017. http://www.psychiatrictimes.com/suicide/apa-position-medical-euthanasia. Accessed July 12, 2018.
24. Pies RW, Hanson A. Twelve myths about physician assisted suicide and medical aid in dying. MD Magazine. July 7, 2018. https://www.mdmag.com/medical-news/twelve-myths-concerning-medical-aid-in-dying-or-physicianassisted-suicide. Accessed July 12, 2018.