Madelyn Hsiao-Rei Hicks, MD, MRCPsych

I am an adult psychiatrist who has worked in public sector psychiatry in the US and the UK. In both countries, physicians struggle with the ethics and professional meaning of legalized or proposed physician-assisted suicide (PAS). I was recently asked by an organization to host a CME course titled “Best Practices in the 

.” Passed in 2016, the Act legalized the practice of PAS in California.

Thank you very much for your invitation to join in providing a CME about “Best Practices in the End-of-Life Options Act.”

I understand and appreciate your wish to institute best medical practices in the context of the very serious and complex ethical and legal issue of PAS.

At one point in my 14 years of examining and writing about PAS and euthanasia, I thought that, even though I found PAS to be unethical, in situations where it became legal, perhaps the best that psychiatrists and other physicians could do would be to provide thorough assessments and treatment options for individuals requesting PAS.

However, as I continued to weigh and evaluate the ethics of PAS, analyzing the logic, sociocultural context, and history of medical ethics has led me to this opinion: To facilitate an unethical practice-even with the best of intentions, even if legal, and even if one does a little good in the process-is to be unethical. Here are the logical arguments that point me to this conclusion:

Does making something legal make it ethical?

Medical ethics is not based on legality. The death penalty is legal in some states, yet it is recognized as unethical for doctors to participate in executing prisoners, even if the prisoner requests a doctor to assist by administering a drug.

 are legal, or have been legalized, yet it is recognized that it is unethical for physicians to participate in the process of torture, even indirectly. If doctors are required by law to do something unethical, that does not make it ethical.

, doctors could make prisoners more comfortable and administer a more peaceful death, but they would still be participating in execution, and so this is recognized as unethical. Doctors have been used in torture in attempts to extract information for “the greater good,” and to treat and assess victims so as to prevent the individuals from dying during the torture process. In these circumstances, it is still considered unethical for physicians to take part in the torture process.

In PAS, the data from multiple nations and states show that doctors being part of a PAS/euthanasia process (including safeguards), does not prevent the act from being administered to individuals who lack capacity, who are treatable, or who otherwise do not meet criteria for PAS.

This is a relatively recent sociocultural imperative in public discourse. Proponents of PAS apply it with bias, selectively ignoring that:

• A value or preference is not a right.

• Autonomy is control over one’s own body, choices, and life (eg, suicide or living; accepting or declining treatment).

• Autonomy is not making or coercing others to do what one wants (ie, taking away another person’s autonomy by requiring them to provide you with lethal substances to die or requiring them to kill you if you choose).

• Physicians also have a right to autonomy as individuals and to practice according to the basic, long-standing ethics of their profession.

Let’s turn autonomy on its head to make this social variable clearer: What if “Solidarity” or “Utility” became the sociocultural imperative, as has also happened in societies? Would it then become ethical for physicians to provide or to administer lethal means with the goal of death to individuals who disrupt the social fabric or who are a burden to their families or to society? The fact that PAS/euthanasia is currently being considered an “exception” to the ethical principle that doctors should not kill patients should be a warning sign of its incompatibility with ethical practice.

Are physicians necessary for assisted suicide or assisted death?

The answer is no. There is very little physical or intellectual skill needed in the act of providing a standardized prescription of a lethal dose or in pushing a plunger for an injection. The great and complex skills of medicine are in preventing death and in maximizing health as individuals pass through manifold illnesses in their lives.

The fact that assisted suicide is being channeled through physicians shows that there is societal ambivalence with the act, as with death itself. We enable society to avoid ambivalence by normalizing and participating in assisted suicide.

We lead by example. When there are ethical dilemmas and conflicting pressures on physicians’ choices, younger and more junior physicians generally follow the examples set by leaders in their field. Leaders not only set the norm, but they set the aspirational standard.

Perhaps we simply disagree on whether or not it is ethical for physicians to participate in PAS. However, if you believe that PAS is unethical or against the interests of patients’ health, then I hope your example to early-career or uncertain physicians will be to behave ideally as a physician faced with a professional, ethical conflict, even in the face of a complex legal situation.

I am sure that you have also wrestled with these very difficult issues. For my part, I must decline your invitation because I think that if I provided CME education on how to comply with the End-of-Life Options Act, I would become complicit in the PAS process and in normalizing something that is unethical for us all.

This piece represents solely the views of the author and not necessarily those of 

the University of Massachusetts, or its affiliates. 

[The letter has been edited for style and clarity. -Ed]

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Just because something is legal does not make it ethical, in the opinion of this psychiatrist, who turned down an invitation to be a presenter on the topic of PAS.

Madelyn Hsiao-Rei Hicks, MD, MRCPsych

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