Thursday, February 14, 2019

Why Norway and Sweden Should Not Allow Physician-Assisted Suicide

(youtube video of his presentation)
Mark Komrad completed a 4-lecture tour of Norway and Sweden where he presented arguments to prevent the development of legislation and associated policies that would permit physician-assisted suicide (PAS) or euthanasia. He spoke to Members of Parliament, academics, physicians, other health care professionals, students, advocacy organizations, and members of the public. He also debated with proponents of these practices in Norway.
 

This article was translated and published in newspapers in conjunction with his appearances and is reprinted with permission.

Dr Mark Komrad
By Mark S. Komrad, MD 
Faculty of Psychiatry: Johns Hopkins, University of Maryland, Tulane University

The 2300-year-old history of medical ethics is grounded in the core ethical foundations established at the dawn of medicine — the Hippocratic values “professed” by physicians as a covenant-based community of values. This is the meaning of the word “profession.” The most distinguishing principle of the Hippocratic Oath has been the tenant rejecting the practice of euthanasia: “I will give nobody a poison, nor counsel any others to do so.” This is the root of the mighty tree from which the House of Medicine was built, this value persisting as societies and their demands have come and gone. To this day, the World Medical Association and many other major medical organizations continue this venerable and persistent ethical stance against physician-assisted suicide and euthanasia.

Several governments, in the last two decades, have invited and permitted physicians to transgress this prohibition against killing their patients. For example, Oregon, Canada, and Benelux have asked physicians to provide the means for certain patients who request the means to commit suicide or receive a lethal injection. These laws have empowered one class of human beings (ironically, physicians) to literally take the life of another class of human beings. Originally, the class who can be voluntarily killed or helped to suicide was limited to those at the very end of life. However, principles of justice have made it very difficult to limit such procedures to that category of people. The more experience a country has with such practices, the more the horizon of eligibility has expanded far beyond extreme end-stage cases.

In Oregon there is no way to distinguish between encouragement and coercion by those who “support” terminally-ill loved ones taking lethal drugs prescribed to cause death. There are no regulations to keep lethal prescriptions from being diverted. There is evidence of a contagious increase in ordinary suicide, subsequent to legalizing assisted suicide. New legislation is being pursued there to move to more active euthanasia and to make prognostic criteria for eligibility more vague. The law even allows patients whose conditions are not considered “terminal” to make themselves so, by choosing to refuse life-sustaining treatments — diabetics stopping their insulin, for example.

In Canada, the rate of euthanasia increased by 30% in the last half of 2017. One province has declared that it is neither ethical nor legal for a conscientiously objecting physician to refuse to refer a patient to a colleague who is more open to providing euthanasia. As is the nature of assisted suicide and euthanasia laws, suicide has been converted from a freedom to a right. Refusing to participate in the chain of duty to service that right can have adverse legal and professional consequences for some Canadian doctors. In Sweden, there are already adverse professional consequences, supported by law, for those qualified health care practitioners who refuse to provide abortion on demand, prior to 18 weeks. Such an established pathway mandating physician participation, even against conscientious objection, would be an existing, facilitated channel into which legalized assisted suicide in Sweden would easily flow.

In the Benelux, where these practices have evolved over 18 years, and 4% of all human deaths are by physicians’ injections, the slope has slipped to include eligibility for those with non-terminal illnesses, psychiatric conditions, young children, and uncomfortable lifestyles. Advanced directives and proxy consent for euthanasia of the incompetent are honored. There are strong advocacy efforts to de-medicalize the criteria for such procedures by allowing those who are “tired of living” or feeling that their life is “complete” to ask for euthanasia, with the hopes of developing a “suicide pill” that can be obtained without a medical evaluation or prescription — a high sanctification of autonomy. Organ donation by those seeking euthanasia is encouraged as a “virtue opportunity.” 


The profound changes to a civilized society produced by such laws are unnecessary and undesirable. The suffering and disabled should have even more access to the very latest, state-of-the art palliative care, without it being economically or morally short-circuited by institutional killing promoted as a seductive virtue — referring to it as “dying with dignity” or self-determination. The so-called “choice“ that is offered to the suffering to end their lives is a pseudo-choice, filtered through a physician’s own values, and commonly forced, by having very limited choices in other domains — economics, social support, healthcare, etc. It is unjust, and therefore impossible, in a democratic society, to limit these procedures to some — like the terminally ill — but refuse it to others — like those with chronic physical and psychiatric disabilities. Yet, it signals that chronic disability and its sufferings might constitute a “life not worth living.” It is an unfair and confusing public health message to designate one category of people who are helped to suicide, but another who are actively prevented from doing so with psychiatric care. It elevates autonomy as a value that overshadows, even crushes, other values that are necessary for the common good. 

Medicalizing suicide out-sources to the medical establishment the moral responsibility for a taboo about taking one’s own life by suicide, reducing the moral deterrence to suicide and lowering the threshold of acceptability for all suicide. It takes the protected and vital ethos of health care professionals away from their millennia-old Hippocratic commitment to be providers of comfort, hope, and healing, to become providers of death, not just supporters of the dying.

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