Assisted Suicide Should Not Be Provided by Physicians: A Response to H. Steven Moffic, MD

motortion/AdobeStock

FROM OUR READERS

I appreciate H. Steven Moffic, MD’s reflections regarding his personal choice of possibly receiving assisted suicide in his future. However, as Dr Moffic graciously referenced in his piece, I have published here several times,^1-3 arguing that systematic legalization and institutionalization of physician-assisted suicide and medical euthanasia is neither good medical ethics, nor good public policy. I want to make the point in response to Dr Moffic that suicide is generally legal in most places, and there are ways of ending one’s life (eg, voluntary stopping of eating and drinking⁴) that do not involve the agency of a professional to implement it. To go to a physician (or other medical professional) with the request that they aid and abet suicide, by either prescribing a chemical gun or starting a lethal intravenous drip, is a profound violation of Hippocratic medical ethics.

The mighty 2500 year old tree of medicine is firmly rooted in Hippocratic values, the most distinct and core of which is the statement, “I will not give poison to anyone though asked to do so, nor will I suggest such a plan."⁵ This proscription against actively killing your patient has been a through-line in history as societies and nations have come and gone. This Hippocratic dictum has over 2 millennia of ethical momentum and is now sustained by the stewardship of the World Medical Association, which is “firmly opposed to euthanasia and assisted suicide.”⁶ Historical examples when physicians have capitulated to societal demands to deviate from this, like the Nazi T4 program,⁷ have later been morally condemned by physicians. All ethics, including medical ethics, are vulnerable to being swept off their moorings in the torrent of rapidly changing social mores—as is occurring now. Though physicians can and must sometimes step out of the way of death and provide state-of-the-art palliative support, for a physician to administer death, or abet suicide, is an inversion of the fundamental ethos of what it means to be a physician. This is especially so for psychiatrists, who have a core professional dedication to preventing, not providing, suicide.

Though there are many reasons why legalizing these procedures is bad public policy, in terms of medical ethics, the Swiss approach is slightly better. It does not directly require physicians to participate in their suicide clinics. However, it does include doctors in the chain of culpability, as they must certify that individuals have the capacity to consent to suicide. Indeed, I have received many calls from individuals throughout the US asking if I would evaluate them for capacity to go to the Dignitas clinic in Switzerland. I would not.

Paul Farmer, MD, won the prestigious Berrugen Prize for Philosophy and Culture in part for his notion of accompaniment in medicine. Accompaniment means, “I'll go with you and support you on your journey wherever it leads. I'll keep you company.”⁸ We devotedly travel with patients in their journeys of illness, sometimes to the very edge of the cliff. We peer over that cliff with them, hold their hand, and comfort them, but do not push them off. There is much we can do to support and minister to those who are terminally ill. Psychiatrists are particularly experienced in this kind of accompaniment. We are equipped to process and ameliorate feelings like “life is not worth living any more,” or anxiety about impending death, debilitation, or disability. We have these and other skills to help such emotions—independent of a patient's diagnosis. Indeed, we can even help with these kinds of thoughts and feelings for those who have no psychiatric diagnosis. This is what we do; we do not provide death, but we can help individuals prepare for it. It is not irrelevant that it is unethical for physicians to administer lethal injections for the death penalty.⁹

So, a critical piece of the conversation is—who is satisfying the kinds of desires that Dr Moffic is contemplating. To designate doctors as dealers of death is to institutionalize a fundamental change in our civilization itself, which is undergoing so many rapid vertiginous changes now. Legalizing one set of human beings who can provide the means for suicide, or could actively kill certain others, even on request, is a profound moral decision. But to give that task to physicians, of all people, is another level of ethical contortion altogether. It also conveys the idea that assisted suicide and euthanasia are “medical” procedures, which they are not. The British Medical Association just recently declared “assisted suicide is not a ‘health activity.’”¹⁰ Medicalizing these activities obscures the moral culpability of these suicides by depicting them as just another medical service we can provide. This softens the taboo against suicide which, unlike stigma, is a vital aspect of suicide prevention. It also parses suicide into 2 tiers—the suicide we should provide and the suicide which we should prevent. Distinguishing who belongs in each category is both clinically and morally impossible, not made any easier by deploying euphemisms for one of them, like "death with dignity.”

Back in the days of Dr Kevorkian's activities, former Chair of Psychiatry at Johns Hopkins Paul McHugh wrote¹¹:

“Patients are seduced... by isolating them, sustaining their despair, revoking alternatives, stressing examples of others choosing to die and sweetening the deadly poison by speaking of ‘death with dignity. If even psychiatrists succumb to this complicity with death, what can be expected of the lay public?"

Dr Komrad is a psychiatrist on the teaching staff of Johns Hopkins Hospital in Baltimore, Maryland. He is also a clinical assistant professor of psychiatry at the University of Maryland in Baltimore and on the teaching faculty of psychiatry at Tulane University and Louisiana State University in New Orleans, Louisiana.

Dr Komrad gratefully acknowledges the help of Ronald W. Pies, MD, in reviewing this manuscript.

References

1. Komrad MS, Hanson A, Geppert CMA, Pies RW. Beyond terminal illness: the widening scope of physician-assisted suicide in the US. Psychiatric Times. June 6, 2024. https://www.psychiatrictimes.com/view/beyond-terminal-illness-the-widening-scope-of-physician-assisted-suicide-in-the-us

2. Komrad MS, Glass O. Euthanasia in animals and humans: distinctions to consider. July 29, 2024. Psychiatric Times. https://www.psychiatrictimes.com/view/euthanasia-in-animals-and-humans-distinctions-to-consider

3. Komrad MS. Medical euthanasia in Canada: current issues and potential future expansion. June 29, 2018. Psychiatric Times. https://www.psychiatrictimes.com/view/medical-euthanasia-canada-current-issues-and-potential-future-expansion

4. Wax JW, An AW, Kosier N, Quill TE. Voluntary stopping eating and drinking. J Am Geriatr Soc. 2018;66(3):441-445.

5. The Hippocratic Oath. BMJ. 1998;317(7166):1110.

6. WMA Declaration on Euthanasia and Physician-Assisted Suicide. World Medical Association. November 23, 2021. Accessed April 21, 2025. https://www.wma.net/policies-post/declaration-on-euthanasia-and-physician-assisted-suicide/

7. Euthanasia Program and Aktion T4. Holocaust Encyclopedia. Accessed April 21, 2025. https://encyclopedia.ushmm.org/content/en/article/euthanasia-program 

8. Mott T. To repair the world: Paul Farmer speaks to the next generation. Fam Med. 2015;47(5):406-407.

9. Capital punishment. AMA Code of Medical Ethics. Accessed April 21, 2025. https://code-medical-ethics.ama-assn.org/ethics-opinions/capital-punishment

10. Consultants conference 2025: agenda. British Medical Association. Accessed April 21, 2025. https://www.bma.org.uk/media/0vznagee/uk-consultants-conference-agenda-2025-final.pdf

11. McHugh P. The Kevorkian Epidemic. The American Scholar. 1977;66(1):15-27.