Cynthia M. A. Geppert, MD, MPH

There are moral absolutes that our profession should stand up for, in spite of legislative or popular pressure, say the authors in this rejoinder to Drs Kious and Battin’s "

Response to Physician Aid-in-Dying and the Proper Role of Physicians.

" Also see the original article by Ronald W. Pies, MD; Annette L. Hanson, MD; Mark S. Komrad, MD; and Cynthia M.A. Geppert, MD, MPH: 

PAS Versus Involuntary Commitment: Is There a Moral Dilemma?

for the opportunity to provide a rejoinder to their response." In their 

, Drs Kious and Battin argue that the long-established practice of psychiatrists to make every effort to prevent suicide including the use of involuntary commitment and the relatively new availability of physician aid-in-dying (PAD) create a moral dilemma. Their proposed resolution of the dilemma is to permit psychiatric patients, as well as those with medical illnesses, to access PAD when their suffering is severe and irremediable. Our commentary rejects the fundamental presumption that any physicians, much less psychiatrists, should be involved of the work of killing rather than the calling of healing, among other criticisms.

In this rejoinder, we first dispute some of the practical claims Drs Kious and Battin suggest in their response and then refute their challenges to the philosophical foundations of our position We would favor the term physician-assisted suicide, “PAS,” when referring to our 

 position as more clearly conveying that the practice is incompatible with the professional ethos of medicine.

In their response to our article, Drs Kious and Battin, repeat their claim that involuntary psychiatric commitment for suicide prevention (IPCSP) can in some situations constitute a value judgment about the severity or remediability of a person’s suffering. We believe their description of the relationship of suffering to IPCSP is based on a legal and ethical misunderstanding of the legal and ethical grounds for IPCSP. The warrant for IPCSP is solely contingent upon a person’s 

under the well-established legal doctrines of 

 and the police powers of the state-and is not contingent on any 

 or clinical judgment regarding how “severe and irremediable” a person’s “suffering may be.” In our combined 128 years of clinical practice, we have never seen a case in which a psychiatrist failed to pursue IPCSP, based on the judgment that a mentally competent patient’s suffering was so severe and irremediable as to justify suicide. That is, we don’t say, as clinicians, “Oh, we made a big mistake hospitalizing this patient, because it turns out his suffering is really, really bad and his choice to die is reasonable!”

We agree with Drs Kious and Battin that, like abortion, PAD in contemporary American society may generate irreconcilable differences of opinion. However, we note that abortion does not represent the risk to public health that a suicide contagion poses. Thus, IPCSP can provide protection beyond the effect on the individual patient. Physicians also have a duty to promote and protect the health of the public-not just treat and protect the vulnerable patient. In any case, irreconcilable differences do not warrant abandoning a critical examination of the opposing arguments, given such a momentous departure from traditional medical praxis. For example, we fundamentally disagree with our two colleagues that public opinion is an ethically appropriate means of informing public policy decisions or even more crucially, determining professional norms of physicians.

Polls have not just moral but also methodological problems. Response rates are often low, and typically it is those with the strongest feelings about the issue who respond. Responses are also highly sensitive to the ways questions are worded (eg, “assisted suicide” vs. “aid in dying.”

) The most robust and proper way to explore ethical questions-especially radical shifts proposed in such an enduring and venerable professional ethos as this one-is not by simply doing a “gut check,” and quickly answering a poll. It is by a process of deep examination, study and consultation with a variety of professional experts in philosophy, medical ethics, and sociology, as well as our patients. Medical ethics is not so much about finding the one “right answer” as it is about pursuing the right process.

This “deep dive” is precisely the process that was brought to bear by the 

 (WMA) in their recent reexaminations of their ethical opposition to these practices.

 several times at the request of PAS proponents, and each time, though acknowledging the caring intentions on both sides of the issues, these organizations kept coming to the same conclusion-that these practices are “firmly opposed.” Similarly, for the second largest medical organization in the US-the American College of Physicians

-and even for the organization that works professionally in the “end-zone” of life-the International Association for Hospice and Palliative Care

-these and other articulations, are not mere polls. They are robust deliberations by organizations representing physicians and others, whom society is asking to do the killing. Moreover, no medical organization in the US has actually endorsed PAS as a laudable practice so far. At most, those organizations not opposed to PAS have expressed official “neutrality” on this issue.

Drs Kious and Battin may well be right that general polls of the public do show an increasing trend toward acceptance of PAD. However, the same cannot be said of the professional organizations which are the guardians of the core values of the medical ethics. They are overwhelmingly opposed to PAD precisely because they hold it is antithetical to the ethical identity of physicians as healers. In their response, Drs Kious and Battin incorrectly assume that this conception implies we would “have no role in a how a patient’s death goes.” This is a classic strawman argument. Physicians have an ancient place, standing at the bedside of the dying, palliating pain and offering compassion for suffering-the very meaning of “compassion” is “to suffer alongside.” Where we contend physicians should not stand is where Drs Kious and Battin would have them stand: in the position of bringing about the death of any human being. Palliative care physicians are experts in the relief of the discomfort of dying. That expertise does not require PAD and can successfully manage the very symptoms that are the rationale for PAD.

It is an argument of accident rather than substance to say that physicians have prescribing powers; hence, they must be the ones to administer PAD. States are already authorizing pharmacists to prescribe some medications and can as easily add lethal medications to that list. Our prescriptive privileges have no bearing on our ethical duties when the latter conflict with the purpose for which those medications are prescribed.

Our colleagues are correct that in our initial article, we may not have clearly stated that Drs Kious and Battin do not consider 

 suffering, as potentially justifying PAD, although we feel this does not change the strength of our argument. Nor do we disagree with the claim that, in theory, there is suffering so severe and irremediable that it might legitimate a person’s seeking assistance to die. The vendor of death could be a clergyman or a cousin-or even a cadre of trained “thanatologists” who are not in the house of medicine. Our main argument is simply that 

cannot ethically comply or collude with even the most desperate of requests to end-a patient’s life by suicide.

We now turn to Drs Kious and Battins’ critique of our philosophical position as “essentialism” and “historicism.” If by “essentialism,” they mean that we hold certain medical ethical truths to be constant, enduring, and not “will-o-the-wisp” notions dependent on polls and plebiscites, then, yes-we are guilty of “essentialism.” While we would acknowledge that “evolving social expectations” do have some influence on “what is permissible for physicians,” we would deny that such expectations are infinitely elastic and 

 vis-Ã -vis what is ethically permissible. Would the authors change their 

 position favoring “assisted dying” if new polls showed that most physicians oppose the practice? Or do they base their position in favor of PAS on their own view of what is “essential” to the role of physicians? If we make medical ethics dependent upon polls, we are opening the field to a kind of post-modern relativism that undercuts the very concept of a “profession.” Medical ethics are not a kind of weather vane, changeable with each new poll that comes out! We would argue that PAS is really an outgrowth of, and is contemporaneous with, the consumer movement of the past 50 to 60 years and is therefore an 

It is not the literal wording of the Hippocratic Oath, but the subsequent development of those values that has provided a moral compass for the medical profession. That growth, intellectually and experientially, resembles, for example, the development of religious values, not confined to, but inspired by the esteemed teachers and holy books of the world’s great religious traditions. These are evolving and venerable moral compasses for covenantal communities. The current Tree of Medicine is rooted in its Hippocratic soil. It has ramified branches of thoughts and values yet embodies a core ethos that has persisted through the rise and fall of many societies.

Our colleagues should not so easily dismiss the lessons of history as mere “historicism.” We believe very much in Santayana’s famous wisdom: “Those who cannot remember the past are condemned to repeat it.” Changing social mores and highly popular notions, championed by celebrities, intellectuals, and policy makers, have swept physicians off their ethical moorings in the past. Consider the historic example of Soviet psychiatry. Civil commitment was used to isolate dissidents, and the doctors went along with it. Physicians, especially psychiatrists, participated with relish in eugenics-inspired forced sterilization programs of the mentally ill in the US.

 There are moral absolutes that our profession should stand up for, in spite of legislative or popular pressure. Public health policy should not be contingent upon popularity. Many popular ideas were proved both wrong and harmful (eg. conversion therapy for homosexuals).

a physician friend about the social pressure on physicians to kill in the name of mercy, observing that:

The followers of Hippocrates were dedicated completely to life under all circumstances, regardless of rank, age, or intellect-the life of a slave, emperor, foreign man, defective child . . . This is a priceless legacy which we cannot afford to tarnish. But society has repeatedly attempted to make the physician into the killer . . . It is the duty of society to protect the physician from such requests.

Dr Geppert is Professor of Psychiatry and Medicine, and Director of Ethics Education, University of New Mexico School of Medicine; and Ethics Section Editor of 

Dr Komrad is on the psychiatry faculty of Johns Hopkins, University of Maryland, and Tulane University. Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics & Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor-in-Chief Emeritus of 

2007-2010). Dr Hanson is Director of the Forensic Psychiatry Fellowship at the University of Maryland.

Physician Aid-in-Dying and Suicide Prevention in Psychiatry: A Moral Crisis?

2. Magelssen M, Supphellen M, Nortvedt P, Materstvedt LJ. Attitudes towards assisted dying are influenced by question wording and order: a survey experiment. 

3. Dany L, Baumstarck K, Dudoit E, et al. Determinants of favourable opinions about euthanasia in a sample of French physicians. 

4. World Medical Association. WMA Declaration on Euthanasia and Physician-Assisted Suicide. 

https://www.wma.net/policies-post/declaration-on-euthanasia-and-physician-assisted-suicide

5. Snyder L, Sulmasy DP, Ethics, Human Rights Committee ACoP-ASoIM. Physician-assisted suicide. 

6. De Lima L, Woodruff R, Pettus K, et al. International Association for Hospice and Palliative Care Position Statement: Euthanasia and Physician-Assisted Suicide. 

7. Pies RW. Physician-Assisted Suicide and the Rise of the Consumer Movement. 

https://www.psychiatrictimes.com/couch-crisis/physician-assisted-suicide-and-rise-consumer-movement

Keepin America Sane: Psychiatry and Eugenics in the United States and Canada, 1880-1940.

 New York: Cornell University Press; 2003.

9. Mead M. The Hippocratic Registry of Physicians. 

Articles

The current Tree of Medicine is rooted in its Hippocratic soil. There are moral absolutes that our profession should stand up for, in spite of legislative or popular pressure, say the authors.

Psychiatrists Must Prevent Suicide, Not Provide It

Physician-assisted suicide (PAS) violates the norms of Hippocratic medical ethics. Involuntary hospitalization to prevent suicide affirms those norms, according to the authors.

Editor's note: Read the response to this article by Drs Kious and Battin here: 

Physician Aid-in-Dying and the Proper Role of Physicians

, psychiatrist-ethicist Brent M. Kious, MD, PhD, and philosopher-ethicist Margaret P. Battin, PhD,

 present what they see as a “moral dilemma.” Specifically, the authors argue that

Involuntary psychiatric commitment for suicide prevention [IPCSP] and physician aid-in-dying (PAD) in terminal illness combine to create a moral dilemma. If PAD in terminal illness is permissible, it should also be permissible for some who suffer from non-terminal psychiatric illness: suffering provides much of the justification for PAD, and the suffering in mental illness can be as severe as in physical illness. But involuntary psychiatric commitment to prevent suicide suggests that the suffering of persons with mental illness does not justify ending their own lives, ruling out PAD.

We wish to challenge this thesis and argue that the supposed “moral dilemma” Kious and Battin suggest is purely factitious. Indeed, it is easily disposed of once the underlying rationale for “physician aid-in-dying”-a 

-is exposed as inconsistent with the values of Hippocratic medicine.

Moral dilemmas typically arise in medicine when two courses of action represent competing goods of roughly equal “weight,” or of commensurate risks and benefits. For example, when only one kidney is available for transplant, and there are two equally appropriate recipients in urgent need of the organ, transplant physicians face a classic moral dilemma.

We do not believe that the seeming conflict between PAS and IPCSP represents such a moral dilemma, because, in our view, PAS does not represent a “moral good” of any kind. That the legislative intent behind the laws underlying these two procedures may be contradictory-or in 

conflict with one another-does not perforce create a “moral dilemma” for anyone, especially physicians. Law and ethics are not necessarily congruent domains. Indeed, Oxford University law professor Charles Foster

 rightly observes that Kious and Battin conflate “. . . the different functions of law and ethics.”

, PAS is ethically impermissible there is no 

 succinctly puts it, “The dissonance stops (and the [Kious and Battin] article’s main complaint is resolved) as soon as PAD is taken off the statute book.”

The putative intent of physician-assisted suicide-to reduce suffering and respect the patient’s autonomy-does not salvage the practice, when viewed through the lens of medical ethics. While reducing suffering and honoring the patient’s autonomy are laudable moral ends, PAS is not an ethical means to these ends. Furthermore, there are alternative means for reducing suffering, which do not entail the moral problems of PAS; eg, state-of-the-art palliative and hospice care, and-in extreme cases-voluntary stopping of eating and drinking (VSED) and palliative sedation.

 We do not accept the moral theory, implicit in the ideology of PAS, that eliminating suffering human beings is an ethically acceptable path to eliminating human suffering. Indeed, once we strip away the anodyne euphemisms of the PAS movement-such as “medical aid in dying”-its philosophy is reduced to the claim that the patient’s self-determination takes precedence over all other moral goods. In our view, this apotheosis of autonomy represents a radical distortion of Hippocratic values.

Assisted suicide and involuntary hospitalization are ethically and legally distinct

We believe that the moral issue regarding PAS is quite clear, consistent with the position of the American Medical Association; the American Psychiatric Association; the American College of Physicians; and the World Medical Association: 

PAS is incompatible with the ethical principles underlying Hippocratic Medicine.

the case with respect to involuntary psychiatric commitment for suicide prevention (IPCSP)-an entirely separate ethical issue from assisted suicide. IPCSP has long been upheld as an ethical means of protecting the lives and well-being of suicidal patients, as the American Psychiatric Association has affirmed.

 Importantly, ethically-based IPCSP is used only when the patient’s life and well-being cannot be secured through less restrictive means. In a move of surpassing perversity, the advocates of PAS turn this ethos on its head by enabling vulnerable individuals to 

 their lives-ostensibly for the sake of their well-being!

And while we have pointedly distinguished legal from ethical issues, it is notable that IPSCP is legal, subject to various limitations and conditions, in 

 US states. IPSCP laws are grounded in the two principles of 

(the authority of the state to protect persons legally unable to act on their own behalf) and the “police power” of the state.

 There is no such broad legal acceptance of PAS in this country, which has legal status in only nine US states and the District of Columbia.

Indeed, almost all states criminalize assisted suicide, and six states specifically outlaw assistance of suicide by physicians.

 Furthermore, in the last ten years, at least nine US states have strengthened their laws against assisted suicide/euthanasia.

 In addition, in the Assisted Suicide Funding Restriction Act of 1997, the US Congress prohibited the use of federal funds to facilitate the practice of PAS;

 and, in 2017, the US House of Representatives introduced a resolution condemning PAS.

 Finally, it is notable that legislative initiatives to legalize PAS have failed more than 125 times in 50 states since 1995.

This is not to say that the matter of IPSCP is ethically uncontroversial, or that it is not subject to misuse or abuse; but its ethical (and legal) status is far different in the US than that of PAS. It is also important to distinguish brief, emergency “holds” or emergency hospitalization (usually 48 to 72 hours) for purposes of psychiatric evaluation from 

. Physicians from any specialty; police officers; social workers; and others with legal standing may initiate an emergency hospitalization, whereas only a judge or magistrate may institute the long-term civil commitment of a patient.

 immediately create conceptual problems for themselves by positing that PAS is “permissible.” We deny that premise, in any 

sense of the term “permissible.” We understand that PAS is 

 in several US states, but we deny that it is morally or ethically permissible 

based on long-standing principles of Hippocratic medicine.

 This immediately renders moot the supposed “moral dilemma” the authors have posited. There may indeed be conflicts that arise as a matter of 

-ie, difficulties reconciling the legislative rationales underlying PAS and IPSCP-but no such conflicts arise within the purview of medical ethics. Indeed, we would take the authors conditional statement (“If PAD in terminal illness is permissible, [then] it should also be permissible for some who suffer from non-terminal psychiatric illness”) and counter with the claim, “If PAS is 

 morally permissible for any patients, then it is not morally permissible for those who suffer from non-terminal psychiatric illness.” This is consistent with the line of reasoning pursued by Prof Foster.

, and there is no “moral crisis” for physicians. Genuine ethical dilemmas present a choice between two equally “right” or good options. Unlike the involuntary hospitalization of suicidal patients, PAS, in our view, is manifestly wrong. In short, there is no “moral equivalence” between PAS and IPSCP; and hence, no “moral dilemma” arises for physicians who oppose PAS but support IPSCP.

Indeed, we have argued that it is morally incumbent upon physicians to oppose PAS.

That a state can legalize physician-assisted suicide, as Oregon has done, highlights the difference between what is legal and what is ethical; what the state allows [state] residents to do and what members of a given profession, in this case medicine, believe they ought to do.

Indeed, in our view, the American Medical Association’s third principle of medical ethics makes it incumbent upon physicians to oppose PAS laws: “A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.”

“Self-killing” is not the same as physician-assisted suicide

We also take issue with the way Kious and Battin

 have framed the matter of “self-killing.” They argue that, “. . . the implicit rationale for laws allowing PAD in the US is that suffering can be an adequate reason for self-killing; but this implies . . . that suffering due to mental illnesses should at least sometimes be an adequate justification for self-killing, too.”

We certainly acknowledge that psychiatric illness is often a cause of significant suffering, though we would take issue with the very broad claim that either mental or physical suffering “. . . can be an adequate reason for self-killing.” (Is 

 such suffering, even for a day or a week, adequate reason for self-killing? Is suffering that can be substantially relieved with appropriate treatment adequate reason for self-killing?). However, even if it were true that “. . . suffering due to mental illnesses should at least sometimes be an adequate justification for self-killing . . .” it would hardly follow that physicians are acting ethically when they 

in a patient’s self-killing (suicide). Rather, it is our calling as physicians to do all in our power to offer help and give hope to distressed and suffering patients who seek to end their lives.

“Self-killing” (suicide), of course, has occurred in many forms for all of recorded human history. In contrast, physician-assisted suicide is a relative newcomer to medical ethical discourse and is largely contemporaneous with the “

 Self-killing per se has nothing fundamentally to do with the ethics of 

 self-killing. On the contrary: a core ethos of psychiatry is to help people find a path to a better future; mobilize their support systems; and provide other resources to fortify hope. Psychiatry can also play a unique role in helping patients requesting PAS find meaning in their suffering.

 Unfortunately, most PAS laws do not require mental health professionals as part of the initial evaluation process; hence, the unique skill set of psychiatrists is rarely deployed in behalf of the suicidal patient.

For similar reasons, the issue of the patient's “autonomy” raised by Kious and Battin

 proves to be a red herring. For example, they write that, “. . . respect for autonomy is an important part of the justification for the [PAS] laws in Hawaii and other states. . .” But once again, we must distinguish between what underlies 

. Furthermore, even if some notion of “autonomy” led to the conclusion that mentally competent patients ought to be 

 to end their own lives-for example, via VSED

-it would by no means follow that physicians ought to be involved in prescribing lethal drugs to patients who want to end their lives. Nor would such a notion of unimpeded personal liberty amount to a “right” to assisted suicide at the hands of physicians-a right the US Supreme Court (USSC) has said does not exist (eg, in 

, 80 F.3d 716 [2d Cir. 1996]). As the USSC pointedly noted, “The distinction between 

. . . it is clear that the justification for PAD laws in the US, as elsewhere, depends in large part on the recognition that suffering-whether due to painful sensations or to the loss of dignity, self, or independence-can sometimes be an adequate reason to end one’s own life, and that persons who suffer severely because of a terminal physical illness and who retain decision making capacity 

This line of argument radically mistakes the ethical question 

. It is not a question of whether suffering patients “should be allowed to pursue” physician-assisted suicide; clearly, a few states (Oregon, California, etc.) have ruled that they should be. (That PAS is legal in these states does not mean that it is ethically sound or good social policy). Rather, the question is whether physicians are ethically justified 

, the patient’s pursuit of assisted suicide. We say the answer is no, consistent with the numerous professional medical organizations cited above. As Dr Leon Kass

The legalization of physician-assisted suicide [perverts] the medical profession by transforming the healer of human beings into a technical dispenser of death. For over two millennia the medical ethic . . . has held as an inviolable rule, ‘Doctors must not kill.’ The venerable Hippocratic Oath clearly rules out physician-assisted suicide. Without this taboo, medicine ceases to be a trustworthy and ethical profession . . .

Indeed, we would go further and argue that there is very little 

 difference between handing the patient a lethal prescription and handing him or her a loaded gun. (The differences are mainly instrumental and esthetic). Neither action comports with the ethics of Hippocratic medicine. Both shred the fabric of medical ethics beyond repair. Both constitute what Foster

 rightly calls “a distortion of the doctor-patient relationship.”

 suicide-we do not provide it. In the words of Dr Leon Kass,

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

Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics & Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor-in-Chief Emeritus of 

). Dr Hanson is Director of the Forensic Psychiatry Fellowship at the University of Maryland. Dr Komrad is on the psychiatry faculty of Johns Hopkins, University of Maryland, and Tulane University. Dr Geppert is Professor of Psychiatry and Medicine, and Director of Ethics Education, University of New Mexico School of Medicine; and Ethics Section Editor of 

The Danger of Assisted Suicide Laws. Part of the Bioethics and Disability Series. National Council on Disability. October 9, 2019. 

Response to Open Peer Commentaries on “Physician Aid-in-Dying and Suicide Prevention in Psychiatry.”

2. Pies RW. Brittany Maynard and the loose language of suicide. 

https://www.medscape.com/viewarticle/835014

3. Pies R. Assisting Suicide is Not Assisting Nature. 

https://pro.psychcentral.com/assisting-suicide-is-not-assisting-nature

Kious and Battin’s Dilemma Resolved: Outlaw Physician Aid-in-Dying

Why Physicians Should Oppose Assisted Suicide.

Leading a Worthy Life: Finding Meaning in Modern Times. A Dignified Death and Its Enemies: Why Doctors Must Not Kill

7. Bruce SD, Hendrix CC, Grentry JH. Palliative sedation in end-of-life care. 

8. Sulmasy LS, Mueller PS. Ethics and the Legalization of Physician-Assisted Suicide: An American College of Physicians Position Paper. 

9. WMA Statement on Physician-Assisted Suicide. 

 February 21, 2019. https://www.wma.net/policies-post/wma-statement-on-physician-assisted-suicide. Accessed October 22, 2019.

10. Position Statement on Involuntary Hospitalization of the Mentally Ill (Revised). 

11. Testa M, West SG. Civil commitment in the United States. 

12. Physician-Assisted Suicide Fast Facts. CNN. August 1, 2019. 

https://www.cnn.com/2014/11/26/us/physician-assisted-suicide-fast-facts/index.html

13. Pope Thaddeus. 2018. Legal History of Medical Aid in Dying: Physician Assisted Death in U.S. Courts and Legislatures. 

https://open.mitchellhamline.edu/cgi/viewcontent.cgi?article=1433&context=facsch

14. Schadenberg A. In the Last Ten Years, at Least Nine U.S. States Have Strengthened Their Laws Against Assisted Suicide/Euthanasia. 

http://alexschadenberg.blogspot.com/2019/04/in-last-ten-years-at-least-nine-us.html

15. H. Rept. 105-46 - Assisted Suicide Funding Restriction Act of 1997. 

https://www.congress.gov/congressional-report/105th-congress/house-report/46/1

16. H.Con.Res.80 - Expressing the sense of the Congress that assisted suicide (sometimes referred to as death with dignity, end-of-life options, aid-in-dying, or similar phrases) puts everyone, including those most vulnerable, at risk of deadly harm and undermines the integrity of the health care system. 

https://www.congress.gov/bill/115th-congress/house-concurrent-resolution/80/text

17. Patients Rights Council. Issues (United States). 

http://www.patientsrightscouncil.org/site/laws-issues-by-state

 Washington, DC: American Psychiatric Press; 2007.

19. Komrad MS, Pies RW, Hanson AL, Geppert CMA. Assessing Competency for Physician-Assisted Suicide Is Unethical

20. Lagay F. Physician-Assisted Suicide: The Law and Professional Ethics. 

https://journalofethics.ama-assn.org/article/physician-assisted-suicide-law-and-professional-ethics/2003-01

21. American Medical Association. AMA Code OF Medical Ethics. 

https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/principles-of-medical-ethics.pdf

Physician-Assisted Suicide and the Rise of the Consumer Movement

23. Ganzini L, Goy ER, Miller LL, et al. Nurses’ experiences with hospice patients who refuse food and fluids to hasten death. 

24. State may ban physician-assisted suicide - Vacco v. Quill, 117 S. Ct.  2293 (U.S. 1997). 

https://biotech.law.lsu.edu/cases/pro_lic/Vacco_v_Quill.htm

https://www.firstthings.com/article/1996/08/dehumanization-triumphant

Physician-assisted suicide violates the norms of Hippocratic medical ethics. Involuntary hospitalization to prevent suicide affirms those norms, according to the authors.

It is interesting that some of the thorniest ethical dilemmas in psychiatry evolve around food: 

 in anorexia nervosa, artificial nutrition and 

 at the end of life, and the subject of the 

-the covert administration of psychotropic medications.

Here is a brief recap of the case to reorient us before we turn to the quiz answers and commentary. Mr. B, an 85-year-old with vascular dementia, had been transferred to an acute geropsychiatric unit. Mr. B was admitted for psychiatric stabilization after he became aggressive toward residents at the dementia care facility where he has resided since his daughter, who is also his medical power of attorney, could no longer safely manage him.

Initially, the patient responded well to valproic acid and was about to be discharged back to the facility when he began to refuse the drug. His behavioral disturbances rapidly returned and required several emergency administrations of antipsychotics. When none of the environmental and behavioral techniques the team tried could persuade Mr. B to take the mood-stabilizing medication, the pharmacist suggested covert administration in applesauce. The treatment team was sharply divided on whether such 

 of the medication was ethical and requested an ethics consult to assist them.

Readers were asked to imagine they were the ethics consultation team leader and to work through a series of 4 questions about the case. There were some very perceptive comments online that I will try to incorporate into the commentary.

1. When reviewing the case summary the attending has prepared, the opinion of the psychologist seems most consistent with which major ethical theory?

Clinicians, including myself when I am not wearing my ethics hat, often think ethicists spend way too much energy on ethical theories that often seem the secular equivalent of analyzing how many angels can dance on the head of a pin. We should instead just get about the business of doing what is best for the patient. Yet determining what is best is often surprisingly difficult: ethical theory, like changing the lens in your glasses, can often help us see aspects of the ethical concern previously not appreciated, such as the view of the psychologist. The answers offer a mini-tour of ethical theory.

 For the consequentialist theories of which utilitarianism is the most well-recognized branch in health care, the outcome of an act or rule is determinative of what is best. In each situation, what is right or good is the action or decision bringing about the most happiness or health for the most people. Covert administration of valproic acid will quell the agitation that is keeping Mr. B from being discharged to his care facility, which is after all what his daughter and the treatment team both want to happen. This theory best characterizes the view of the psychiatric pharmacist.

 Deontologists often take positions diametrically opposed to utilitarianism, and that is the situation here. Deontology comes as close to endorsing absolute values as any theory. The psychologist, although he would likely not use the word, is a deontologist. The theory supports the psychologist in his moral claim that the duty to tell the truth outweighs any other ethical principle.

There is another layer though to the psychologist’s argument, and it is a bit of word play on “categorical.” Immanuel Kant, the founder of deontology, formulated the categorical imperative, one version of which is a philosophical restatement of the golden rule.

 Since no human being wishes to be lied to, the psychologist is arguing that Mr. B does not lose his human dignity when he receives a diagnosis of dementia.

 Aristotle’s virtue theory finds the good and right in the character and conduct of exemplary human beings. This is a favored theory among clinicians because we all can easily recognize a “good doctor or nurse.” Yet there are in our scenario no real obstinate villains but only uncertain heroes searching for the cleanest way to promote Mr. B’s welfare.

 Principlism would consider the big 4 ethical principles of autonomy, nonmaleficence, beneficence, and justice and through a process of weighing and specifying arrive at the optimal resolution of the dilemma. But such a process requires prioritization, and the nurses see not doing harm as most important, the pharmacist as doing good through managing the behavioral disturbances, and the psychologist as respecting the patient’s autonomy. So, while we have succeeded in identifying the salient values, we are no closer to knowing which one prevails in the case.

2. This question underscores the need to involve the daughter in the discussion and to clarify her authority to make the decision.

Those who commented on this question on the website hit the target when they asked, “Where is the daughter in all this, and what can she do?” To which the various answers explicated below offered answers.

 Before losing capacity, Mr. B named his daughter as what is technically called the health care agent (HCA) in his durable power of attorney for health care. This gives the daughter the legal right and responsibility to make the decisions about covert administration on behalf of her father in some states.

 This answer speaks deontological language: the daughter, even if she has the legal authority, does not have the moral authority to consent for a human being to be intentionally deceived.

 In many but not all jurisdictions, the daughter as in option A would have the authority to provide informed consent on her father’s behalf to the administration of covert medications. However, in some states, consent for psychotropic medications is reserved to a court-appointed conservator of treatment guardian or even the court itself. Dementia bedevils practitioners and courts alike as there is no judicial or clinical consensus on whether it is a psychiatric or a neurological, or a medical disorder.

 This is a variation on option C and would be true in a state where an HCA does not have the legal sanction to provide consent for psychotropic medication and conversely the court-appointed treatment guardian may not always be able to make medical decisions.

 The warrant for the judicial bifurcation is that psychiatric treatment requires a higher level of protection because of the vulnerability of the patient and the risks of the intervention, which is analogous to the more rigorous standard often required in 

3. Those experts who contend that surreptitious administration can be an ethical option specify conditions that must be met for the practice to be justified.

Question 3 assumes the daughter is empowered to provide informed consent for surreptitious medication and asks what ethical qualifications the consultant should stipulate. The answers were phrased in the negative, so readers were asked to pick which of the 4 listed choices should not be included.

 As with any treatment, the decision to administer the medication covertly should not be open-ended or unsupervised. The rights and welfare of the patient require that effectiveness of valproic acid in reducing the behavioral disturbances as well as any serious adverse effects such as thrombocytopenia or distressing symptoms such as gastrointestinal distress be monitored. Both the adverse and the positive effects may well alter the risk to benefit balance that underlies the ethical acceptability of the practice.

 While-depending on hospital policy-signature informed consent may or may not be required, a written treatment agreement protects all involved by ensuring the entire team has reached consensus about this unusual means of medicating Mr. B and that the daughter as HCA is informed of and concurs with the treatment plan.

 A formal treatment plan also is a safeguard against covert administration being a treatment of convenience. The staff should continue to try to persuade Mr. B to take the mood stabilizer and continue to find any other non-pharmacological interventions that can help manage his behavior.

 This answer describes what ethicists call a “right of conscience” or “conscience clause.” Staff who from a virtue or deontological perspective truly believe it is wrong to deceive any patient, even an incapable one, should probably be excused from the care of Mr. B out of respect for their moral beliefs. However, this recusal depends on hospital policy, ethical codes, and the pragmatic consideration of staffing.

4. This question comes back to the ethics consultant who having heard the ethical concerns of all the stakeholders must now make a recommendation. As a prelude to this, he considers the arguments and counter-arguments. Question 4 asks readers to identify the strongest of the latter.

 There is a consensus in law and ethics that in a true emergency that endangers a patient, other patients, or staff, psychotropic medication can be administered over the objections of a patient.

 The risk of course is that staff out of fear, burnout, or convenience will “find” or worse “provoke” the emergency. For this reason, many states require the permission of the court to administer antipsychotic medication on any regular basis against the will of the patient or his or her ethically appropriate decision maker. The nurses also have a humanistic point that holding Mr. B down and jabbing a needle in his arm is more painful and degrading than is sprinkling medication on his pudding.

 While beleaguered staff in taxing situations acting out of soft paternalism often question the motives of family members, there is no evidence in the case scenario that the daughter wants anything other than her father’s well-being. She refuses to consent to antipsychotics. As one astute reader pointed out, 

 is not a benign drug and for real informed consent this would need to be stressed.

Argument C is one of the strongest arguments in favor of covert administration of medication, as it has a track record of getting Mr. B back to the neuropsychiatric baseline where he can return to live in his nursing facility. The caveat being, as readers stated, that he may be given even more psychotropics in that setting without any of the due process protections the ward is utilizing.

 This option takes the long and most deontological and virtue theory view of the decision. Despite his dementia, Mr. B may well grasp that he is being “fooled” and become even more resistant to treatment and, more importantly, distrustful of not just the staff, but of his daughter when a nursing assistant, as frequently happens, tells him that his daughter consented to the deception.

When I was in training, one of my teachers told me, “We will all end up being geriatric psychiatrists,” and he was prescient. As the population, including us clinicians, ages-and sans the miracle cure or preventive for dementia we all hope to see-dilemmas like this one will increasingly be encountered, which is one reason ethical theory will always have a place in ethical deliberations.

Dr. Geppert is Professor of Psychiatry and Director of Ethics Education, University of New Mexico School of Medicine; and Chief, Consultation Psychiatry and Ethics, New Mexico VA Health Care System, Albuquerque, NM.

Some of the thorniest ethical dilemmas in psychiatry evolve around food: forced feeding in anorexia nervosa, artificial nutrition and hydration at the end of life, and the covert administration of psychotropic medications

Author | Cynthia M. A. Geppert, MD, MPH

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