Given our highly polarized society, I greatly appreciate Joshua Pagano, DO’s, desire to find “common ground” in what is undeniably a complex and controversial topic in his response, “Finding Common Ground in This Life.” Indeed, Dr Pagano and I share the goal of providing terminally ill patients with the comprehensive and holistic array of services he outlines. That said, he may be relieved that this will be my final serve in our stimulating volley!
Dr Pagano posits a hypothetical, terminally ill patient who has had access to marvelously comprehensive care, including “pain management,” assessment of underlying mental illnesses, personal and family counseling, and information regarding “all possible options.” Dr Pagano then opines that—notwithstanding such stellar care—there will still be “the patient who will legitimately choose medical aid in dying.” He then asks if I “acknowledge that this person exists.”
Before replying to the hypothetical case, I am constrained to point out that in most American states, such a comprehensively cared-for, terminally ill patient is scarcely to be found. For example, a 2019 report by the Center to Advance Palliative Care (CAPC) found that,
“Access to palliative care for people living in rural America remains limited. Ninety percent of hospitals with palliative care are in urban areas. Only 17% of rural hospitals with 50 or more beds report palliative care programs… [And] in Alabama, Mississippi, New Mexico, Oklahoma, and Wyoming… fewer than 40% of hospitals [are] reporting palliative care teams.”1
As for careful assessment and treatment of underlying psychological vulnerabilities and disorders in terminally ill patients, I think the record is poor. For example, even in Oregon—which legalized physician-assisted suicide (PAS) in 1997 and gets a good grade for palliative care1—only a minuscule percentage of PAS patients undergo a mental health evaluation. In Oregon, as in most PAS-permissive states, requesting a psychological or psychiatric evaluation is optional for the physician. Consequently, in Oregon, over 96% of PAS patients are prescribed the lethal drugs without such evaluation.2
Nevertheless, as a medical ethicist, I feel I owe Dr Pagano a more considered answer, playing out his hypothetical scenario and probing its ethical import. Suppose, then, that we located “Mr Alden”—a terminally ill patient who has had access to all the care and services in Dr Pagano’s scenario. Would this person nevertheless be someone who could “legitimately choose medical aid in dying”? Frankly, I do not know. Much depends on what we mean by “legitimately” (rationally? understandably? ethically?). But I truly believe that we, as physicians, are not ethically or legitimately empowered to honor Mr Alden’s choice of assisted suicide.
In closing, I would encourage Dr Pagano to reflect on our Hippocratic roots, as physicians. I am not speaking solely of the famous “Hippocratic Oath,” with its solemn vow, “I will give no deadly medicine to anyone if asked, nor suggest any such counsel…” I am referring to the entire tradition of Hippocratic medicine, over the past 2500 years. The refusal to administer a lethal drug to dying patients was a distinguishing feature of Hippocratic physicians—setting them apart from their contemporary colleagues.3 It is only since the rise of the consumer rights movement in the 1960s—whereby patients became “service users” and physicians, mere “providers”—that assisted suicide has been seriously advanced as a medical “service.”4
As medical ethicist and physician Leon Kass, MD, PhD, has observed:
“In forswearing the giving of poison, the physician recognizes and restrains a godlike power he wields over patients, mindful that his drugs can both cure and kill. But in forswearing the giving of poison when asked for it, the Hippocratic physician [also] rejects the view that the patient’s choice for death can make killing him—or assisting his suicide—right.”5
Yes, in medical ethics, it is laudable to find common ground. More laudable still is knowing when one is treading on hallowed ground.
Dr Piesis 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 Psychiatric TimesTM (2007-2010).
1. America’s Care of Serious Illness. Center to Advance Palliative Care. 2019. Accessed January 21, 2022. https://reportcard.capc.org/wp-content/uploads/2020/05/CAPC_State-by-State-Report-Card_051120.pdf
2. Doerflinger R. A reality check on assisted suicide in Oregon. Charlotte Lozier Institute. April 13, 2017. Accessed January 21, 2022. https://lozierinstitute.org/a-reality-check-on-assisted-suicide-in-oregon/#_ftn8
3. Pies RW. Deferring to the mastery of death: Hippocrates, Judge Gorsuch, and the autonomy fallacy. Psychiatric Times. April 3, 2017. https://www.psychiatrictimes.com/view/deferring-mastery-death-hippocrates-judge-gorsuch-and-autonomy-fallacy
4. Pies RW. Physician-assisted suicide and the rise of the consumer movement. Psychiatric Times. August 1, 2016. https://www.psychiatrictimes.com/view/physician-assisted-suicide-and-rise-consumer-movement
5. Kass LR. A dignified death and its enemies: why doctors must not kill. In: Leading a Worthy Life: Finding Meaning in Modern Times. Encounter Books; 2017:218.