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

 (2007-2010). Dr Pies is the author of several books. A collection of his works can be found on

Ronald W. Pies, MD

I thank Joshua Pagano, DO, for his very thoughtful and nuanced response, “

Medical Aid in Dying Allows for a Focus on Living

“Is ‘Death with Dignity’ Really Possible?”

 In essence, the response argues that physician-assisted suicide (PAS) is “…the preference of many patients with terminal illness [who wish]…to pass away peacefully while surrounded by family and friends,” and that this option provides them with “peace of mind” and “enormous comfort,” even if the patient never actually takes the lethal drug. It further asserts that “medical aid in dying has gained momentum…as many patients find it necessary to fight for the option to end their suffering…” and points to polls showing that most Americans support “medical aid in dying” or “doctor-assisted suicide.” The piece notes “…there is something distinctly different about the terminally ill person who is staring at the last 6 months of their life”—and who may be making a “rational” or “reality-based” decision to die—versus “someone suffering with mental illness.” Finally, employing a version of the Golden Rule, Pagano concludes that he could not, “…in good conscience deny someone a choice that I myself would want as an option under the same grim circumstances.”

While I appreciate Dr Pagano’s heartfelt comments, my colleagues and I reach very different conclusions on these matters, as summarized in the following paragraphs.

Voluntary Stopping of Eating and Drinking

Only a small minority of persons with a terminal disease seek a physician’s prescription for a lethal drug. Furthermore, there is no reason to believe that the only way terminally ill patients can “pass away peacefully while surrounded by family and friends” is to ingest a lethal dose of barbiturates. For thousands of years, dying human beings have managed to die peacefully in the embrace of family and friends without recourse to “Death with Dignity” legislation. And, as I noted in my article, terminally ill patients may choose voluntary stopping of eating and drinking (VSED), which, according to a study involving hospice nurses, results in a more satisfactory death than seen with PAS. In fact, “…as compared with patients who died by PAS, those who stopped eating and drinking were rated by hospice nurses as suffering less and being more at peace in the last 2 weeks of life.”

The gentle, pastoral scene evoked in the response is far from assured, given current US procedures for PAS. One of the myths surrounding PAS is that it invariably provides a rapid, uncomplicated, and peaceful death. On the contrary, PAS is sometimes messy, prolonged, and uncomfortable. The person who ingests the lethal drug does not always “gently fall asleep.” Indeed, “Physicians who support [PAS] need to consider…the potential for adverse outcomes, including longer time to death than expected (up to 24 hours or more), awakening from unconsciousness, nausea, vomiting, and gasping.”

Leaving aside methodological problems with the type of polls cited (for example, the 72% figure cited in the Gallup poll dropped to 65% when the question included the words, “commit suicide”), the central question is whether medical ethics ought to be governed by polls and plebiscites—or whether there are enduring and inalienable values that guide medical practice. I would ask the following: If 65% of the American public supported the euthanization of babies born with severe birth defects, would that justify the practice? Most major medical organizations—including the American Medical Association, the American College of Physicians,

 and the World Medical Association—have consistently opposed PAS on essentially ethical grounds. Recently, the College of Psychiatrists of Ireland also registered its firm opposition to PAS.

Most requests for medical aid in dying are not made by patients experiencing untreatable pain or unbearable suffering, as data from Oregon have shown. Rather, the most common reasons for requesting medical aid in dying were loss of autonomy (97.2%), inability to engage in enjoyable activities (88.9%), and loss of dignity (75.0%).

It is not clear how genuinely rational or reality-based PAS decisions are, as Cynthia Geppert, MD, MA, MPH, MSBE, DPS, and I have discussed in our article, “

Two Misleading Myths Regarding ‘Medical Aid in Dying.

 Indeed, research has shown that some cancer patients requesting assisted suicide have subtle cognitive distortions, such as “Nobody can help me,” that are clouding their judgment.

 Thus, people who are dying may be psychologically vulnerable to coercion in ways that are not readily detected under current PAS protocols. As the College of Psychiatrists of Ireland noted, “Perceived pressures in favor of induced death can be subtle. These cannot be excluded by tests of mental capacity, such as those used in psychiatric practice.”

The issue is not, as was argued, whether it is rational to avoid foreseeable and inevitable suffering—I believe it clearly is. Rather, the issues are 1) whether physicians are morally justified in helping patients kill themselves weeks or even months before patients would otherwise die of their underlying illness; and 2) whether PAS is the only way of avoiding suffering at the end of life

 VSED is clearly an alternative to PAS that does not raise grave ethical questions for physicians, and which may result in a more peaceful death than does PAS, as noted above.

 And, contrary to a popular misconception, VSED is not starvation, since “…The body of a person who has a life-limiting illness is in the process of shutting down. They no longer require a great deal of nutrients or calories…and [do] not experience hunger or thirst in the way a healthy person does.”

Although we always aim to comfort our patients, this must be done within the constraints of sound medical practice and medical ethics. Comfort alone is not sufficient grounds for an action that may, in some important sense, be injurious to the patient—such as inducing or contributing to the patient’s death (think PAS). For example, suppose a depressed patient with chronic pain and a history of frequent 

 tells his doctor that he would find “enormous comfort” in having a large supply of oxycodone on hand “just in case I need it for pain.” This sense of comfort would hardly justify such a prescription under those conditions.

PAS does not merely allow a single individual—the patient—a choice. By legislative fiat, it entangles the physician in a bureaucratized system of assisted killing. It is true that no physician is compelled to participate directly or actually carry out PAS; however, most PAS legislation is crafted so that the refusing doctor must provide medical records to a physician who provides PAS [Annette Hanson MD, personal communication, 12/30/21]. In my view, this vitiates the first physician’s conscientious opposition to PAS and forces him or her to collude with an unethical practice.

The response states that, “Further stigmatizing those suffering with suicidal ideation 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.” I am in complete agreement on this point. This is why my colleagues and I oppose the position of the American Association of Suicidology (AAS), which has tried to draw a sharp distinction between “conventional” suicide (eg, in the context of a mental illness) and what they call “physician aid in dying.”

 It is certainly true that we can discern subtypes of suicide; eg, impulsive vs planned; underlying psychiatric disorder vs reactive/situational, etc. But suicide (self-killing) is suicide regardless of the subtype.

 Even the AAS acknowledges that there is an “undetermined amount of overlap” between the 2 categories they propose.

 We do not need a 2-tiered classification, in which there are good and bad, approved and unapproved, methods of taking one’s own life—leaving harried physicians to sort out which is which.

—one version of it, at least—seems a very decent and compassionate response. But the Golden Rule is not necessarily the best guide to medical ethics. For example, suppose we are considering the question, “Should psychiatrists be allowed to have sexual relations with their current patients?” Some might say, “Well, as a competent, consenting adult, I would want the choice of having or not having sexual relations with my psychiatrist. How, then, in good conscience, could I deny that right to someone else?” The problem, of course, is that it is a clear violation of long-established 

 for psychiatrists to have sexual relations with their patients—Golden Rule or not. It is a forbidden boundary violation.

In my view, PAS is an infinitely more egregious boundary violation, whether or not one might wish that option for oneself—and whether or not the dying patient consents to it. Indeed, a patient’s consenting to be killed does not mean a physician is ethically justified in acceding to the request.

Rather than focusing on ways to assist suicide, physicians should rededicate themselves to securing state-of-the-art palliative care and supportive counseling for terminally ill patients. In closing, I thank Dr Pagano for reflecting on these difficult issues with me, and I hope he will reconsider his position in light of this response.

is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and editor in chief emeritus of 

1. Pies R. Is “death with dignity” really possible

https://www.psychiatrictimes.com/view/is-death-with-dignity-really-possible-

Nurses’ experiences with hospice patients who refuse food and fluids to hasten death.

Beyond legalization - dilemmas physicians confront regarding aid in dying

4. Snyder Sulmasy L, Mueller PS; Ethics, Professionalism and Human Rights Committee of the American College of P. 

Ethics and the legalization of physician-assisted suicide: an American College of Physicians position paper. 

5. Baker N. Psychiatrists issue stark warning over assisted dying legislation. 

. December 20, 2021. Accessed Janaury 6, 2022. 

https://www.irishexaminer.com/news/arid-40769343.html

6. Loggers ET, Starks H, Shannon-Dudley M, et al. 

Implementing a Death with Dignity program at a comprehensive cancer center.

Two misleading myths regarding “medical aid in dying.” 

9. Hospice care guidance: nutrition at the end of life. Crossroads Hospice & Palliative Care. Accessed January 6, 2022. 

https://www.crossroadshospice.com/hospice-resources/nutrition-hydration/

10. Creighton C, Cerel J, Battin MP. Statement of the American Association of Suicidology: “suicide” is not the same as “physician aid in dying.” October 30, 2017. Accessed January 6, 2022. 

https://suicidology.org/wp-content/uploads/2019/07/AAS-PAD-Statement-Approved-10.30.17-ed-10-30-17.pdf

11. Dworkin G. Suicide, strictly speaking. 3 Quarks Daily. July 22, 2019. Accessed January 6, 2022. 

https://3quarksdaily.com/3quarksdaily/2019/07/suicide-strictly-speaking.html

12.Yang YT, Curlin FA. Why physicians should oppose assisted suicide. 

Physician-assisted suicide and the autonomy myth.

-Komrad MS, Pies RW, Hanson AL, Geppert CMA. 

Assessing competency for physician-assisted suicide is unethical. 

Articles

If a patient gives consent to be killed, is a physician ethically justified in acceding to the request?

Physician-Assisted Suicide: An Egregious Boundary Violation

” has been a part of the American Psychiatric Association’s (APA’s) 

Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry

 Known as “Annotation 7.3,” the Goldwater Rule prohibits psychiatrists from proffering diagnoses of current public and political figures who have not been professionally examined.

 More precisely, the annotation states, “… it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”

It is a seemingly straightforward statement that has not been substantially modified since its inception. However, in 2017 and 2018—in response to some psychiatrists’ concerns about the mental health of then-President Donald Trump—the APA Ethics Committee reaffirmed and tightened Annotation 7.3 by clarifying what is meant by “a professional opinion.”

Making a diagnosis, for example, would be rendering a professional opinion. However, a diagnosis is not required for an opinion to be professional. Instead, when a psychiatrist renders an opinion about the affect, behavior, speech, or other presentation of an individual that draws on the skills, training, expertise, and/or knowledge inherent in the practice of psychiatry, the opinion is a professional one. Thus, saying that a person does not have an illness is also a professional opinion.

Since 1973, the Goldwater Rule has served its original purpose of keeping psychiatrists and other mental health professionals from making flippant, speculative, and/or unverifiable inferences about the mental health of (living) public and political figures. In our view, the Goldwater Rule’s basic rationale is correct. However, ethical guidelines are not meant to remain static and fixed. Over years or decades, provisions may need to be revised or at least further delineated. Such is the case, in our opinion, with respect to the Goldwater Rule.

, “A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.”

 Accordingly, there needs to be acceptable and ethical ways for psychiatrists and other mental health professionals to opine about political and public figures on behalf of the public’s well-being and society’s greater good. Serving society and the public health does not occur in a clinician’s office—it often requires reaching out to the public via the media. And because of explosive advances in technology, the media now include cable television, radio, print, internet websites, audio recordings, video recordings, tweets, podcasts, and so many more platforms. It is through these various media outlets that psychiatrists and other mental health experts can responsibly influence and improve the community and public health.

Back in 1973, when Annotation 7.3 was adopted, only a handful of media outlets were available. Today, the media are vast and ever-present, and an expert’s opinions can be seen and heard almost instantaneously throughout the world. Having a clear understanding of what is ethically acceptable will make interacting with the media more comfortable and effective.

The public is bombarded with mountains of information and opinions on a minute-by-minute basis. Unfortunately, much of the material is inaccurate and even harmful. Misinformation and disinformation regarding mental health and mental illness now abound. Who better to provide accurate and helpful knowledge than mental health experts, whose education, training, knowledge, and expertise can be brought to bear on the prevailing public and social issues of the day?

By necessity, then, the Goldwater Rule needs to be better defined, clarified, and expanded so that it provides a clear direction for psychiatrists who want to interact ethically with the media. Building on a 2016 article by Pies,

 we propose that the following 5 categories of professional discussion and opinion be deemed ethical and specifically incorporated into a revised Goldwater Rule.

A professional opinion may explain the positive and negative effects of a specific mental disorder in a hypothetical public or political figure. For example, psychiatrists could explain how antisocial or narcissistic personality disorder might manifest in a hypothetical elected public official.

A provisional diagnosis or professional opinion regarding a (deceased) historical figure may teach us something about current public or political figures. An example would be a discussion of Abraham Lincoln’s depression or Richard Nixon’s well-documented alcohol abuse and paranoia.

A professional discussion regarding a living public or political figure may focus exclusively on publicly observable behaviors or behavior patterns that, in principle, might affect the person’s ability to perform their duties. This type of discussion would not proffer a diagnosis or reach a conclusion regarding the person’s fitness for duty, dangerousness, or ability to serve in a specific capacity. To illustrate, we offer 1 inappropriate and 1 appropriate response to a typical media- generated question:

“Senator Brown” has been observed, on several occasions, walking unsteadily in public and slurring his speech. There are persistent rumors in the lay press that Senator Brown has a drinking problem. A mental health professional is asked by a television news reporter, “Doctor, can you comment on Senator Brown’s abnormal behavior? Do you think he is an alcoholic? Is he fit to do his job?”

 “Based on his unsteady gait and slurred speech, it is my professional judgment that Senator Brown likely has a serious drinking problem. This could well impair his ability to carry out his functions as a senator and lead to some dangerous behaviors.”

 “I have not evaluated Senator Brown, so I do not want to speculate on his condition or mental capabilities. Certainly, when someone shows gait instability and slurred speech, I would want to have that person evaluated medically. The problem could be some type of intoxication, involving alcohol or some other substance. But these reported behaviors could also be consistent with a metabolic or neurologic disorder of some sort. For example, hypoglycemia and various postictal (ie, following a seizure) states may be mistaken for alcohol intoxication.

 Whether the senator’s condition—whatever it may be—would impair his ability to carry out his duties or cause dangerous behaviors would require a careful neuropsychiatric examination.”

A professional discussion may focus on the differential diagnosis of publicly observed behaviors or behavior patterns in relation to a current public or political figure. As in the previous example, a discussion could be provided by a mental health professional without diagnosing the person in question or opining on the person’s job fitness or dangerousness. Again, we provide an inappropriate and an appropriate professional response:

“Congresswoman Young” is running for president of the United States. Over the past 6 months, reports in the media have raised the question of manic-depressive illness or bipolar disorder. Reports in the lay press have cited Congresswoman Young’s extreme mood swings and intervals of abnormal speech and erratic, impulsive behaviors that have lasted for 2 to 3 days. A psychiatrist is asked by a newspaper reporter, “Doctor, can you comment on Congresswoman Young’s mood swings and erratic, impulsive behaviors? Could she have bipolar disorder, and would this render her unfit for the presidency?”

 “In my professional opinion, Congresswoman Young’s obvious and extreme mood swings; emotional lability; rapid, pressured speech; and periods of irritability all point to a diagnosis of bipolar disorder. This condition, if left untreated, could well impair her ability to function in the role of US president.”

“I have not evaluated Congresswoman Young, so I do not want to speculate on her condition or mental capabilities. When psychiatrists evaluate the behaviors you are describing, we consider a number of neuropsychiatric disorders in our differential diagnosis. For example, bipolar disorder can, indeed, be characterized by significant mood swings; emotional lability; rapid, pressured speech; and periods of irritability. But similar symptoms may be seen in several substance use disorders, such as methamphetamine use disorder, or in borderline personality disorder.

 Endocrine disturbances, such as abnormal thyroid function, or the periodic use of corticosteroids can also produce signs and symptoms that may be mistaken for a mood disorder. Only a professional evaluation can determine what is actually going on with a particular person and what degree of impairment exists.”

A discussion of specific behaviors or behavior patterns attributed to a current public figure may be related to general categories of mental disorders. For example, the constellation of repeated lying; multiple legal infractions or arrests; interpersonal manipulativeness; and lack of empathy and concern for the rights of others could be discussed in relation to certain personality disorders (eg, narcissistic personality disorder, antisocial personality disorder). Absent a professional evaluation, care must be taken to avoid implying that the public figure in question fits one of these categories. Again, mental health professionals should refrain from making a diagnosis or speculating on the job fitness or dangerousness of a living public figure.

As can be seen, there are at least 5 ways in which psychiatrists and other mental health professionals can educate, inform, and provide guidance regarding public or political figures without violating the intent and spirit of the Goldwater Rule. To better understand and implement Annotation 7.3, it would be helpful for examples of the type we have provided to be presented and discussed in the revised annotation. Once revised, the Goldwater Rule could serve as a roadmap for psychiatrists and others who have a responsibility to improve the community and better the public health as they avoid the pitfalls of “armchair diagnosis.”

Finally, it must be emphasized that the Goldwater Rule does not limit psychiatrists or other mental health professionals as private citizens from expressing political views concerning a current situation, policy, or political figure. Health care professionals may always offer their opinions as concerned citizens without characterizing their views as professional judgments.

 Indeed, our representative democracy functions best when all its citizens are active, vocal, and assertive.

 is a clinical and forensic psychologist in private practice in Birmingham, Alabama. He is also clinical associate professor in the Department of Psychology at the University of Alabama at Birmingham. 

 is professor emeritus of psychiatry and lecturer on bioethics and humanities at SUNY Upstate Medical University. He is also clinical professor of psychiatry at Tufts University School of Medicine and Editor-in-Chief Emeritus of 

 is an award-winning psychiatrist who specializes in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is retired from his tenured professorship at the Medical College of Wisconsin.

The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry

. Section 7. American Psychiatric Association; 2013. Accessed November 15, 2021.

Goldwater Rule’s origins based on long-ago controversy

. August 25, 2016. Accessed November 15, 2021. 

. American Psychiatric Association. March 16, 2017. Accessed November 15, 2021.

American Psychiatric Association Ethics Committee Opinion

. American Psychiatric Association. March 15, 2017. Accessed December 2, 2021.

Deconstructing and reconstructing the “Goldwater Rule.”

. October 7, 3016. Accessed November 27, 2021.

Do some leaders have ‘first-rate madness’?

 WBUR Radio Boston. August 25, 2011. Accessed November 15, 2021.

Latest Nixon biography portrays an isolated leader

. NPR. May 30, 2007. Accessed November 15, 2021.

Alcohol intoxication mimics: ED DDx + approach to management

. emDocs. August 30, 2017. Accessed November 15, 2021.

Affective instability as rapid cycling: theoretical and clinical implications for borderline personality and bipolar spectrum disorders

Psychiatry, “dangerousness,” and the president

. February 16, 2018. Accessed December 2, 2021. ❒

How can we better define, clarify, and expand the Goldwater Rule for ethical and effective use in today's society?

The Goldwater Rule Is Fine, if Refined. Here’s How to Do it.

The concept of some kind of “way station” between heaven and hell—or between salvation and damnation—is apparently an ancient one, going back to Biblical times. But it was not until the late Middle Ages—around the year 1200—that the Christian concept of purgatory was fully developed. As medieval history professor Clifford R. Backman, PhD, explains, purgatory was then understood as “a sin-cleansing way station where devout, but imperfect souls might be absolved of their guilt and prepared for God’s salvation.”

Theological perspectives of this sort are important for mental health professionals to understand. But there is also a psychological meaning to “purgatory” that seems well-suited to the current state of the COVID-19 pandemic. Indeed, in August of this year, psychologist David Rakovsky spoke of “pandemic purgatory” in these terms:

When you’re in pandemic purgatory, it seems that there’s no solid ground to make any plans with. We felt like there was a light at the end of the tunnel, there was a vaccine, and that most people would be taking it and we’d be out of this by now—making plans, dates, and all kinds of things. Now it seems that for the time being, we’re kind of out of traction again.

I think Rakovsky was right: After some initial optimism at the beginning of last summer, we found ourselves, by late August, in the grips of the highly contagious Delta variant. At the same time, we were blessed with safe, effective, and promising vaccines. It was not exactly hell, but it certainly was not heaven. Suspended between dread and hope, we struggled to find the right image or metaphor, often verging on cliches: “The light at the end of the tunnel”? “Circling the airport”? “Caught between a rock and a hard place”? For many, late summer was a kind of dark-shrouded borderland, with no discernible boundaries and no clear way out. I felt myself resonating with Dante Alighieri, in the first lines of his masterpiece, the 

Now, 4 months later, as winter bears down on us, we are faced with yet another assault from the Greek alphabet: the rapidly spreading Omicron variant.

 And once again, many people find themselves in that state of psychic and spiritual suspension from which no immediate exit is apparent. As Roger Cohen observed:

Uncertainty bedevils plans. Panic spreads in an instant even if, as with the Omicron variant, the extent of the threat is not yet known. Vaccines look like deliverance until they seem a little less than that. National responses diverge with no discernible logic. Anxiety and depression spread. So do loneliness and screen fatigue. The feeling grows that the COVID era will go on for years, like plagues of old.

Indeed, it seems likely we will be dealing with many evolving variants of SARS-CoV-2 for the foreseeable future. Yet this dismaying reality comes at a time of considerable medical progress in this country. While by no means a deliverance from the pandemic, several approved vaccines can avert the worst outcomes of COVID-19.

 (Sadly, many low-income countries have not been so fortunate.)

 Progress is also being made in developing oral antiviral agents that reduce the likelihood of hospitalization and death, among those already infected with COVID-19.

As psychiatrists, we need not adopt a theological perspective on purgatory, although some may be comfortable doing so. We have enough depth psychology to help our patients—and each other—deal with the pandemic’s polarities of hope and despair. First, we can recognize that many people coping with the pandemic are 

. Demoralization is related to, but distinct from, clinical depression, and is not a “disease.”

 Psychologist John F. Schumaker has defined demoralization as “an overarching psycho-spiritual crisis in which victims feel generally disoriented and unable to locate meaning, purpose, or sources of need fulfilment.”

 He goes on to explain that, when we are demoralized:

The world loses its credibility, and former beliefs and convictions dissolve into doubt, uncertainty, and loss of direction. Frustration, anger, and bitterness are usual accompaniments, as well as an underlying sense of being part of a lost cause or losing battle. The label “existential depression” is not appropriate since, unlike most forms of depression, demoralization is a realistic response to the circumstances impinging on the person’s life.

In short, demoralization is the bitter fruit of this pandemic purgatory. To help our patients and our fellow health care professionals, we need to recognize this syndrome and help guide the demoralized person back to the straight path. But to be clear: That path is likely to be different for each person, and it is not our role to choose the right path to follow. Yet there is much we can do by providing emotional support, empathy, and validation of the person’s emotional struggle. As I wrote in an 

, we can act as midwives to our patients’ inner transformation—supporting and encouraging them as they struggle to give birth, often painfully, to new meaning in their lives.

Purgatory, after all, was never conceived as a permanent state. Rather, it is a place of internal transformation and a gateway to something better.

How to face uncertainty in ‘pandemic purgatory.’

. August 24, 2021. Accessed December 15, 2021.

. Centers for Disease Control and Prevention. Updated December 20, 2021. Accessed December 15, 2021.

Across the world, Covid anxiety and depression take hold

. December 13, 2021. Accessed December 15, 2021.

We have enough Covid vaccines for most of the world. But rich countries are stockpiling more than they need for boosters

Pfizer says COVID-19 pill near 90% protective against hospitalization, death

. December 14, 2021. Accessed December 15, 2021.

Psychiatry and the dark night of the soul

. April 1, 2016. Accessed December 15, 2021.

But we can help our patients cope with the polarities of hope and despair.


We Are Still in Pandemic Purgatory

“I write entirely to find out what I'm thinking…What I want and what I fear.” ― Joan Didion

My 50th high school reunion had been postponed a full year, owing to the COVID-19 pandemic. When I got word that it was on for 2021, and an old friend and classmate contacted me, hoping I would attend, I felt an odd mix of anxiety and ambivalence. Out of the 300 or so members of the class of 1970, I had been close with only a handful. And, it would be a big trip, driving from the Boston area to my small hometown in western New York. Then there were the risks of exposing my wife and me to COVID-19, given that the proposed gala event would involve a sizeable crowd, packed into a small dance hall. In short, there were some fairly rational reasons why, in the end, I chose to skip the thing.

It was only weeks later, after gazing at dozens of emailed photos from the party, that I felt a wave of emotion wash over me. As I wrote about this unexpected reaction, I began to understand the real reason I had decided not to go to the reunion. And that insight, as Joan Didion understood, required an act of writing. Here is the short poem that helped me uncover a hidden part of myself.

Upon Viewing Photos from the High School Reunion I Did Not Attend

We were strong and sleek, ready for sex or war,

I didn’t find out until I wrote this poem…

Why I Skipped My 50th High School Reunion

The home hospice nurses were frustrated and discouraged. My 89-year-old mother, dying of uncorrected aortic stenosis, was refusing the pain medication the nurses repeatedly offered her. Years earlier, she had declined to undergo aortic valve replacement, despite my recommendation to do so. (In my family, it is praiseworthy to raise a child to be a physician, but foolish to listen to one.) Owing to a failed operation for a bowel problem, my mother was experiencing moderate, intermittent pain. But she refused repeated offers of oxycodone or morphine because, as she put it, “I want to keep my head clear.” My mother died in her own way, stoically enduring her pain, guided by her own idea of “death with dignity.”

Shortly after 9/11, the novelist Don DeLillo wrote, “Language is inseparable from the world that provokes it.” Referring to “people falling from the towers, hand in hand,” DeLillo noted, “Before politics, before history and religion, there is the primal terror.”

 I believe that the world of death and dying—even the mere imagining of it—evokes a similar primal terror in most of us; and this, in turn, provokes a linguistic response. The ubiquitous shibboleth, “death with dignity,” represents our deep-seated wish for control, comfort, and personal autonomy. That is all entirely understandable.

To see a response to this article, please see 

But over the past several decades, death with dignity has become a kind of battle cry. Owing to the lobbying and proselytizing efforts of groups promoting physician-assisted suicide—euphemistically called, “medical aid in dying”—the phrase, death with dignity, has become nearly synonymous with the deliberate ingestion of lethal drugs, prescribed for people with terminal illnesses.

 In the marketplace of ideas, other modes of dignity in dying—and more importantly, 

It is not my intent here to relitigate the heated debate over the ethics of 

 (PAS), the term adopted by both the American Medical Association

 My colleagues and I have already expressed our strong opposition to PAS in several venues.

 Rather, I want to take a deep dive into the notion of death with dignity by asking 2 main questions: First, is death with dignity even a viable concept? Second, how is the idea of a “dignified” death understood in a non-Western spiritual tradition—that of Jainism? Finally, I want to suggest that a fervent fixation on death with dignity can blind us to human values of greater depth and import.

In an extremely controversial essay published in 1974,

 renowned ethicist Paul Ramsey famously asserted, “There is nobility and dignity in caring for the dying, but not in dying itself.” Arguing from the perspective of a Christian ethicist, Ramsey insisted that:

“We do not begin to keep human community with the dying if we interpose between them and us most of the current notions of ‘death with dignity.’ Rather, do we draw closer to them if and only if our conception of ‘dying with dignity’ encompasses…the final indignity of death itself, whether accepted or raged against.”

Ramsey’s argument is complex and convoluted, but very clear in one respect: It calls attention to the “…grief over death which no human agency can alleviate.” I think Ramsey is arguing that we risk trivializing “the dreadful visage of death”—his phrase—by endowing it with a bogus aura of “dignity.” In this regard, I suspect that Ramsey would be largely in accord with the late Sherwin B. Nuland, MD, the surgeon whose book, 

remains a classic of clear-headed realism. Nuland wrote:

“...the belief in the probability of death with dignity is our, and society’s, attempt to deal with the reality of what is all too frequently a series of destructive events that involve by their very nature the disintegration of the dying person’s humanity. I have not often seen much dignity in the process by which we die. The quest to achieve true dignity fails when our bodies fail.”

Death With Dignity, Without Lethal Prescribed Drugs

Jainism is among the most ancient of the Indian religions, dating to at least the 7th–5th century BCE.

 Jainism is probably best known for its concept of 

defined as non-injury to all living creatures. Less familiar to most in the West is the Jain practice of 

“Sallekhana is embracing the death voluntarily when both householders and ascetics foresee that the end of the life is very near, either due to the old age, incurable disease, severe famine, attack from the enemy or wild animal, etc. At such time, one overcomes all the passions and abandons all the worldly attachments by observing austerities such as gradually abstaining from the food and the water and simultaneously meditating on the true nature of the Self until the soul parts the body.”

From the Jain perspective, Sallekhana is distinct from suicide in that, “Contrary to the suicidal intention, there is no desire to put an end to life quickly by some violent or objectionable means…” Rather, “…The person adopting this vow [of Sallekhana] wants to be liberated from the bondage of 

 [the cosmic principle of causation] which has been responsible for all his ills in this world, and [from] the cycle of rebirths…”

Is Sallekhana an example of death with dignity? Some would say so—but the Jain view is that Sallekhana represents “a person’s ethical choice 

 (italics added). I will come back to the life-with-dignity theme shortly. The main point for now is that, in marked contrast to PAS, Sallekhana is largely an 

practice, requiring no assistance from a medical professional legally authorized to dispense lethal drugs.

Sallekhana’s secular counterpart is called voluntarily stopping eating and drinking (VSED). Though far from a quick and easy way of dying, VSED is widely recognized as an ethical and compassionate option in end-of-life care—provided the patient and family are adequately prepared and emotionally supported.

 In some instances, VSED is used in conjunction with palliative sedation.

 Importantly, in one study comparing VSED to PAS, “…as compared with patients who died by physician-assisted suicide, those who stopped eating and drinking were rated by [hospice] nurses as suffering less and being more at peace in the last 2 weeks of life.”

Life With Dignity: An Important Ethical Value

I paid tribute to an Englishwoman, Hilary Lister, who died at the age of 46 after a long voyage of pain, endurance, and courage.

“Ms. Lister was relegated to her couch for years by a degenerative disease that rendered her immobile from the neck down and left her in near-constant pain. At one point, the agony and tedium became too much to bear, and she resolved to end her life. ‘I had been a very active person as a child,’ she told The Sunday Telegraph of London in 2008. ‘I did sport. I played the clarinet. I went to Oxford University and studied biochemistry, and yet at that point, I not only couldn’t do anything, but I was also in terrible pain…I just couldn’t see the point in continuing, really.’ Then a friend persuaded Ms. Lister to come sailing, and she found a reason to live.”

Over the years, Lister became an adept sailor who could navigate sailboats using mechanisms similar to those that control electric wheelchairs. Most remarkably, in 2005, Lister became the first quadriplegic person to sail alone across the English Channel, and later, to circumnavigate Britain entirely on her own. Throughout her many years of sailing, she endured almost unimaginable physical challenges. Nevertheless, she described how sailing renewed her sense of pleasure in life, saying, “It was as if I was free.”

 In 2018, she died in the hospital with her husband, Clifford, at her side.

, even in the face of profound suffering and incapacity. Her physical and spiritual odyssey—and her rejection of suicide—is a bold rejoinder to the death with dignity movement. The philosopher Michel de Montaigne (1533-1592) expressed a similar sentiment, shifting our perspective from dignity-in-death to 

“Philosophy commands us to have death always before our eyes, to foresee it and to reflect upon it in advance…[but] if we have not known how to live, it is wrong to teach us how to die…If we have known how to live steadfastly and calmly, we shall know how to die in the same way…Life should contain its own aim, its own purposes; its proper study is to regulate itself, guide itself, and endure itself…”

To be clear: Admiration for Lister’s fierce will to endure should not be construed as condemnation of people who take their own lives. Our role as psychiatrists is to understand what drives people to that tragic end, and to offer our best services in behalf of preserving their lives. And, to be sure, we have good reason, while we are healthy, to put our affairs in order; to stipulate what medical interventions we do or do not desire, should we be nearing death; and to exercise our right to discontinue futile treatments that merely prolong dying.

So, finally, is there such a thing as death with dignity? If there is, I believe it consists of facing death with courage and equanimity. Here again, we benefit from Montaigne’s plain-spoken wisdom: “I want death to find me planting my cabbages, neither worrying about it nor the unfinished gardening.”

As for dignity itself, I have resisted offering a clear definition of the term, because it has been used in so many different ways throughout history.

 On one level, dignity may be understood as the value each human being possesses merely by virtue of being human. On the existential and spiritual level, I believe that dignity is an outgrowth of how we live each day. It emerges from the moral choices we make; from our acts of courage, kindness, and forgiveness; and from the beneficial contributions we make to our family, our loved ones, and society. Dignity grows in us when we “live steadfastly and calmly.” And dignity in death—if such a thing exists—is far less central to our humanity than dignity in life.

The philosopher Baruch Spinoza (1632-1677) put it this way: “The free person thinks least of all of death, and his wisdom is a meditation not on death, but on life.”

. December 21, 2001. Accessed November 15, 2021.

Physician assisted suicide: code of medical ethics opinion 5.7

4. Snyder Sulmasy L, Mueller PS; Ethics, Professionalism and Human Rights Committee of the American College of Physicians. 

Ethics and the legalization of physician-assisted suicide: an American College of Physicians position paper

5. Geppert CMA, Komrad MS, Pies RW, Hanson AL. 

Psychiatrists must prevent suicide, not provide it

. November 18, 2019. Accessed November 15, 2021.

6. Pies RW, Komrad MS, Geppert CMA, Hanson A. 

. July 8, 2021. Accessed November 15, 2021.

7. Pies RW, Hanson AL, Komrad MS, Geppert CMA. 

PAS versus involuntary commitment: is there a moral dilemma?

. October 28, 2019. Accessed November 15, 2021.

The indignity of ‘death with dignity.’

Has this slogan crowded out the importance of life with dignity?