Do We Need 'Thanaticians' for the Terminally Ill?

Ronald W. Pies, MD

The Ethical Dilemma of Physician-Assisted Suicide

My 89-year-old mother had been losing ground for some years, experiencing what geriatricians sometimes call "the dwindles." Toward the end of her life, she was beset by a deteriorating heart; an inability to walk; and occasional, severe gastrointestinal pain. My family got her the best medical treatment available -- eventually including home hospice care -- and she generally maintained a positive attitude throughout her long downhill slide.

But one day, as I sat beside her bed, she seemed unusually subdued. "Honey," she said, "How do I get out of this mess?" I had a pretty good idea of what she was really asking me, but I deflected her question with another question: "Ma, what 'mess' do you mean?" I asked. "It's all right," she replied, smiling sadly, "I'll manage."

My mother was doing what she had always done: sparing her children from pain. In this case, it was the pain of dealing with the waning days of her life and the frustration of knowing there was no easy escape from the burdens of dying slowly. "Ma, I'll always make sure you are getting enough treatment for your pain," I added, taking her hand -- knowing that the prospect of unremitting pain is often an underlying fear of terminally ill persons.

Yet, unspoken in my mother's question was the issue of so-called physician-assisted dying, sometimes called "physician-assisted suicide" -- an enormously heated controversy both outside and within the medical profession. In my home state, Massachusetts, the issue has come to the fore, owing to a November ballot initiative for a measure that would allow terminally ill patients to be prescribed lethal drugs.^[1] A closely related bill (H.3884) has also come before the Massachusetts Legislature's Joint Committee on the Judiciary.

Similar to laws already on the books in Oregon and Washington state, the proposed Massachusetts law builds in numerous "safeguards": For example, patients would be required to submit their request in writing twice, and those requests must be 15 days apart. As reported recently in the New York Times,^[2] fears regarding widespread overuse or abuse of the so-called "death with dignity" laws in Oregon and Washington have largely failed to materialize, at least according to some studies.

Nevertheless, the Massachusetts Medical Society (MMS) has long been opposed to physician-assisted suicide. In March 2012, the MMS President, Dr. Lynda Young, testified before the Joint Committee^[3] and did not mince her words. Allowing physicians to participate in assisted suicide, she stated, "...would cause more harm than good," and she argued that "...physician-assisted suicide is fundamentally incompatible with the physician's role as healer." Instead, Dr. Young asserted, the physician's role should be to ensure that the terminally ill patient "...continue[s] to receive emotional support, comfort care, adequate pain control, respect for patient autonomy, and good communication."

With considerable ambivalence, I agree with Dr. Young. In my view, terminally ill but mentally competent patients should be at liberty not only to refuse further medical treatment, but also to end their own lives -- for example, by refusing to accept liquid or solid food. Contrary to a widespread belief, voluntary refusal of food and fluids does not result in an agonizing or painful death, according to a2003 report in the New England Journal of Medicine.^[4] Indeed, medical ethicist Dr. Cynthia Geppert informs me that voluntary refusal of food and drink is now considered an accepted approach to dying in palliative care.

As Dr. Thomas Szasz has argued in his book, Fatal Freedom: The Ethics and Politics of Suicide,^[5] a liberty is not the same as a right, because the latter entails a reciprocal obligation on someone else's part. (If I have a right to free speech, the state has a reciprocal obligation to protect that right.) Moreover, the liberty to commit suicide does not entail the "right" to have one's physician prescribe a lethal dose of medication. Indeed, Dr. Szasz believes that "physician-assisted suicide" is really a euphemism for "medical killing" -- more technically, "heterohomicide" on the part of the physician.

While I disagree with Dr. Szasz on many issues in psychiatry, I think his analysis here is essentially correct. Physician-actuated heterohomicide, in my view, is "fundamentally incompatible with the physician's role as healer." I believe that permitting physicians to write prescriptions for lethal drugs will eventually erode the trust that all patients should place in their physicians. More than a euphemism, "physician-assisted suicide" may be a contradiction in terms. And in my view, the very concept violates both the implicit ethical contract between physician and patient, and that between the physician and society.

To be clear: None of this means that physicians should collude in the cruel and unnecessary prolongation of dying, as is often seen in hospital settings. As physician and ethicist Dr. Fred Rosner has argued,^[6] "To prolong life is a [commandment], to prolong dying is not." Thus, in the Jewish medicoethical tradition, "removing impediments to death" is sometimes acceptable -- that is, discontinuing treatments that needlessly prolong the dying of a suffering, terminally ill patient, but without actively bringing about the patient's death. (The distinction between "letting" someone die and "making" someone die was supported in the 1997 US Supreme Court case of Vacco v Quill,^[7] which upheld New York State's ban on assisted suicide.)

But what about those suffering, terminally ill, mentally competent patients who will not choose to end their lives by refusing food and drink and instead seek out "assistance" from healthcare professionals? Again, I do not believe that medical professionals should participate in assisting a patient's suicide. But I sometimes wonder whether society ought to permit somebody to do so.

For lack of a better term, let's call such a hypothetical individual a "thanatician." Let's posit that carefully trained and closely monitored thanaticians would be permitted to provide medically screened, dying patients the same type of lethal medication now prescribed by physicians in Oregon and Washington -- under essentially the same restrictions and safeguards.

But wait: Isn't this proposal a cop-out? Doesn't it merely place the moral issue of assisted suicide in the lap of the nonphysician, allowing the dying patient's physician to shuffle off with a clear conscience? Even worse: Would the use of such death-dealing personnel amount to abandonment of the patient, as Dr. Geppert recently suggested to me?

Still other questions arise. As my colleague Dr. James L. Knoll has suggested, might not the training, monitoring, and supervising of thanaticians create more problems and headaches than it would solve? Finally, doesn't the very notion of "thanaticians" suggest that we have lost faith in what Dr. Knoll rightly calls "the intensely personal journey" of doctor and patient?

I, too, struggle with these questions and find no easy answers. I suspect that at present, the best approach to the dying patient is through the skills of the palliative care physician. Palliative sedation, for many terminally ill patients, may be a viable alternative to managing suffering without ending life. Moreover, a careful psychiatric assessment of patients requesting physician-assisted death is always indicated, because major depression may distort the patient's judgment as death approaches.

How we deal with terminally ill patients is a painful topic that I never discussed with my mother, who was fortunate enough to have excellent home hospice care in her final days. But I believe this is a discussion we urgently need to have.

Acknowledgment: I wish to thank Cynthia M.A. Geppert, MD, PhD, and James L. Knoll IV, MD, for their valuable comments on earlier drafts of this article. The views presented here, however, are solely my own.

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CEBID - Centro de Estudos em Biodireito