Whatever Happened to the Instinct that ‘Doctors Must Not Kill’?

In a 1992 article in the Journal of Clinical Ethics titled, “Doctors Must Not Kill,” renowned physician and bioethicist Edmund Pellegrino reminded fellow physicians—with incisive logic and strong passion—of their historic duty to be healers, not killers. As one who is not a physician but will one day be a patient facing the end of his life, I would take comfort in knowing that my physician was committed to heal me and, if healing were not possible, to provide me comfort and care to the day of my natural death. Pellegrino’s plea that “doctors must not kill,” however, evidently is falling on the deaf ears of more and more physicians.

The notion that mercy can entail ending the suffering of a patient by ending his or her life, combined with an almost uncritical acquiescence to patient autonomy, seem to be the major factors behind the increasing acceptance by physicians of PAS (physician-assisted suicide). According to the Medscape Ethics Report 2016, 57% of physicians believe PAS should be available to terminally ill patients who request it, up from 54% in 2014 and 46% in 2010. This aligns with the increasing public acceptance of PAS. A 2016 Gallup Poll found that 68% of Americans support the legalization of PAS, up 10% from the previous year.

What happened to the instinct that “doctors must not kill?” One would hope that this instinct runs deeper than even the historic commitment of physicians to be healers first and foremost. One would hope that it is, at its most basic and fundamental level, a human instinct.

I personally know a young police officer who recently resigned because he experienced this instinct not to kill. Facing numerous tense situations over the course of five years, he had drawn his service weapon dozens of times but, thankfully, had never been forced to fire. That nearly changed when he was charged by a machete-wielding man sky-high on drugs. “Sir, drop your weapon,” he repeated again and again to no avail, as the man quickly closed the distance. For the first time in five years, he exerted pressure on the trigger of his Glock. Two more steps by the man and two more pounds of trigger pressure by the officer, and both lives would be altered forever. One would be dead and one would have to answer for a split-second decision to use lethal force. Fortunately for both, the man loosened his grip on the machete and it fell to the ground. The officer breathed a sigh of relief.

“Dad,” my son told me, “I wasn’t afraid. I would have pulled the trigger if he had taken two more steps. I knew I would have been justified in doing so. But he wasn’t a murderer, a rapist, a bank robber, or a terrorist. He was just a crazy fool out of his mind on drugs. And though he was an imminent threat to my life, I didn’t want to shoot him.” Waxing philosophic, he added, “In that moment, I realized how unnatural it is to take the life of another human being. The instinct not to kill was overwhelming. Yes, I would have shot the man had he taken two more steps. But then I’d have to live with that decision the rest of my life.”

Granted, the case of a police officer deciding whether to shoot is different in many important respects from the case of a physician deciding whether to prescribe lethal drugs where PAS is legal. What intrigues me now, however, is that very strong instinct my son felt that night; that taking the life of another human being – even when legally justified – went against the very grain of his humanity. What does it say, then, when physicians who have sworn historically to be instruments of healing are now willing to be instruments of death? What happened to that instinct and commitment that Dr. Pellegrino so forcefully affirmed, “doctors must not kill”?

A brief thought on rising suicide rates

A recent article in The Washington Post describes a very disturbing trend: “The U.S. suicide rate has increased sharply since the turn of the century, led by an even greater rise among middle-aged white people, particularly, women, according to federal data released Friday [April 22]” The article offers some suggestions as to why things have been so grim: last decade’s severe recession, drug addiction, social isolation, and the rise of the Internet and social media are among some of the possible explanations. Beyond this, the authors suggest, “economic distress—and dashed hopes generally—may underpin some of the increase, particularly for middle-aged white people.” These explanations are all plausible.

I am wondering, however, if something is missing from this analysis. Economic distress is not the only relevant factor in the United States from the past 15 years. We have also witnessed an increase in the presence of “assisted death” laws.  Procon.org states that four states have legalized physician-assisted death via legislation (California [2015], Washington [2008], Oregon [1994], and Vermont [2013]) and  in one state it has been permitted through court ruling (Montana, 2009).  Might it be that these laws and the public debate that accompanies them have changed people’s attitudes towards suicide? There is a certain kind of logic here. If death with dignity is an ultimate good, why is it limited only to those who are terminally ill?  If I have suffered an irreversible personal loss – my job, my wealth, or my family – why can’t I logically conclude that enough is enough and decide to end it all?

I am not suggesting that the physician assisted death laws are the cause of the higher suicide rate. I am simply wondering about their overall impact on our cultural thinking on death and dying. Although The Washington Post article is accompanied by helpful information from the American Foundation for Suicide Prevention, and many compassionate people and organizations are committed to providing help to those in need, it might be that in the current cultural climate, the goal of suicide prevention has been made more difficult.