Please don’t allow me to kill people: an open letter to Scott Adams

(Last Saturday, Scott Adams, the creator of the brilliant comic strip “Dilbert,” wrote in his blog a raw piece about physician-assisted suicide, which has created something of a stir. If you wish to read it, it is here; but I warn you, it is not pleasant reading, and it is full of profanity.)

Mr. Adams,

My deepest, deepest condolences. I don’t know you, but I am a Family Physician, and I have stood more times than I can count at the bedsides of people going through situations similar to your father’s. I have sat in too many rooms with families as their loved ones have withered away; too many times, I have been unable to offer healing, but only comfort, support, presence, and respect for the dying and his or her family.

Please don’t ask me to offer more than that. I know your blog post was written in the midst of “hideous unpleasantness,” and I can pardon your wish for me to die a slow, horrible death because I am opposed to using my power to kill people. But such extreme frustration, grief, and anger as you are experiencing is not in itself an argument for giving one class of people the right to kill others.

A long time ago, we doctors did kill people. We with the power to heal have always had the power to kill, and at one time we were allowed to use both powers indiscriminately. We were salesmen, technicians, offering whatever the customer wanted, whatever the market would bear.

But then someone, or maybe it was a group of people, who assumed the name “Hippocrates,” came out and said, “No more. We will not use our power to kill people. We know that Power can be used for good. But Power by its very existence begs to be used, and it knows no distinction between good and bad uses. We are well-meaning, but we know we are flawed. Therefore, we will place the most stringent restraints we know on our Power: we will not use our Power for killing.” And it was at that moment that we stopped being technicians and became Professionals.

But our record isn’t perfect. As recently as the middle of the last century some of our number in Germany thought we could safely use our Power to kill for beneficial purposes. And more recently, our colleagues in a few European countries — and now a few of our own states — have been given the go-ahead to use our Power (oh, so much greater now than in Hippocrates’ time) for just the purpose you advocate: to actively end a person’s life. And I must gently dispute your assertion that such policies are working “with little problems.” On the contrary, the problems those policies are facing are huge ones.

So please, don’t ask the government to give me the power to kill. I am human, like you, and, even with the best of intentions, I can’t properly handle such power. You can ask me not to abandon my dying patients. You can ask me to sit at my dying patients’ bedsides and weep at their funerals. You can ask me to do whatever I can to help their families. You can ask me to stop using unwelcome powers of healing that serve no other purpose to keep bodily functions going, and I will gladly comply; and I will use every bit of power within my reach to help alleviate pain, short of killing the sufferer. I will do it all in “com + passion,” which literally means “suffering with.”

But please don’t ask me to end suffering by using my Power to do away with the sufferer. Because there are just some things a Doctor shouldn’t do.

 

Clarifying the arguments regarding physician assisted suicide

The citizens of Massachusetts will be voting on a proposed death with dignity law that would make physician assisted suicide legal in Massachusetts similar to the states of Oregon and Washington. An article in the Atlantic by Wendy Kaminer earlier this week titled “How the Catholic Church Misunderstands Death With Dignity” critiques what Cardinal Sean O’Malley has said in opposition to the proposal. While I am not a Roman Catholic, Cardinal O’Malley’s statements that are being criticized fall within the established ideas of Christian ethics and are not specific to Roman Catholics.

One thing he said was that there is a moral distinction between treating pain with whatever amount of medicine is needed to control the pain even if the pain medicine may unintentionally lead to a shortening of the person’s life and intentionally using medicine to end a person’s life. He is correct that intent is morally significant. A surgeon who undertakes a very risky surgery at the patient’s request even though it is known that the patient is likely to die is doing something morally very different from one who intentionally kills the patient. The importance of intent in the distinction between morally appropriate palliative care and euthanasia was criticized by saying that while God knows each person’s intent, law enforcement officials do not and that physicians would be inhibited from giving adequate palliative care out of fear that they would be accused of killing the patient. This critique neglects to realize that adjusting pain medicine based on the patient’s response to pain is quite different from giving an intentional overdose and can be properly documented to make the intent clear.

Another thing that was not understood in the critique of Cardinal O’Malley was his use of the concept of a life not worth living. One of the fundamental moral objections to physician assisted suicide is that it assumed by the proposed law that there are some people whose lives are not worth living and that the physician who assists in a patient’s death must confirm that the patient’s life is not worth living. The idea that every human life has meaning and value is a protection for those who are the most vulnerable in society. If we say that someone can make a determination that there is any human life, even that of a terminal patient, that is not worth living, then we are removing that protection from the most vulnerable in society. That has been a reason why some of the most vocal opponents of assisted suicide have been disability rights advocates who cling to the protection provided by the concept that every human life has value. Cardinal O’Malley’s affirmation of the statement by the US Conference of Catholic Bishops that “a society that devalues some people’s lives, by hastening and facilitating their deaths, will ultimately lose respect for their other rights and freedoms” is an expression of the importance of forbidding any determination that a person’s life is not worth living. This is a significant moral concept and not statement that “makes little sense.”

A third problem with this critique of the objections to physician assisted suicide is the idea that it can be logically limited to voluntary, self-administered, lethal prescriptions for the terminally ill. If the intentional ending of human life is accepted as a legitimate way to deal with suffering then there is no way to logically limit it to voluntary action or the terminally ill. This is not an empirical argument, but a logical one. The reasons for accepting the intentional ending of a human life by physician assisted suicide as permissible are seeing it as a form of compassion and seeing it as an expression of the person’s autonomy, but as Gilbert Meilaender has expressed (Bioethics: A Primer for Christians, p 60-61) the arguments from compassion and autonomy do not need to be taken together. If they are reasonable arguments they can stand alone. If compassion is a reason to accept physician assisted suicide, then it is not reasonable to deny the use of death as a way to end the suffering of someone who is suffering just as much but is unable to swallow the prescribed medicine or who has become unable to make her own decisions or who is an infant who is suffering unbearably. If autonomy is a reason to accept physician assisted suicide, then it is a reason to accept death as an end to the suffering of those who choose it whether they are terminal or not and no matter what type of physical or emotional suffering has caused them to choose to die. There is no logical reason to restrict the use of death as a means to relieve suffering to just those who are terminal and able to give themselves the fatal dose of medicine.

When the arguments against the permissibility of physician assisted suicide are looked at more clearly, they provide a more reasonable basis for deciding that we should not allow this to be a part of our society than Ms. Kaminer would suggest. They are not a misunderstanding of physician assisted suicide, but a clear understanding of what accepting the use of death as a means of ending suffering means to our society.

Physicians’ role in assisted dying

In a recent Perspective article in the 7/12/12 issue of the New England Journal of Medicine, Julian J.Z. Prokopetz and Lisa Soleymani Lehmann take an interesting perspective on what physicians’ role in assisted dying should be. Although they admit that assisted dying, in which patients acquire a lethal dose of medicine with the explicit intention of ending their life (also known as assisted suicide), is generally illegal, they take the position that assisted dying is a desirable way for terminal patients to express their autonomy. They see anything that would hinder patients from being able to do this as a barrier that needs to be removed. They mention several of the objections that have been raised against assisted dying, but do not give much credence to any of them including the concern that participating in the intentional ending of a human life goes against the sanctity or inherent value of human life.

What is most interesting, particularly for Lehman who is a physician, is how they regard the objections to allowing assisted dying that are made by physicians. They note that in a 2003 survey of AMA members 69% objected to physician assisted suicide, and that there are national and state medical associations (including the AMA) that are officially opposed to physician assisted suicide. They note that those physicians “believe it’s inappropriate or wrong for a physician to play an active role in ending a patient’s life.” Their response to that is to suggest that physicians be relieved of the role of providing the lethal dose of medicine to those who request assisted dying. They propose that physicians be limited to determining the patient’s prognosis so the patient can take that information to a government agency to prescribe the lethal medication.

This proposal has some interesting implications. It assumes that the majority of physicians who are opposed to physician assisted suicide have no good reason for why they are opposed. It says that when those who care for the dying say that they do not think that helping those who have a terminal illness kill themselves is the best way to care for those patients we should pay no attention to them. It takes respect for autonomy to the extreme that says the physician should just provide diagnostic and prognostic information and the patient should get their treatment from a technician who simply does what the patient asks, even if that is to help kill the patient.

It is correct that one of the objections to participation in physician assisted suicide that physicians and physician organizations have is that it runs counter to the fundamental principles of the medical profession which is focused on providing care that is in the best interest of their patients and not doing harm to those patients by helping them kill themselves. Rather than suggest that physicians who have those principles should be circumvented, it would be good to recognize that the underlying principles of the medical profession which make assisting in suicide incompatible with the profession are good principles for anyone who is caring for those who are ill or dying. It is not just that assisted dying is incompatible with the medical profession; it is incompatible with caring for those who are dying in a way that respects the value of their lives as human beings.

Finding a way around those physicians who want to protect their patients by not participating in assisted suicide is like finding away to drive around those pesky crossbars at a railroad crossing that keep me from going where I want to go. Both are assertions of autonomy that fail to understand that there are good reasons that there are some things we should not do.

Human rights and euthanasia

The Parliamentary Assembly of the Council of Europe recently added an amendment to a resolution on advance directives to state that “euthanasia, in the sense of the intentional killing by act or omission of a dependent human being for his or her alleged benefit, must always be prohibited”. It is refreshing that the body charged with harmonizing the human rights laws among European states, and which bases its decisions on the European Convention on Human Rights, appears to have understood that the protection of human rights should lead to the prohibition of euthanasia.

Those who promote euthanasia see human rights in terms of individual autonomy and the ability of an individual to do whatever he or she wants. If we understand more clearly what is involved in human rights it is easier to see why those charged with upholding human rights should prohibit euthanasia.

Universal human rights are based on an understanding that all human beings have an inherent moral worth by virtue of being human beings. There are no characteristics other than being a member of the human family that are needed for a person to have full moral worth. The intentional ending of an innocent human life is a violation of the inherent worth of that human life. Since the inherent worth of every human life is the foundation of universal human rights, euthanasia is an attack on the foundation on which all human rights depend.

The Council of Europe appears to have made that connection.

Safe Passage

I came across this description of the duties of a physician, from an 1858 lecture to medical students:  diagnosis, treatment, the relief of symptoms, and the provision of safe passage.

The provision of safe passage struck me as a concept we would do well to rehabilitate.  It is an evocative phrase:  protecting and helping someone on a long voyage.  That is generally not how we are taught to think about death in medical school.  Death is failure!  It is a cliff, a precipice to be avoided, rather than a voyage that everyone ultimately has to make.  We have a tendency to approach the precipice in one of three ways:  most often, we try to keep the dying patient from falling over the edge, wrapping them up and pulling them back  from the brink with ventilator hoses and feeding tubes and intravenous drips and every heroically inappropriate medical intervention and test we can conceive of;  or we realize that there’s nothing we can do, so we abandon them;  or, increasingly, in the name of “compassion,” we push them over the edge with physician-assisted suicide.  What a difference it could make if, instead of treating death as a precipice from which we attempt to keep a patient indefinitely, we understood death as a voyage each person will have to make.  What a difference if, instead of being trained to stave off the inevitable at any cost, doctors were trained to recognize — and to help patients recognize — when the voyage is approaching, how to help patients to prepare for it, and how to help them to make it a “safe passage,” a good death for them and their families.

 

Suicide Assistance for Sale

The Oregon Senate recently approved a bill to ban the sale of suicide kits.  It is interesting that this occurred in the first state to legalize physician assisted suicide.  The move was in response to the death of a 29-year-old Oregon man who suffered from depression related to problems with pain and fatigue and took his life using a helium hood suicide kit that he bought by mail order for $60.  The helium hood method of suicide was developed and promoted by Derek Humphry and the kit was sold by a follower of Humphry to whom he refers business.  Humphry, who lives in the same area in Oregon as the man who committed suicide, founded the Hemlock Society that was a primary force behind the passage of Oregon’s assisted suicide law.

Although the Oregon law he helped to pass limits physician assisted suicide to those with a terminal illness, Humphry made it clear in an interview with The Register-Guard, the local Eugene, Oregon newspaper, that limiting assisted suicide to those with a terminal illness is not important to him.  Speaking of this particular case, Humphrey said, “It may be very sad and tragic, but if this man had ongoing health issues and had struggled with that, I wouldn’t criticize his decision.  It was his right.”

The logic of assisted suicide is clear.  If we accept that ending the life of the sufferer is an appropriate response to suffering and that a person who is suffering should be able to request assistance to end his or her life, then there is no reason to limit that assistance to those whose suffering we think is intolerable or who are terminal or who request the assistance from a physician.  A mail order kit fits the logic just as well.