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Physician-assisted suicide: the debate continues.
Physician-assisted suicide (PAS) is a hotly debated matter of ethics for psychiatrists and other clinicians. Recently, several doctors have shared their views on the topic through Psychiatric TimesTM. If you missed the conversation, catch up here.
In October of 2019, Ronald W. Pies, MD; Annette L. Hanson, MD; Mark S. Komrad, MD; and Cynthia M.A. Geppert, MD, MA, MPH, MSBE, DPS, shared their view that PAS violates the norms of Hippocratic medical ethics, and involuntary hospitalization to prevent suicide affirms their position.
They asserted 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, these 4 doctors said PAS is incompatible with the ethical principles underlying Hippocratic Medicine.
The authors ended with the firm statement: “In short, psychiatrists strive to prevent suicide-we do not provide it. In the words of Dr Leon Kass, ‘We must care for the dying, not make them dead.'”
In response to that article, Brent M. Kious, MD, PhD, and Margaret P. Battin, PhD, offer a worthy counterargument: Is PAS acceptable for individuals with terminal illnesses?
They stated, “the primary reason to allow [PAS] for persons with terminal physical illnesses is that it can sometimes be a reasonable response to their severe and irremediable suffering, that persons with severe psychiatric illnesses can sometimes suffer as severely and irremediably as persons with terminal illnesses, and thus that there is a prima facie reason to allow some persons with severe, irremediable psychiatric illness to pursue [PAS].”
They argued that PAS is supported by a slight majority of American physicians (58% in a 2018 Medscape poll of 5200 physicians), and a substantial majority of the American public (72% in a 2018 Gallup poll), suggesting an overall consensus of PAS’s favorability with the public.
They also added that the true moral dilemma is determining how severe and how irremediable suffering must be to gauge whether PAS is necessary.
“There are moral absolutes that our profession should stand up for, in spite of legislative or popular pressure,” responded Cynthia M.A. Geppert, MD, MA, MPH, MSBE, DPS; Mark S. Komrad, MD; Ronald W. Pies, MD; and Annette L. Hanson, MD.
The authors stated that although public polls show an increasing trend toward acceptance of PAS, professional organizations did not, standing firm for “the core values of the medical ethics.”
In this point-by-point rebuttal, the 4 authors argue that medical organizations overwhelming opposition to PAS is due to the fact that “…they hold it is antithetical to the ethical identity of physicians as healers.”
The debate began anew when Ronald W. Pies, MD, asked a few vital 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.”
Through the story of his own mother’s passing, Pies debates whether “dignity in death” exists, and if it is less important than another concept: dignity in life.
After reading Dr Pies’ article, Joshua Pagano, DO, fought for the necessity of PAS. Nine states now have laws legalizing PAS, and 1 in 5 Americans have access to it, according to Pagano.
He argues that while PAS is a challenging and stigmatizing topic, its importance comes from a place of humanity: “…my sympathy for those who request medical aid in dying comes from within. For, I cannot in good conscience deny someone a choice that I myself would want as an option under the same grim circumstances.”
Dr Pies responds by insisting PAS is a “forbidden boundary violation,” not unlike the ethical wrongness of psychiatrists having sexual relations with their patients: “… a patient’s consenting to be killed does not mean a physician is ethically justified in acceding to the request.”
He asserted that physicians should rededicate themselves to securing state-of-the-art palliative care for patients, and supporting counseling, rather than focusing on ways to assist suicide.
In a short response, Dr Pagano returned by stating that, even with every option available—voluntary stop eating and drinking, counseling, a death doula, relevant psychotherapy, etc—there will always be a patient who will choose PAS.
“This person is currently invisible in the majority of states across our country. The first step is to acknowledge that they exist. To see them. To believe them.”
In the last installment of this debate, Dr Pies encourages clinicians to reflect on their Hippocratic roots when considering physician-assisted suicide: “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.”
He ended by suggesting that, while common ground is important, it is vital to understand when one is on “hallowed ground.”
The Debate Continues
Do you have an opinion on PAS? Is it a violation of medical ethics or a humane necessity? Let us know your thoughts: PTEditor@MMHGroup.com.