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. Also see: Psychiatrists Must Prevent Suicide, Not Provide It.
In an influential paper, psychiatrist-ethicist Brent M. Kious, MD, PhD, and philosopher-ethicist Margaret P. Battin, PhD,1 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 euphemism for physician-assisted suicide2,3—is exposed as inconsistent with the values of Hippocratic medicine.
Moral dilemmas in medical ethics
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 legal 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 Foster4 rightly observes that Kious and Battin conflate “. . . the different functions of law and ethics.”4 If, as we and others argue, PAS is ethically impermissible there is no moral dilemma for physicians.5,6[pp202-227] As Prof Foster4 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.”4
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.7 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.8,9 But this is clearly not 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.10 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 end 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 all US states. IPSCP laws are grounded in the two principles of parens patriae (the authority of the state to protect persons legally unable to act on their own behalf) and the “police power” of the state.11 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.12
Indeed, almost all states criminalize assisted suicide, and six states specifically outlaw assistance of suicide by physicians.13 Furthermore, in the last ten years, at least nine US states have strengthened their laws against assisted suicide/euthanasia.14 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;15 and, in 2017, the US House of Representatives introduced a resolution condemning PAS.16 Finally, it is notable that legislative initiatives to legalize PAS have failed more than 125 times in 50 states since 1995.17
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 long-term civil commitment. 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.18[pp120-121]
1. Kious BM, Battin MP. Response to Open Peer Commentaries on “Physician Aid-in-Dying and Suicide Prevention in Psychiatry.” Am J Bioeth. 2019;19:W14-W17.
2. Pies RW. Brittany Maynard and the loose language of suicide. Medscape. November 19, 2014. https://www.medscape.com/viewarticle/835014. Accessed October 22, 2019.
3. Pies R. Assisting Suicide is Not Assisting Nature. Psych Central Professional. Apr 25, 2017. https://pro.psychcentral.com/assisting-suicide-is-not-assisting-nature. Accessed October 22, 2019.
4. Foster C. Kious and Battin’s Dilemma Resolved: Outlaw Physician Aid-in-Dying. Am J Bioeth. 2019;19:50-51.
5. Yang T, Curlin FA. Why Physicians Should Oppose Assisted Suicide. JAMA. 2016;315:247-248.
6. Kass LR. Leading a Worthy Life: Finding Meaning in Modern Times. A Dignified Death and Its Enemies: Why Doctors Must Not Kill. New York: Encounter Books; 2017.
7. Bruce SD, Hendrix CC, Grentry JH. Palliative sedation in end-of-life care. J Hosp Palliat Nurs. 2006;8:320-327.
8. Sulmasy LS, Mueller PS. Ethics and the Legalization of Physician-Assisted Suicide: An American College of Physicians Position Paper. Ann Intern Med. 2017;167:576-578.
9. WMA Statement on Physician-Assisted Suicide. World Medical Association. February 21, 2019. https://www.wma.net/policies-post/wma-statement-on-physician-assisted-su.... Accessed October 22, 2019.
10. Position Statement on Involuntary Hospitalization of the Mentally Ill (Revised). Am J Psychiatry. 1973;130:392.
11. Testa M, West SG. Civil commitment in the United States. Psychiatry (Edgmont). 2010;7:30-40.
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. Accessed October 22, 2019.
13. Pope Thaddeus. 2018. Legal History of Medical Aid in Dying: Physician Assisted Death in U.S. Courts and Legislatures. New Mexico Law Review. https://open.mitchellhamline.edu/cgi/viewcontent.cgi?article=1433&context=facsch. Accessed October 22, 2019.
14. Schadenberg A. In the Last Ten Years, at Least Nine U.S. States Have Strengthened Their Laws Against Assisted Suicide/Euthanasia. Euthanasia Prevention Coalition. April 3, 2019. http://alexschadenberg.blogspot.com/2019/04/in-last-ten-years-at-least-nine-us.html. Accessed October 22, 2019.
15. H. Rept. 105-46 - Assisted Suicide Funding Restriction Act of 1997. https://www.congress.gov/congressional-report/105th-congress/house-report/46/1. Accessed October 22, 2019.
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. Accessed October 22, 2019.
17. Patients Rights Council. Issues (United States). http://www.patientsrightscouncil.org/site/laws-issues-by-state. Accessed October 22, 2019.
18. Simon RI, Shuman DW. Clinical Manual of Psychiatry and Law. Washington, DC: American Psychiatric Press; 2007.
19. Komrad MS, Pies RW, Hanson AL, Geppert CMA. Assessing Competency for Physician-Assisted Suicide Is Unethical. J Clin Psychiatry. 2018;79(6).
20. Lagay F. Physician-Assisted Suicide: The Law and Professional Ethics. Virtual Mentor. 2003;5:17-18. https://journalofethics.ama-assn.org/article/physician-assisted-suicide-law-and-professional-ethics/2003-01. Accessed October 22, 2019.
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. Accessed October 22, 2019.
22. Pies RW. Physician-Assisted Suicide and the Rise of the Consumer Movement. Psychiatric Times. 2016;33(8).
23. Ganzini L, Goy ER, Miller LL, et al. Nurses’ experiences with hospice patients who refuse food and fluids to hasten death. N Engl J Med. 2003;349:359-365.
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. Accessed October 22, 2019.
25. Kass LR. Dehumanization triumphant. First Things. August 1996. https://www.firstthings.com/article/1996/08/dehumanization-triumphant. Accessed October 22, 2019.