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”?

Physician-Assisted Suicide and Canada…Again

Though a relative “latecomer” in the legalization of physician-assisted suicide (PAS), Canada seems determined to make up for lost time. Already the question of organ donation after PAS has been raised. Very recently, the medical “savings” made possible by the legalization of PAS in 2016 was brought to light.

The January 23, 2017 volume of the Canadian Medical Association Journal (CMAJ) published the results of a study by Aaron J. Trachtenberg and Braden Manns titled, “Cost Analysis of Medical Assistance in Dying in Canada.” The authors stated that the aim of the study was “to determine the potential costs and savings associated with the implementation of medical assistance in dying.”

The study found that the legalization of PAS will save the Canadian healthcare system between $34.7 and $138.8 million per year; a savings far exceeding the $1.5 to $14.8 million in direct costs associated with the implementation of PAS (physician consultations, drug costs, etc.). Following the lead of a study conducted in the Netherlands (where both PAS and voluntary active euthanasia are legal), the researchers considered the following factors in their calculation: (1) the effect of PAS on patients’ longevity of life (patients requesting PAS would not live as long as patients choosing palliative care); (2) the average cost of care for end-of-life patients suffering from various diseases, especially cancer; and (3) the expected number of PAS deaths. The conclusion was that patients electing PAS will “save” the healthcare system millions of dollars that otherwise would have been spent on their palliative care.

The obvious first question is why would the CMAJ, Canada, or the authors be interested in the cost savings associated with PAS? More than curiosity must have driven the study. Seemingly, the main impetus was to gain assurance that the implementation of PAS was not costing more money than offering palliative care: “Our analyses suggest that the savings will almost certainly exceed the costs associated with offering medical assistance in dying to patients across the country, and that the inclusion of medical assistance in dying in the services covered by universal health care will not increase health care spending.”

Nevertheless, the researchers must have felt some uneasiness about the perceptions this study might generate. Thus, they assure readers of the study: “We are not suggesting medical assistance in dying as a measure to cut costs. At an individual level, neither patients nor physicians should consider costs when making the very personal decision to request, or provide, this intervention.”

Alex Schadenberg, the executive director of the Euthanasia Prevention Coalition, doesn’t feel assured (“Awful Study Says Euthanizing More Patients Will Save the Government Money,” Ottawa, Canada, January 24, 2017). First, he points out that associating PAS with cost savings implies that it is a social good. I agree. When health care costs are covered primarily by the government, as they are in Canada, the prospect of “saving” tens of millions of dollars might easily be seen as best decision for the (financial) good of the country. Second, connecting PAS with significant financial savings pressures patients to elect PAS rather than continuing to live. Again, I agree that this is a legitimate concern. There is evidence that some patients, at the end of life, worry about being an emotional and a financial burden to their loved loves. If patients are aware of the findings of this study, they might also come to feel that their continuing existence is a burden to State as well.

The study might well assure Canadian power brokers that PAS will greatly strengthen the financial stability of the health care system. As Schadenberg points out, “Dead people don’t need palliative care.”

However, the study does little to encourage sick and dying patients to live out their remaining days, convinced that a willing and compassionate healthcare system will provide necessary and effective palliative care. When patients are struggling with the decision to request PAS or to continue living, I wonder if the findings of this study will ever rattle around their minds. Will any patients think at this very vulnerable moment, “But I could save the country a lot of money and my family a lot of trouble if I would just go ahead and die”? I hope not. But with the publication of the findings of this study, it is not unimaginable that they would.

Christianity and Physician-Assisted Suicide (2)

October 10, 2016

A few blogs ago, I discussed a Time op-ed that spoke of a Christian perspective to physician assisted suicide. Understanding that Christian is a hopelessly ambiguous term, I wanted to see if there was anything noticeably Christian about the op-ed.

My reflection at the time was that any advocate of PAS – Christian, religious, spiritual, or secular—could have written the piece. The only spiritual elements were prayer and having peace with the decision.

Last week Archbishop Emeritus and Nobel Peace Prize laureate Desmond Tutu wrote an op-ed in the Washington Post stating that as he grows older, he wants to lend his voice to the cause of “death with dignity.” What makes Tutu’s op-ed interesting to me is that he couches his conclusion in the language of Christianity: “In refusing dying people the right to die with dignity, we fail to demonstrate the compassion that lies at the heart of Christian values.”

The question, of course, is whether or not PAS is an adequate expression of Christian compassion to the dying? Tutu places the choice starkly: if you don’t allow PAS, people will suffer horribly. It is almost as if to him palliative care is a non-entity. He overlooks the historic Christian example of providing comfort and support to the dying, be it the believers of the early church or the contemporary hospice movement.

I have long agreed with those who think that love should be at the center of Christian ethics, because of its central place in the teaching of Jesus (see the “Two Commandments” of Matt 12:37-38). Tutu’s invoking of compassion as the Christian basis of PAS makes me think that further clarification of what it means to love is very much needed.