Monday, November 25, 2019

Psychiatrists Must Prevent Suicide, Not Provide It

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition



Psychiatrists Cynthia Geppert, Mark Komrad, Ronald Pies and Annette Hanson are leading voices against the involvement of Psychiatrists in the acts of euthanasia and assisted suicide. 

During the past several months there have been a series of articles and rebuttles between Geppert, Komrad, Pies and Hanson with Drs Kious and Battin. Dr Margaret Battin is a long-time euthanasia activist who has published articles and studies since the 1980's.

The recent rubuttal with Kious and Battin was published in the Psychiatric Times on November 19, 2019. The recent Geppert et al response concerns the following:

Kious and Battin argue that the long-established practice of psychiatrists to make every effort to prevent suicide including the use of involuntary commitment and the relatively new availability of physician aid-in-dying (PAD) create a moral dilemma. Their proposed resolution of the dilemma is to permit psychiatric patients, as well as those with medical illnesses, to access PAD when their suffering is severe and irremediable. Our commentary rejects the fundamental presumption that any physicians, much less psychiatrists, should be involved of the work of killing rather than the calling of healing, among other criticisms.
Cynthia Geppert
Kious and Battin argue that the majority of Americans support assisted suicide, but Geppert et al suggest that polling alone does not determine right or wrong, that in fact a deep analysis of the issue is necessary. Geppert et al argue that the research by the American Medical Association, the World Medical Association and more enables a better understanding of the issues. They state:
This “deep dive” is precisely the process that was brought to bear by the American Medical Association (AMA) and the World Medical Association (WMA) in their recent reexaminations of their ethical opposition to these practices.4 That process was repeated several times at the request of PAS proponents, and each time, though acknowledging the caring intentions on both sides of the issues, these organizations kept coming to the same conclusion—that these practices are “firmly opposed.” Similarly, for the second largest medical organization in the US—the American College of Physicians5—and even for the organization that works professionally in the “end-zone” of life—the International Association for Hospice and Palliative Care6—these and other articulations, are not mere polls. They are robust deliberations by organizations representing physicians and others, whom society is asking to do the killing. Moreover, no medical organization in the US has actually endorsed PAS as a laudable practice so far. At most, those organizations not opposed to PAS have expressed official “neutrality” on this issue.
Kious and Battin argue that Geppert et al hold to a position of essentialism and historicism, which they suggest changes over time. Geppert et al respond:
We now turn to Drs Kious and Battins’ critique of our philosophical position as “essentialism” and “historicism.” If by “essentialism,” they mean that we hold certain medical ethical truths to be constant, enduring, and not “will-o-the-wisp” notions dependent on polls and plebiscites, then, yes—we are guilty of “essentialism.” While we would acknowledge that “evolving social expectations” do have some influence on “what is permissible for physicians,” we would deny that such expectations are infinitely elastic and determinative, vis-à-vis what is ethically permissible. Would the authors change their own position favoring “assisted dying” if new polls showed that most physicians oppose the practice? Or do they base their position in favor of PAS on their own view of what is “essential” to the role of physicians? If we make medical ethics dependent upon polls, we are opening the field to a kind of post-modern relativism that undercuts the very concept of a “profession.” Medical ethics are not a kind of weather vane, changeable with each new poll that comes out! We would argue that PAS is really an outgrowth of, and is contemporaneous with, the consumer movement of the past 50 to 60 years and is therefore an anomaly in the history of medical ethics.7 
Ronald Pies
Geppert et al then defend Hippocratic medicine:
It is not the literal wording of the Hippocratic Oath, but the subsequent development of those values that has provided a moral compass for the medical profession. That growth, intellectually and experientially, resembles, for example, the development of religious values, not confined to, but inspired by the esteemed teachers and holy books of the world’s great religious traditions. These are evolving and venerable moral compasses for covenantal communities. The current Tree of Medicine is rooted in its Hippocratic soil. It has ramified branches of thoughts and values yet embodies a core ethos that has persisted through the rise and fall of many societies.
Annette Hanson
They then challenge the attack that they are simply historicists:

Our colleagues should not so easily dismiss the lessons of history as mere “historicism.” We believe very much in Santayana’s famous wisdom:  “Those who cannot remember the past are condemned to repeat it.” Changing social mores and highly popular notions, championed by celebrities, intellectuals, and policy makers, have swept physicians off their ethical moorings in the past. Consider the historic example of Soviet psychiatry. Civil commitment was used to isolate dissidents, and the doctors went along with it. Physicians, especially psychiatrists, participated with relish in eugenics-inspired forced sterilization programs of the mentally ill in the US.8 There are moral absolutes that our profession should stand up for, in spite of legislative or popular pressure. Public health policy should not be contingent upon popularity. Many popular ideas were proved both wrong and harmful (eg. conversion therapy for homosexuals).
They conclude their rebuttal by referring to anthropologist Margaret Mead:
Anthropologist Margaret Mead9 presciently warned a physician friend about the social pressure on physicians to kill in the name of mercy, observing that:
The followers of Hippocrates were dedicated completely to life under all circumstances, regardless of rank, age, or intellect—the life of a slave, emperor, foreign man, defective child . . . This is a priceless legacy which we cannot afford to tarnish. But society has repeatedly attempted to make the physician into the killer . . . It is the duty of society to protect the physician from such requests.9
We would do well to heed her warning.
I am sure that this debate will continue. Geppert, Komrad, Pies and Hanson hold to the truth, that physicians must not kill their patients and psychiatrists prevent suicide, not provide it.

Dr Geppert is Professor of Psychiatry and Medicine, and Director of Ethics Education, University of New Mexico School of Medicine; and Ethics Section Editor of Psychiatric Times. Dr Komrad is on the psychiatry faculty of Johns Hopkins, University of Maryland, and Tulane University. Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics & Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor-in-Chief Emeritus of Psychiatric Times (2007-2010). Dr Hanson is Director of the Forensic Psychiatry Fellowship at the University of Maryland.

References:

1. Kious BM, Battin MP. Physician Aid-in-Dying and Suicide Prevention in Psychiatry: A Moral Crisis? Am J Bioeth. 2019;19:29-39.

2. Magelssen M, Supphellen M, Nortvedt P, Materstvedt LJ. Attitudes towards assisted dying are influenced by question wording and order: a survey experiment. BMC Med Ethics. 2016;17:24.

3. Dany L, Baumstarck K, Dudoit E, et al. Determinants of favourable opinions about euthanasia in a sample of French physicians. BMC Palliat Care. 2015;14:59.

4. World Medical Association. WMA Declaration on Euthanasia and Physician-Assisted Suicide. https://www.wma.net/policies-post/declaration-on-euthanasia-and-physician-assisted-suicide. Accessed November 7, 2019.

5. Snyder L, Sulmasy DP, Ethics, Human Rights Committee ACoP-ASoIM. Physician-assisted suicide. Ann Intern Med. 2001;135:209-216.

6. De Lima L, Woodruff R, Pettus K, et al. International Association for Hospice and Palliative Care Position Statement: Euthanasia and Physician-Assisted Suicide. J Palliat Med. 2017;20:8-14.

7. Pies RW. Physician-Assisted Suicide and the Rise of the Consumer Movement. Psychiatric Times. 2016;33(8). https://www.psychiatrictimes.com/couch-crisis/physician-assisted-suicide-and-rise-consumer-movement. Accessed November 18, 2019.

8. Dowbiggen I. Keepin America Sane: Psychiatry and Eugenics in the United States and Canada, 1880-1940. New York: Cornell University Press; 2003.

9. Mead M. The Hippocratic Registry of Physicians. https://www.hippocraticregistry.com. Accessed November 18, 2019.


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