is a forensic psychiatrist at Cherry Hospital in Goldsboro, North Carolina.

Joshua Pagano, DO

(In honor of Women’s History Month, we invited our contributors to write about the women who inspire them.—Ed.)

I am proud to work with Holly Manley, PhD, at Cherry Hospital, a state-operated psychiatric facility. In her roles as both a forensic evaluator and the forensic coordinator, Dr Manley has demonstrated a quality of being a Jill of all trades and master of some. She shifts seamlessly between coordinating with treatment teams, coordinating with attorneys, and testifying in court regarding her expert opinion about a defendant’s capacity to proceed. She does all this regardless of whether or not she is pregnant, has COVID-19, or receives an equal salary that acknowledges her worth.

I will not perpetuate patriarchal oppressive forces here by glorifying all the self-sacrifice Dr Manley has made. Self-sacrifice is part and parcel of a system that does not value families and makes life so difficult for working mothers trying to raise the next generation while receiving less pay and less administrative support than their male counterparts.

Therefore, the qualities that I will acknowledge are her leadership and her tenacity. Dr Manley leads by example. She has an open-door policy. This puts her in the know about her colleagues’ strengths, weaknesses, and needs. Her consistency makes her a safe space. Staff across many departments count on her. They feel safe in the knowledge that she can handle any situation. I have seen her increase morale by simply walking into the room.

And where does her consistency come from? Her tenacity. Her iron will. Her inner compass. The system will not reward her for her skills, her work ethic, or her level of impact—but she carries on anyway. She stays true to herself. In a world run by carrots and sticks, Dr Manley has tapped the perpetual motivation of becoming the best version of herself every single day. That kind of resolve inspires hope—hope that, even in a rigid patriarchal system built on a foundation of inequity, individuals can still live in the power of authenticity with the knowledge that every true word is a victory.

Articles

This mother and leader is an inspiration. 

A Jill of All Trades

I would like to thank Ronald Pies, MD, for his response, “

Physician-Assisted Suicide: An Egregious Boundary Violation

 It is truly quite a compendium of critiques against physician-assisted suicide. I am not going to rebut his arguments point by point. I respectfully acknowledge that such arguments have been ongoing throughout history.

There are well-documented, strong arguments on both sides. For example, Lydia S. Dugdale, MD, and colleagues

 provide an excellent and succinct summary of positions both for and against physician-assisted suicide. Briefly, they describe how respect for patient autonomy and the compassionate relief of suffering are major arguments in favor of physician-assisted suicide and how unintended harm through suicide contagion and the slippery-slope argument are commonly raised to refute physician-assisted suicide.

 I know Dr Pies is well aware of these arguments. What I am interested in is exploring our common ground.

Is “Death with Dignity” Really Possible?

Medical Aid in Dying Allows for a Focus on Living


Part of Dr Pies’ conclusion states, “Physicians should rededicate themselves to securing state-of-the-art palliative care and supportive counseling for terminally ill patients.”

 I am in complete agreement on this point. In fact, I believe that Dr Pies and I already agree on many points. I absolutely agree we must improve access to care so that everyone receives high-quality health care. I absolutely agree we must treat all underlying mental illnesses and medical conditions. I absolutely agree we must provide pain management. I absolutely agree we must provide relevant psychotherapy and grief counselling. We should also pursue all relevant consultations, hire a death doula, and have conferences with the family and friends. We absolutely should give patients the option to choose to voluntarily stop eating and drinking (VSED). We should provide them with all possible options. And after being provided all the options and receiving all the treatments, I believe there is the patient who will legitimately choose medical aid in dying.

This person is currently invisible in the majority of states across our country. The first step is to acknowledge that they exist. To see them. To believe them. Do we share this common ground, Dr Pies? Do you acknowledge that this person exists?

1. Pies R. “Physician-assisted suicide: an egregious boundary violation.” 

. January 11, 2022. Accessed on January 13, 2022. 

https://www.psychiatrictimes.com/view/physician-assisted-suicide-an-egregious-boundary-violation

One doctor believes there are patients who will legitimately choose medical aid in dying—we just have to acknowledge them. 

Finding Common Ground in This Life 

I recently read an excellent article here called 

“Is ‘Death with Dignity’ Really Possible?”

 Ronald Pies, MD, delivered some powerful arguments that stayed with me long after I finished reading his article, and that challenged me to reconsider my own opinions about physician-assisted suicide. The following is the result of my meditation (and a fair amount of reading).



The preference of many patients with terminal illness is to pass away peacefully while surrounded by family and friends. This pastoral scene is unlikely to come true in states that discourage discussing the topic of physician-assisted suicide by making it illegal. The threat of legal actions against those who help the dying hasten their deaths is a significant deterrent.

 But perhaps most devastating is that the shadow of stigma prevents meaningful communication and closure with loved ones. The family members of those who have chosen their time and place to die with dignity describe a feeling of gratitude that they were able to be there with their lucid loved one as they gently fell asleep for the last time.


Nine states—California, Colorado, Hawaii, Maine, New Jersey, New Mexico, Oregon, Vermont, and Washington—and the District of Columbia have passed laws legalizing medical aid in dying. One in 5 Americans now has access to this option. While vocal opponents may give the misleading impression that the majority of physicians are against assisted 

, the numbers tell a very different story. For example, a 2020 Medscape survey of 5130 US doctors across medical specialties found that 55% of physicians believe that medical aid in dying should be available as an end-of-life option.

 There is even greater support among the general public. A 2018 Gallup poll found that 72% of Americans support medical aid in dying.

 Similarly, the Pew Research Center found that 68% of Americans supported “doctor-assisted suicide” in their 2015 poll.

 There is public demand for this service.

Medical aid in dying has gained momentum over the years, as many patients find it necessary to fight for the option to end their suffering. I am reminded of Brittany Maynard, who, in 2014, was diagnosed with terminal brain 

 At that time, California did not have the end-of-life option. So, Brittany Maynard moved to Oregon to die with dignity. As a consequence, California Governor Jerry Brown enacted the End of Life Option Act in 2016.

Many opponents are concerned with the possibility that physician-assisted suicide may target traditionally vulnerable populations. However, Maynard’s journey illustrates that the opposite is true—only the most privileged with the greatest resources are able to successfully obtain medical aid in dying. Al Rabadi and colleagues (2019) conducted quantitative research with a retrospective observational cohort study of all the lethal medications prescribed for medical aid in dying in Oregon and Washington from the passage of those states’ death with dignity laws until 2017.

 A demographic analysis of the 76% of patients who chose to ingest their prescribed lethal medication shows that 51% of them were male, 95% of them were white, 72% of them went to college, and 89% of them had health insurance. The speculation that physician-assisted suicide will target marginalized groups has been shown to be mistaken. As in the rest of health care, only the most privileged are accessing this service.

It is worth noting that, as with many prescriptions, after receiving their lethal prescription, a patient will not necessarily use it—indeed, many patients do not.

 Twenty-four percent of patients in Oregon and Washington chose not to take their lethal prescriptions.10 Merely having the option to use it is sufficient reassurance. The peace of mind of knowing they can choose to take it offers enormous comfort.

 One advocate, Dan Diaz, reflects, “This truly is an option. If a person has decided on their own to apply for and qualify for the prescription, then you get to focus on living life.”

The stigma surrounding both suicide and physician-assisted suicide is a challenging topic. On one hand, some of the previous efforts to distance physician-assisted dying from suicide have increased the 

, thus making suicide more difficult to discuss.

 Barriers to discussing suicidal thoughts cause people to suffer in silence, and ultimately, increase suicide attempts. Shaming people for having a mental illness is reprehensible behavior. Further stigmatizing those suffering with 

 in the context of mental illness in order to positively differentiate those with a terminal illness who desire medical aid in dying is not the way forward. We need to work to decrease stigma for all people, to improve access to care, and to prevent suicide in the context of an untreated or undertreated mental illness.

On the other hand, there is something distinctly different about the terminally ill person who is staring at the last 6 months of their life—6 months filled with loss after loss, indignity after indignity, and grief after grief, all inexorably culminating in a slow death by starvation. To conflate this wish for a physician-assisted death with the suicidal thoughts of someone suffering with mental illness invalidates the reality-based appraisal of the terminally ill patient’s very stark situation. The desire to avoid both foreseeable and inevitable suffering is rational. And finally, perhaps most undeniably, my sympathy for those who request medical aid in dying comes from within. For, I cannot in good conscience deny someone a choice that I myself would want as an option under the same grim circumstances.



Is “death with dignity” really possible?

. November 30, 2021. Accessed on December 3, 2021.

Getting a prescription to die remains tricky even as aid-in-dying bills gain momentum across the U.S.

. March 29, 2021. Accessed December 16, 2021.

This couple died by assisted suicide together. Here’s their story.

. March 6, 2018. Accessed December 8, 2021.

Ending the stigma around medically assisted death.

 June 4, 2019. Accessed December 8, 2021.

5. Kane L. Life, death, and painful dilemmas: ethics 2020. 

. November 13, 2020. Accessed December 8, 2021.

Americans’ strong support for euthanasia persists.

. May 31, 2018. Accessed December 8, 2021.

California legalizes assisted suicide amid growing support for such laws.

 Pew Research Center. October 5, 2015. Accessed December 8, 2021.

. November 2, 2014. Accessed December 8, 2021.

This terminally ill man says California’s aid-in-dying law means he can end his life ‘fully, thankfully and joyfully.’

. August 3, 2016. Accessed December 8, 2021.

10. Al Rabadi L, LeBlanc M, Bucy T, et al. 

Trends in medical aid in dying in Oregon and Washington.

. February 18, 2020. Accessed December 8, 2021.

. August 28, 2015. Accessed December 8, 2021.

Overturning of California right-to-die law draws Brittany Maynard’s husband back into fight he thought he won.

. May 16, 2018. Accessed December 8, 2021.

Medically assisted dying and suicide: how are they different, and how are they similar?

The stigma surrounding both suicide and physician-assisted suicide is a challenging topic. One of our readers tackles it. 