The word “physician” is ultimately derived from the Greek word, physis [φύσις]; roughly translated, physis means “Nature.”  Coupled with the suffix, -ian, we can define “physician” as “one who works with, or assists, Nature.”  Thus, the English physician, Thomas Sydenham (1624-89), long recognized as a founder of clinical medicine, stated, “I assist Nature, as Hippocrates bids me.”

Every physician recognizes that death and dying are natural processes. For many centuries, the physician’s role in the patient’s final days has been one of easing pain and suffering; providing support and solace to the patient and family; and bearing witness to the patient’s death.

It is only in modern times—and particularly since the emergence of the “consumer movement” in the past 50 years1—that the notion of “physician-assisted suicide” (PAS) has gained some legitimacy, both among physicians and the general public. Indeed, there are now five states that provide a legislative framework for physician-assisted suicide.

From a medical-ethical standpoint, there are indeed ways in which a physician may “assist” Nature during a terminally ill patient’s final days. First, the physician can respect a competent patient’s informed decision to avoid or discontinue futile (“heroic”) measures that will merely prolong the dying process. Indeed, the patient’s right to forego such futile measures is established in U.S. case law. Thus, in Cruzan v. Director, Missouri Department of Health, the U.S. Supreme Court established a mentally competent patient’s right to refuse medical treatment, even if that refusal would ultimately lead to the patient’s death.

However, since Cruzan, the Supreme Court has not recognized any constitutional “right” to commit suicide–much less a right to physician-assisted suicide. And, in two cases–Washington v. Glucksberg and Vacco v. Quill—the Supreme Court made a critical distinction between allowing death versus hastening death.  Indeed, a competent, terminally ill patient’s request to disconnect feeding tubes or a respirator may be honored by the physician without compromise of medical ethics.

Furthermore, terminally ill patients who want to end their lives may choose voluntary stopping of eating and drinking (VSED), which is recognized as a humane and relatively painless means of allowing death to occur, usually within two weeks.2 VSED has been used by religious orders, such as the Jains, for centuries, as a dignified and humane way of ending one’s life.  Since appetite “naturally” declines precipitously in the later stages of dying, VSED could be considered a legitimate means of assisting the dying process.

Thus, physicians may reasonably support VSED and remain consistent with the principle of “assisting Nature”—or at least, not standing in Nature’s way.2 As a last resort, palliative sedation is also an acceptable means of relieving interminable suffering, during the patient’s final days and may be used concomitantly with VSED. 3

Suicide is Different

Suicide, however, is another matter. Suicide is not only statistically rare, it is also, in a fundamental sense, an “unnatural” act. Quite aside from religious objections to suicide, the act itself is a direct contravention of the strongest natural drive in a living organism; namely, the drive toward self-preservation. The vast majority of people with terminal illnesses do not choose suicide or PAS, and many terminally ill patients choose to embrace life even to the last moment.

Although some ethicists and philosophers have advanced the notion of a “rational suicide,” the vast majority of suicides occur in the context of serious psychiatric illnesses, such as major depressive disorder, which are known to impair rational judgment.  To be sure, suicide in the context of PAS differs in important respects from many suicides in the context of psychiatric disorders.

The latter are often secretive, impulsive and violent, which are not features of state-regulated PAS. In the latter context, dying patients often have time to enlist the support of family and significant others and to prepare loved ones for the path ahead. These distinctions have led some to argue that the term “suicide” should simply not apply to persons who take their lives under the aegis of PAS laws; instead, supporters of PAS prefer the term “the aid-in-dying-patient” for the terminally ill person who wishes to end his life via a prescribed, lethal drug.

But this semantic shift amounts to a euphemistic dodge, and an abandonment of ordinary language. Suicide is conventionally defined as “…the act…of taking one’s own life voluntarily and intentionally, especially by a person of years of discretion and of sound mind.”

The person who chooses to end her life by means of a lethal, prescribed drug —sometimes months before the underlying disease process would prove fatal– is still committing suicide. We may judge the “ethics” of the person’s action differently in such circumstances, compared with a violent and impulsive suicide. Nevertheless, taking one’s own life (auto-homicide or suicide) by means of a lethal, prescribed drug does not constitute “aid in dying” or “assisted dying.”

On the contrary: with PAS, the dying process is terminated—not assisted—by the sudden induction of death. Neither is there any legitimate sense in which a physician’s “assistance” in a patient’s suicide amounts to “assisting Nature.” As I discuss below, it is no coincidence that the Hippocratic Oath explicitly states, “I will give no deadly medicine to anyone if asked, nor suggest any such counsel.” Hippocratic physicians—probably influenced by Pythagorean philosophy—were strong proponents of assisting Nature, but not of assisting suicide.

Rights, Liberties and the Optics of PAS

As noted earlier, there is no recognized “right” to suicide, much less to physician-assisted suicide, in the U.S. In this regard, it is important to distinguish between “rights” and “liberties.” The psychiatrist and libertarian, Dr. Thomas Szasz, observed that a “liberty” does not require the aid or support of another person, nor does it impose obligations on other parties.

In contrast, a “right” requires others to aid, support or facilitate the individual’s action. So, for example, one is at liberty to smoke cigarettes, without any expectation that others will support the action. In contrast, one’s right to vote requires that responsible parties create a structure (ballots, voting booths, etc.) that allows one to exercise that right.

Szasz argued that people ought to be “at liberty” to end their own lives, but denied that there was a “right” to do so. Moreover, Szasz regarded so-called physician-assisted suicide as a convenient euphemism for what he termed “bureaucratized medical killing.”4 (p. 94)

Indeed, Oregon-type legislation authorizing PAS creates a powerful optical illusion. Because the cooperating physician is merely doing what physicians have done for centuries—writing out a prescription—the “optics” of PAS creates an aura of respectability. Never mind that the prescription in question is for a lethal dose of secobarbital. When cloaked in the obfuscating language of “assisted dying” or the euphemism of “death with dignity,” it is not hard to see why PAS legislation has gained a foothold in a minority of states.

This, despite the long-standing opposition to PAS by the American Medical Association, the American College of Physicians, and the American Nursing Association. Ironically, if the term “loaded gun” or “vial of ricin” were substituted for “secobarbital prescription” in PAS legislation, there would be a tidal wave of outrage and opposition. But because the means of assisting the patient’s suicide is that age-old doctor’s device—the prescription—the ethical boundary violation inherent in PAS is artfully camouflaged.

The Hippocratic Tradition and PAS

In the Oath traditionally attributed to Hippocrates or his followers, we find a clear prohibition. The Oath states, “I [the physician] will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect.” As ethicist Steven H. Miles MD has pointed out, it is unlikely that Hippocratic physicians anticipated anything resembling our current model of state-regulated physician-assisted suicide. Indeed, Miles argues that the clause regarding deadly drugs probably “…addresses the fear that physicians would collaborate with murder by poisoning.” (5 p. 73).

Nevertheless, Miles acknowledges that, “Medical ethicists customarily interpret ‘I will not give a drug that is deadly’ as an ancient medical disavowal of euthanasia or physician-assisted suicide.”(5 p. 66) Indeed, the classicist and historian Ludwig Edelstein argues that it is reasonable to interpret the Oath as prohibiting physicians from “aiding or advising suicide” (6 p. 18) even in cases of terminally ill patients. Note that this stricture does not merely prohibit actual “assistance” of a suicide. It also admonishes the physician to avoid even suggesting suicide as a course of action. But to whom, precisely, should one refrain from suggesting this? I interpret the Oath as saying, “Do not suggest suicide as a course of action either to patients, or their family members, or to colleagues who may seek your consultative advice.” After all, who else would seek such advice?

Hippocrates—who was probably influenced by the Pythagoreans’ opposition to suicide–was something of a revolutionary. As Edelstein has observed, “…in antiquity, it was not generally considered a violation of medical ethics to do what the Oath forbade.”(6 p. 14) Some medical contemporaries of Hippocrates probably did provide poisons to their dying patients, in order to spare them protracted suffering. Hippocrates opposed this practice, though he did not believe that terminally ill patients should be exposed to unnecessary and futile medical treatment. As medical ethicist Leon Kass, MD has noted:

“The ancient Hippocratic physicians’ refusal to assist in suicide was not part of an aggressive, so-called “vitalist” approach to dying patients, or an unwillingness to accept mortality. On the contrary, understanding well the limits of the medical art, they refused to intervene aggressively when the patient was deemed incurable, and they regarded it as inappropriate to prolong the natural process of dying when death was unavoidable.” 7

In Miles’ memorable phrase, Hippocratic physicians, faced with a dying patient, “…would have recognized a duty to defer to the mastery of death.”(5 p. 76) The distinction, then, is between a physician’s aiding the suicide of a patient, on the one hand; and withholding or discontinuing futile medical interventions for terminally ill patients on the other. The latter has sometimes been termed, “removing impediments” to death.8 This crucial distinction has been a cornerstone of Hippocratic medicine for many centuries.

Conclusion

There are no simple solutions to the plight of the terminally ill patient, nor is it my intention to condemn those physicians who, in good conscience, participate in PAS. Perhaps there is even a case for creating some legislative mechanism by which terminally ill patients can obtain lethal drugs without including the physician or other health care professionals in the process. A mechanism of this sort was actually proposed by Lehmann and Prokopetz9, who envisioned a “central state or federal mechanism” that would dispense and monitor use of lethal medication for terminally ill patients, without direct involvement of the physician.  That strategy would present its own ethical and logistical problems, but is at least worthy of discussion and debate.

In my view, physician-assisted suicide represents a corruption of the physician’s solemn obligation to ensure the wellbeing of the patient, recognized by Hippocrates over two millennia ago. The physician’s duty to the terminally ill patient remains as it has always been: reduce pain and suffering so far as humanly possible; comfort and support the patient; provide compassionate care to body and soul; and remain true to the ethical code of our healing profession.

References

  1. Pies R. Physician-assisted suicide and the rise of the consumer movement. Psychiatric Times. August 2016;32:40-43.
  2. Ganzini L, Goy ER, Miller LL, et al. Nurses’ experiences with hospice patients who refuse food and fluids to hasten death. N Engl J Med. 2003;349:359-365.
  3. Bruce SD, Hendrix CC, Grentry JH. Palliative sedation in end-of-life care. J Hosp Palliat Nurs. 2006;8:320-327.
  4. Szasz TS:  Fatal Freedom: The Ethics and Politics of Suicide. Syracuse University Press, 2002
  5. Miles SH: The Hippocratic Oath and the Ethics of Medicine. Oxford University Press, 2004.
  6. Temkin O, Temkin CL, Eds. Ancient Medicine: Selected Papers of Ludwig Edelstein. Baltimore, MD: Johns Hopkins University Press; 1967.
  7. Kass LR: A Dignified Death and Its Enemies: Why Doctors Must Not Kill. In: A Worthy Life: Finding Meaning in America, Encounter Books (in press for 2017)
  8. Telushkin J A. Code of Jewish Ethics, Vol. 2. New York: Bell Tower; 2009.
  9. Lehmann LS, Prokopetz JJ. Redefining physicians’ role in assisted dying. N Engl J Med. 2013 Jan 31;368(5):486. doi: 10.1056/NEJMc1209798.

 

Acknowledgment: I would like to thank the committee of the seventh annual Literature and Medicine Conference (held April 1, 2017 at Texas Health Presbyterian Hospital, Dallas); John F. Harper, M.D., FACC, FAHA (Director); and the Texas Health Research & Education Institute for their generous support and encouragement of this essay. I also wish to thank my colleagues Drs. Cynthia Geppert, Mark Komrad, Anne Hanson, Farr Curlin and James Knoll IV for their valuable comments on aspects of this topic.