Debating a Physician's Role in Assisting Patient Death

March 28, 2015

Should a physician use her knowledge and craft as a way to help a suffering patient end his life? Here are two sides of the argument.

Physician-assisted death, physician-assisted suicide, and physician aid in dying are all variations on the same theme: the use of our knowledge and craft as physicians to help a patient end his or her life.

Our choice to become physicians compels us, not only to heal but also to alleviate the suffering of those who entrust their lives to us. It is the latter aspect of our duty that is at issue here. As a surgeon, I know there are times when our attempts at healing can cause pain and suffering.

What we seldom reflect on is: What happens when we can no longer heal? What happens when our patient does not wish to be treated? What is our duty then? What is our moral and professional obligation when we can no longer heal? It is specifically at this time when our responsibility transfers from healer to caregiver, educator, mentor, counselor, and friend. What do we do at that time when death is known, and we're helpless to defeat it? Despite our narcissistic view of our invincibility, we must change our paradigm from fixing the disease to fixing the problem of pain and suffering. It is a complicated but necessary intellectual transformation. And it is a moral and right change.

This transformation brings forth the issue of how to alleviate pain and suffering at the end of life. How do we quantify the pain? And most importantly, is death the ultimate and only option for relief? Should we as physicians use our craft to cause or assist our patient to die to fulfill our obligation to alleviate suffering?

I will answer and illustrate two opposing positions. Then I will summarize and offer a personal conclusion.

Yes, we should assist patients in dying.

The proponents of physician-assisted death (PAD) establish the base of their position with the concept of "death with dignity." Dignity, grounded primarily on the principle of autonomy; that the dignity of a human being is violated when their natural right to free exercise of will is removed.

Respect for autonomy is a fundamental guideline for the moral physician. Autonomy in medicine is not just allowing patients to make decisions. Physicians have an obligation to create the conditions necessary for those decisions. At such a critical and final time as death, the ability to decide for ourselves, i.e., how and when to die, is implicit in our dignity as a person. It is the physician's obligation to respect and enable that request as part of our obligation to alleviate suffering. Assistance in dying is not inconsistent with the principle of beneficence, as recognizing and creating the environment of autonomy is beneficence.

The other grounding of PAD advocates is the idea that the pain of dying patients can only be removed with death. Compassionate physicians should recognize that suffering is not always physical but is also existential.  Death is at times the only treatment.

Finally, and probably the most contentious point, is that PAD already happens despite the laws against it. In the 2004 book, "Physician-Assisted Dying: The Case for Palliative Care & Patient Choice", the authors note that several studies of U.S. physicians indicate "a measurable, fairly consistent incidence of physician-assisted suicide whether legal or not."
The latter argument is assigned to the principle of non-maleficence, i.e., do no harm. Being dishonest with our patient's request to die using disingenuous legal or moral validations is doing harm.

No, we should not assist patients in dying.

The perception that pain and suffering at the end of life removes human dignity is not in question. The question is whether ending life is ever protective of human dignity?

Physician and medical ethicist Daniel P. Sulmasy defines human dignity in three ways: Intrinsic, inflorescent, and attributed. Intrinsic dignity is what dignity we have just for being a human person. Intrinsic dignity obliges us as members of the human kind to comport ourselves consistently and to foment the flourishing of this dignity in all members of the kind. Inflorescent dignity is more complex. Inflorescent dignity is used to refer to individuals who are flourishing as human beings, living lives that are consistent with and expressive of the intrinsic dignity of the human. Attributed dignity is more material; it is based on what is given by society or community.

As a result, dignity is sometimes used to refer to a state of virtue in which a human being acts in ways that expresses the intrinsic value of the human.  For example: "He faced the onslaught of cancer with dignity."

To reduce the concept of dignity, as the proponents of PAD do, to exclusively exercising one's autonomy is to ignore 1,000 years of theology and philosophy.

To actively participate in ending a life by acceding only to the patient's will is to deprive them of their intrinsic dignity by negating all other aspects of dignity.

Three arguments against PAD

Sanctity of life argument against:
Sanctity , according to the Old English Dictionary, is: What is secured by religious sentiment or the like against violation, infringement , or encroachment. Causing the end of life by any means is the prototypical encroachment, violation, and infringement of human "dignity."

Medical/ Psychological argument against:
 A request for assisted suicide is a cry for help. The patient is depressed. Several studies dating back to the 70s conclude that at least 58 percent of terminally ill patients are clinically depressed by several assessment methods. When given viable alternatives to end their pain and suffering, most rational patients almost invariably choose them over death.  Wanting to die is a reflection of exasperation and depression. A perception clouded by pain, and they will it relieved regardless of the consequences.

Violation of professional principles argument:
Hippocratic Oath which states: "I will not administer poison to anyone where asked," and I will "be of benefit, or at least do no harm." Major professional groups such as the AMA oppose assisted death. PAD would undermine the fundamental principles by which physicians practice and further compromise the inherent trust of the doctor-patient relationship.

Conclusion

It is apparent that the proponents of PAD base their support on two points. First is preserving the principle of autonomy and its violation being perceived as an assault on dignity. Second is the perception that only death can relieve these patients' suffering.

The first is arguably rational. However, dignity is more than just autonomy. But, what is more important is that intrinsic dignity defines us as a human being. Immanuel Kant's concept of dignity is "intrinsic" and based on reason. It is not reasonable to wish death to the exclusion of all other means to relieve suffering. To end one's life even through choice violates that dignity.

The second is perceptive. The American Society of Anesthesiologists outlined in their syllabus on ethics : Pain and suffering can be relieved in the vast majority of cases without intentionally causing death. The latter is the conceptual validation for palliative sedation and pain relief that may sometimes hasten death.

In PAD, the death is not a consequence or a circumstance. It is an action of the will. An action incorrectly perceived as a zero option.

Palliative sedation has the advantage of relieving pain and suffering without the intent of causing death. The grounding philosophy of this position is found in the principle of double effect. The principle of double effect states: Accordingly, the bad effects of an action that would be morally wrong if caused intentionally are permitted if these effects are foreseen but unintended. As a result, if the intent is to alleviate suffering even with death as a consequence, the action is morally permissible.

In conclusion, wisdom compels me to do all within my power to alleviate suffering even if the action hastens death; however, my intention will always remain to preserve that intrinsic dignity of the human being. The latter opinion grounds my ethical stance. As physicians, we have an obligation to act in the best interest of our patients. If I can be virtually certain death is the only option, then so be it.