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Physician-assisted suicide? Controlling timing and manner of death is outside scope of medical practice — Dr. Michael T. Vest

A woman is pictured in a file photo holding a sign during a rally against physician-assisted suicide on Parliament Hill in Ottawa, Ontario. Canadian bishops urged political leaders to reconsider changes in a bill that would expand physician-assisted suicide. (CNS photo/Art Babych)

By Dr. Michael T. Vest

I am physician practicing critical care medicine who lives in Hockessin. I oppose any proposal for legalization of physician-assistant suicide (also called physician aid in dying or medical aid in dying).

While there are many pragmatic arguments against physician-assisted suicide, the most compelling arguments for why no physician should be allowed to participate in the intentional death of a patient are ethical. In considering the issue of physician-assisted suicide from the medical ethics viewpoints of beneficence, non-maleficence, autonomy, and justice, the only principle not in opposition to physician-assisted suicide is respect for autonomy. In fact, IF we had appropriately resourced palliative care services to manage symptoms the only reason for requesting physician-assisted suicide would be the patient’s desire to control the exact timing and manner of their death. However, controlling the timing and manner of death is outside the scope of medical practice.

Proponents of physician-assisted suicide often state it gives patients with refractory symptoms a choice. It is horrible to hear that someone died with untreated pain, anxiety, or shortness of breath. Further it is currently unnecessary that this occurs. It does occur only because the healthcare system fails to adequately utilize the tools currently available.

When my own father was diagnosed with pancreatic cancer, advocating to get him the care he needed made me feel like Ethan Hunt in an episode of Mission Impossible. This was the case despite my father having excellent health insurance coverage, me being a physician, having a good understanding of what he needed, and having personal/professional contacts within the healthcare system. For the average person, navigating the healthcare system isn’t just like mission impossible, it is an impossible mission. Offering the “choice” of physician-assisted suicide without the option of optimal medical care seems cruel – this is the cruel “choice” that HB 140 offers. Listening to the testimony of the public and comments from legislators in committee hearing (last month), I was struck by how commonly unnecessary pain and suffering occurs. However, HB 140 will do nothing to fix that.

Giving the same system which is currently failing end-of-life patients the ability to prescribe medication with the intent to end the patients’ lives will not improve this and is not a good reason for allowing this practice.

A demonstrator against assisted suicide joins a protest outside Parliament in London in 2015. (CNS photo/Stefan Wermuth, Reuters)

Further, allowing physician-assisted suicide will result in a slippery slope effect. If I am allowed to end my life by taking a medication by mouth, it seems unfair that someone who is exactly like me in every way except that he lacks the physical ability to take a pill is not able to. So, in the interest of fairness to a person who cannot self-administer the medication, a bill such as HB 140 should be amended to allow another person to give the medication. The slippery slope effect is not a farfetched theory, it is logical to assume that law would need to be adjusted in this way in the interest of fairness.

If the intentional taking of human life is legalized for terminal ill patients, this implicitly diminishes the value of all human life particularly for people with severe physical or mental disabilities. Many of the arguments offered by proponents of physician-assisted suicide also work well to advocate for euthanasia. If euthanasia is allowed for medical patients, then fairness may require that patients with unrelieved suffering due to psychiatric disease also have this option, as is the case in the Netherlands. In April of 2016, JAMA Psychiatry published a report of 66 patients who underwent euthanasia in the Netherlands due to psychiatric disease such as depression causing “irremediable suffering.” The paper raised many questions about the process particularly questioning whether these patients could have had their suffering remediated with better treatment of psychiatric disease (20% had never had a psychiatric hospitalization which presumably would be helpful for treating severe psychiatric disease). To prevent the slippery slope effect, we need to draw clear lines that can never be crossed. One such line needs to be the intentional killing of a patient regardless of whether the patient or provider administers the lethal treatment.

One example of the slippery slope is the death of three patients with “terminal” anorexia nervosa (a psychiatric disease) through medical aid in dying by prescription from a respected Colorado physician. Importantly, this was not something done in secret or with the idea that it was bad. The physician who prescribed the medication authored a paper describing the criteria she used to select patients with anorexia for medical aid in dying. If it were not for her paper, we would probably not know about these cases. A psychiatrist from Johns Hopkins University has authored a paper describing the cases and reasons it is not a good idea (Guarda et al.Journal of Eating Disorders (2022) 10:79).

My experience as critical care physician also suggests that we cannot even accurately identify terminal illness. I have had patients where I initially told their families that I thought I could help them get through a critical illness only to see them progressively worsen and die over hours despite our best efforts. I have also had the pleasure of meeting former ICU patients for whom I, my critical care colleagues, and multiple consultants had repeatedly told their families there was no hope of survival, walking through the lobby of the hospital on their way to outpatient appointments. Given the fact that errors in diagnosis and prognostication are common in current practice despite diligent work to prevent them, it’s inevitable that these errors will be seen in conjunction with any future practice of physician-assisted suicide. However, the consequences of these errors for the patients and physicians will be more severe.

In the ICU it is common for families, especially families of patients from historically marginalized groups such as racial minorities and patients with severe disabilities, to express concern that the medical team does not have their best interests at heart. I have been accused by angry family members of killing or trying to kill their loved one. This lack of trust would be made exponentially worse if physicians were engaged in intentionally prescribing treatment intended to cause death.

While some physician groups support or have opted to take neutral positions on this issue, many in the medical community are firmly opposed. Sometimes the neutral position has been opted to appease a minority within the organization that unfortunately want to add physician-assisted suicide to their practice.

Rep. Paul Baumbach is the sponsor of the physician-assisted suicide bill in Delaware. Dialog photo/Joseph P. Owens

The American College of Physicians, which is a national organization that represents internal medicine physicians, is firmly opposed. It might also be worth noting that despite the politicians in (last month’s) committee hearing using the term “choice” which is often used in discussion of abortion, many physicians and secular medical ethicists view these issues as completely unrelated. As noted above the American College of Physicians strongly opposes legalization of physician-assisted suicide/medical aid in dying but equally strongly supports legalized abortion on demand.

I also learned something interesting listening to the committee hearing on HB 140. One of the representatives asked Rep. Paul Baumbach for the survey question which he cited to say 70% of Delawareans support physician-assisted suicide. When he read the question, it talked about physicians acting in good faith to help a dying patient and unless you had physician-assisted suicide on your mind, the average person responding might not have realized that was the issue. I thought when he read it that it would be easy to mistake that question as asking something like, “If a physician in good faith trying to relieve suffering accidentally kills a patient is that OK?” It would not be surprising at all that majority of people opposed to physician-assisted suicide would be OK with a physician who was not trying to cause death doing so unintentionally in effort to alleviate suffering – medical ethicists and theologians also support that and call it “the principle of double effect.” That is one of the reasons that HB 140 is NOT needed to relieve intractable pain, for example, at the end of life – optimal medical care at end of life currently includes achieving adequate pain relief even if it had the unintended effect of hastening death (which it usually does not).

To the Delaware legislators, I am happy to be a resource in any way in terms of understanding the medical issues surrounding this issue. Please do not hesitate to contact me.

In summary, even in the unlikely event that the practical objections to physician-assisted suicide could be overcome, the damage to medical professionalism and the physician patient relationship would make this practice unethical. The provision of treatment intended to cause death is incompatible with the duties of physicians and should never be permitted under any circumstances. We must continue to strive to provide compassionate care to patients at the end of their life but also recognize our limitations as human beings. One of our limitations as humans is that we cannot determine or decide the exact time or manner of our deaths.

Please do everything you can to oppose HB 140.

Dr. Michael T. Vest, DO, FACP, FCCP, FCCM, is a physician in Delaware