Physician assisted death (PAD) is the subject of intense public debate. As we attempt to reconcile the traditional role of doctors as healers with a desire to allow patients as much control over end-of-life decisions as possible controversy is inevitable. Proponents of PAD make emotional appeals using phrases such as “death with dignity” implying that when faced with an inevitable death, PAD is the only dignified option, and that those who oppose PAD are somehow in favor of an undignified death. Dying with dignity, however, is far more complicated than simply choosing the time and manner in which one dies, and that modern treatment options can provide a dignified death without causing death.
The European Association for Palliative Care (EAPC) issued a ten point statement in 2003 responding to the arguments in favor of PAD. (Materstvedt et al, 2003). Among the issues addressed by the EAPC is the importance of available alternatives to PAD, namely the withholding of lifesaving care and/or the withholding of life sustaining nourishment. These alternatives accomplish the goals of PAD without requiring direct action by a physician to bring about death, preserving the traditional role of doctors as healers who treat suffering rather than making them arbiters over who lives and who dies.
In the United States the law already allows patients to reject both life saving medical intervention and life sustaining food and/or water. The Supreme Court recognized in Cruzan v. Director, Missouri Dep’t of Health and elsewhere that “a competent person has a constitutionally protected liberty in refusing unwanted medical treatment.” (Cruzan v. Director). This allows patients to choose to end their own lives by forgoing treatment or nourishment, bringing death without requiring an overt act by a physician. Doctors may ethically continue to be involved in the care of the patient by providing symptomatic relief to ease suffering as the natural dying process proceeds. (Kamisar, 2012).
Permitting patients to choose to allow the natural dying process to run its course leaves both the decision to die and the responsibility for executing that decision solely with the patient, which is consistent with American legal precedent and medical ethics tradition. Our legal system assigns liability for ones actions when there is both “mens rea” and a “culpable act”. As applied to PAD, a doctor should be free to treat a patient to the best of their ability as death approaches so long as they do not actually do anything with the specific intent of causing death. Doctors who provide patients with the means to cause death and intend to have the patient actually cause their own death have stepped across the line into the traditional realm of criminal liability. They may have noble intentions to ease the suffering of an individual patient, but laws exist to protect both the individual and society as a whole and we should not redefine criminal liability to permit PAD because finding other solutions is difficult or inconvenient.
The distinction between withholding life saving treatment and actively seeking to cause death has been recognized for millennia. The traditional Hippocratic Oath admonishes doctors to “provide no deadly medicine,” even if the patient specifically requests it. (Shmerling, 2015). The fact that doctors may be capable of causing death does not mean it is something we should condone, just as we limit doctors’ actions in other areas to protect society as a whole. For example, we already limit the prescription of narcotic drugs, prohibiting their prescription to addicts for the purpose of maintaining addiction. (Tennant, 1980). We do this because of the potential for narcotics to cause more suffering than they eliminate, our need to protect society from addiction is deemed to be of greater importance than reducing the suffering of an individual addict. With PAD there is a very similar risk that our attempts to reduce an individual’s suffering will cause harm to society as a whole by changing the role of doctors from one as strictly a healer to one in which causing death is acceptable. Acceptance and legitimization of PAD opens the door to problems ranging from potential coercion of the terminally ill to the acceptance of euthanasia by legitimizing the physician’s role in causing death. (Kamisar, 2012).
Dr. Timothy Quill has written extensively on Physician Assisted Death (PAD) and argues that doctors are already helping patients bring about their own deaths. (Quill, 2012). He worries that in the current environment where doctors and patients both face potential repercussions from PAD patients will be unable to talk openly with their caregivers and because PAD is already happening it would be best to bring it out into the open where it can be discussed and regulated. However, Dr. Quill’s argument that to address issues with doctor-patient communication regarding end of life decisions we must legitimize PAD presents a false dichotomy. The available options are not limited to either accepting PAD or living with poor communication between doctors and patients. We can, and should, work to encourage patients to communicate openly with their doctors, with the goal of identifying and treating the suffering that may cause a patient to want to end their life rather than accepting PAD as the only solution to suffering.
With modern hospice and palliative care we are able to treat the vast majority of end of life suffering. In fact, by Dr. Quill’s own statistics less than 0.2% of all deaths in Oregon (where PAD is legal) are the result of PAD. (Quill, 2012). With current care adequately addressing the suffering of nearly all patients, the PAD debate becomes about the wishes of a very small but very vocal minority. This minority no doubt has very real suffering on the individual level, but our focus should be on properly treating their suffering rather than accepting PAD. Proper treatment of each individual patient according to their wishes will permit a death which possesses at least as much dignity as would an assisted death without requiring a complete disregard for the legal and ethical history on which the practice of medicine is based.
The proper role for doctors in end-of-life decisions will continue to be a topic of debate for the foreseeable future, but proponents of PAD’s argument that the only way to provide a dignified death is to allow patients to choose to end their own lives cannot survive scrutiny. The law already allows patients to die naturally if they choose to forgo treatment and to cause their own deaths by not eating or drinking. Doctors are free to provide palliative care to eliminate any suffering caused by patients choosing these options, without having to engage in conduct which actually causes death. That doctors should not cause harm has been the accepted standard of care throughout history because this position protects individual patients, society as a whole, and doctors themselves better than any alternative.
- Materstvedt, L., Clark, D., Ellershaw, J., Ferde, R., Gravgaard, A., Sales, J., and Rapin, C. (2003). Euthanasia and physician assisted suicide: a view from an EAPC Ethics Task Force. Palliative Medicine, 17, 97 – 101.
- Cruzan v. Director, Missouri Dep’t of Health. 497 US 261 (1990).
- Kamisar, Y. (2012). Are the distinctions drawn in the debate about end-of-life decision making “principled”? If not, does it matter? Journal of Law, Medicine, and Ethics, Spring 2012, 66 to 84.
- Shmerling, R. (2015). The Myth of the Hippocratic Oath. Retrieved December 2015 from http://www.health.harvard.edu/blog/the-myth-of-the-hippocratic-oath-201511258447.
- Tennant, F. (Dec 1980). Prescribing Narcotics to Habitual and Addicted Narcotic Users. West J Med, 133(6), 539 – 545.
- Quill, T. (2012). Physicians Should “Assist in Suicide” When It Is Appropriate. Journal of Law, Medicine, and Ethics, Spring 2012, 57 to 65.
