Should physicians be allowed to assist in their patients' dying, and how can physician-assisted suicide be reconciled with the physician’s role as a healer?
He was a therapist and friend who was dying of metastatic cancer. When he asked if we could talk, I began to go by his hospital room, ultimately spending an hour or so with him at the end of each day. During more than 30 such visits we talked about many things-his wife and family, his career, and, at times, his dying. I tried only to be there, to be with him in a way that gave him some relief from his aloneness.1
Courage was an important theme in his life. He was a decorated veteran of the Pacific Island invasions during World War II and an outspoken public speaker on current social injustices. I knew this about him and as death became imminent his anxiety about losing control and "becoming a baby" became obvious. Several days before he died he asked me if it got too much for him would I step on his oxygen tube? Without a moment's hesitation I said, "Yes." Such was not necessary, since he lapsed into a coma and died a day later.
The other occasion on which I was asked if I would help if dying became too difficult was also some years ago. This situation developed in the context of a doctor-patient relationship. I had seen this middle-aged woman and her husband in couples therapy 6 years earlier, and our work together had been successful. She called and asked if I could help with her dying as much as I had helped with her living. She, too, had metastatic cancer. During the 6 months longer that she lived, I saw her and her husband weekly, alternating individual sessions with couples work. She had been the more distant, analytic spouse whose difficulty with intimacy appeared related to childhood experiences with what sounded like a chronically depressed mother, herself a Holocaust survivor.
About a month before she died and during a session that included her husband, she asked whether, if dying became too miserable, I would help her with it? Again, my response was immediate, "Of course," I said. I will not describe in detail the subsequent events- including my discussing the situation with the executive director of my local medical society and his suggestion that I talk with the recently retired pathologist-director of the medical examiner's office about how to help if that was my decision. For present purposes all that is relevant is that she never asked; rather, she, too, slipped into a terminal coma. I have thought often about these 2 situations, particularly in the context of the ongoing legal conflicts about Oregon's physician-assisted suicide law. What has particularly occupied my self-explorations has been the immediacy of my affirmative response to both my friend and my patient. Why-without any thoughts about the implications of what I was being asked to do-did I respond so quickly and emphatically?
One line of my thinking concerns the demands of the context. With both friend and patient in such dire circumstances, how could one have said, "no," or "maybe," or "we'll see?" The context demanded an affirmative response. The dying person needed to hear that help would be available if requested. My immediate and affirmative response reflected my understanding of that context and its demand quality.
I suspect that responding to the context played a role in my response, but there is almost certainly more to it than that. It is hard to avoid the conclusion that my underlying anxiety about my own death must have influenced my response. If my death were unusually painful wouldn't I want someone to slip me the requisite pills?
Death anxiety is considered by many existentialists to be an ultimate concern, one of the most fundamental processes in the entire psychology of the self. Becker,2 in his famous The Denial of Death, proposed that it is the most basic font of all psychopathology, and that we defend vigorously against directly experiencing it. Subsequent research efforts have distinguished conscious death anxiety from unconscious death anxiety. The former is considered multifaceted. Some persons' conscious death anxiety involves separation from loved ones; for others it might be fear of the unknown; there are a handful of interrelated themes involved in conscious death anxiety. Unconscious death anxiety is, of course, more difficult to study. One approach uses a sentence completion format and demonstrates that there are clear distinctions between the 2 types of death anxiety,3 although I think consciously about my own death (after all, I am approaching 82) without severe conscious anxiety, some idea of the extent of my unconscious death anxiety was revealed to me some years ago when I said goodbye to my wife on the way to the operating room for major surgery. So, I know it's there-and that it has to do, at least in part, with separation from her. Is it that deep dread within me that prompted my immediate responses? Is the idea of a prolonged and painful dying so frightening at an unconscious level to me that I leap to assuage those fears in others? This is a reasonable hypothesis, and I suspect it is part of the picture. I say this because my more usual behavior is far more cautious than impulsive, and my immediate and emphatic response to the request for help in dying is not at all typical.A third theme probably operating in my responses was my underlying heroic aspirations. These aspirations may be fulfilled by rescuing a patient or friend from severe pain, hopelessness, and fear of dying. To rescue others has an unknown relationship to the need to be helpful, although as a resident in a then psychoanalytic department of psychiatry, I learned that any hint of "rescue fantasies" was a neurotic trait. It was only after reading Becker's premise that heroic aspirations are ubiquitous and in the service of the search for immortality that the question (for me) came to be not whether one has heroic aspirations but how intense they are and whether they negate the needs of others.2 There is a fourth possible factor suggested, in part, by my behavior following my patient's request. My friend's death was so imminent that I doubted that he had enough conscious time left to ask me to step on his oxygen tube. Recall that after my patient's request I talked with authorities about the clinical situation and my assurance of help if needed. Without thinking about the implications of my response at the time, I knew, at some level, that I had the time to cover my rear. This sounds more like me. These 4 possible explanations of my responses to these requests for help with dying may have all played a role. They are, however, not the whole story. What also seems clearly involved is my assumptive world (or values, belief system, etc). I believe that a person has the right to determine his or her own death, although this belief is heavily qualified by the research suggesting that some chronically ill persons-perhaps 20%-also struggle with major depression and no longer wish to die if their depression is adequately treated. Once that qualification is dealt with, I believe in the right to die on one's own terms.
My critics will say that I avoid the central issue: should physicians be allowed to assist in their patients' dying? Is this not a serious abandonment of the physician's healing role? Is it not the first step in the direction of the Nazi physicians' misuse of and killing of prisoners? Although I have mixed feelings about the pros and cons of this argument, in general I have thought that the domino theory is vastly overdone as a presumed powerful, more-or-less inevitable process in human systems. Earlier in this essay I described turning to a wise executive secretary of my medical society. We talked at length, but what I remember most of all, was his statement, "Jerry, all you must be certain of is that what you do is in the patient's best interests. That's what's right to do." I do believe that my response to these 2 requests for possible help with dying was in the best interests of those dying persons. As I have tried to make clear in this essay, however, the nature of my responses also suggests that it is very likely that a number of personal unconscious processes combined to determine my responses. There are most likely other of my characteristics that also were involved, so I continue from time to time to try to sort it all out, provoked in part by the press reports of the government's attempted intrusion into what seems a highly complex matter between patient and doctor.
Dr Lewis is chairman emeritus of the Timberlawn Psychiatric Research Foundation and clinical professor of psychiatry at the University of Texas Southwestern Medical School. He is also in private practice of individual, marital, and family therapies in Dallas.
1. Lewis JM. Dying with friends: implications for the psychotherapist. Am J Psychiatry. 1982;139:261-266.
2. Becker E. The Denial of Death. New York: The Free Press; 1973.
3. Hayslip B Jr, Guarnaccia CA, Radika LM, Servaty HL. Death anxiety: an empirical test of a blended self report and projective measurement model. Omega: J Death Dying. 2002;44:277-294.