Physician-Assisted Suicide: An Egregious Boundary Violation

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition.

Dr Ronald Pies

In the past few years I have reported on several excellent academic articles that were written by Dr Ronald Pies. Possibly the most popular article co-authored by Dr Pies is 12 Myths About Assisted Suicide and Medical Aid in Dying.

Dr Pies most recent article is his response to Joshua Pagano, DO who challenged Dr Pies article, “Is ‘Death with Dignity’ Really Possible?”

Dr Pies responds to the Pagano by dedicating one paragraph to each concern. Pies begins by explaining why it is not necessary to die by ingesting a lethal drug cocktail.

Only a small minority of persons with a terminal disease seek a physician’s prescription for a lethal drug. Furthermore, there is no reason to believe that the only way terminally ill patients can “pass away peacefully while surrounded by family and friends” is to ingest a lethal dose of barbiturates. For thousands of years, dying human beings have managed to die peacefully in the embrace of family and friends without recourse to “Death with Dignity” legislation.

Pies comments on the potential for adverse outcomes with assisted suicide.

One of the myths surrounding PAS is that it invariably provides a rapid, uncomplicated, and peaceful death. On the contrary, PAS is sometimes messy, prolonged, and uncomfortable. The person who ingests the lethal drug does not always “gently fall asleep.” Indeed, “Physicians who support [PAS] need to consider…the potential for adverse outcomes, including longer time to death than expected (up to 24 hours or more), awakening from unconsciousness, nausea, vomiting, and gasping.”

Pies continues by commenting on the polls that indicate support for assisted suicide.

...the central question is whether medical ethics ought to be governed by polls and plebiscites—or whether there are enduring and inalienable values that guide medical practice. I would ask the following: If 65% of the American public supported the euthanization of babies born with severe birth defects, would that justify the practice? Most major medical organizations—including the American Medical Association, the American College of Physicians, and the World Medical Association—have consistently opposed PAS on essentially ethical grounds. Recently, the College of Psychiatrists of Ireland also registered its firm opposition to PAS.

Pies then corrects the assertion that assisted suicide is requested based on suffering.

Most requests for medical aid in dying are not made by patients experiencing untreatable pain or unbearable suffering, as data from Oregon have shown. Rather, the most common reasons for requesting medical aid in dying were loss of autonomy (97.2%), inability to engage in enjoyable activities (88.9%), and loss of dignity (75.0%)

Pies then comments on the concern of Psychological Vulnerability related to requests for death.

It is not clear how genuinely rational or reality-based PAS decisions are, as Cynthia Geppert, MD, MA, MPH, MSBE, DPS, and I have discussed in our article, “Two Misleading Myths Regarding ‘Medical Aid in Dying.’” Indeed, research has shown that some cancer patients requesting assisted suicide have subtle cognitive distortions, such as “Nobody can help me,” that are clouding their judgment. Thus, people who are dying may be psychologically vulnerable to coercion in ways that are not readily detected under current PAS protocols. As the College of Psychiatrists of Ireland noted, “Perceived pressures in favor of induced death can be subtle. These cannot be excluded by tests of mental capacity, such as those used in psychiatric practice.”

Pies then challenges arguement suggesting that avoiding suffering is a good.

The issue is not, as was argued, whether it is rational to avoid foreseeable and inevitable suffering—I believe it clearly is. Rather, the issues are 1) whether physicians are morally justified in helping patients kill themselves weeks or even months before patients would otherwise die of their underlying illness; and 2) whether PAS is the only way of avoiding suffering at the end of life.

Dr Pies then comments on the arguement that assisted suicide provides comfort to patients.

Although we always aim to comfort our patients, this must be done within the constraints of sound medical practice and medical ethics. Comfort alone is not sufficient grounds for an action that may, in some important sense, be injurious to the patient—such as inducing or contributing to the patient’s death (think PAS). For example, suppose a depressed patient with chronic pain and a history of frequent substance abuse tells his doctor that he would find “enormous comfort” in having a large supply of oxycodone on hand “just in case I need it for pain.” This sense of comfort would hardly justify such a prescription under those conditions.

Dr Pies then comments on assisted suicide legislation and conscience rights.

PAS does not merely allow a single individual—the patient—a choice. By legislative fiat, it entangles the physician in a bureaucratized system of assisted killing. It is true that no physician is compelled to participate directly or actually carry out PAS; however, most PAS legislation is crafted so that the refusing doctor must provide medical records to a physician who provides PAS [Annette Hanson MD, personal communication, 12/30/21]. In my view, this vitiates the first physician’s conscientious opposition to PAS and forces him or her to collude with an unethical practice.

Dr Pies then comments on suicide and assisted suicide.

...my colleagues and I oppose the position of the American Association of Suicidology (AAS), which has tried to draw a sharp distinction between “conventional” suicide (eg, in the context of a mental illness) and what they call “physician aid in dying.”10 It is certainly true that we can discern subtypes of suicide; eg, impulsive vs planned; underlying psychiatric disorder vs reactive/situational, etc. But suicide (self-killing) is suicide regardless of the subtype.11 Even the AAS acknowledges that there is an “undetermined amount of overlap” between the 2 categories they propose.10 We do not need a 2-tiered classification, in which there are good and bad, approved and unapproved, methods of taking one’s own life—leaving harried physicians to sort out which is which.

Dr Pies comments on Pagano's use of the "Golden Rule."

Finally, the closing invocation of the Golden Rule—one version of it, at least—seems a very decent and compassionate response. But the Golden Rule is not necessarily the best guide to medical ethics. For example, suppose we are considering the question, “Should psychiatrists be allowed to have sexual relations with their current patients?” Some might say, “Well, as a competent, consenting adult, I would want the choice of having or not having sexual relations with my psychiatrist. How, then, in good conscience, could I deny that right to someone else?” The problem, of course, is that it is a clear violation of long-established medical ethics for psychiatrists to have sexual relations with their patients—Golden Rule or not. It is a forbidden boundary violation.

Dr Pies then concludes:

In my view, PAS is an infinitely more egregious boundary violation, whether or not one might wish that option for oneself—and whether or not the dying patient consents to it. Indeed, a patient’s consenting to be killed does not mean a physician is ethically justified in acceding to the request.

Rather than focusing on ways to assist suicide, physicians should rededicate themselves to securing state-of-the-art palliative care and supportive counseling for terminally ill patients. In closing, I thank Dr Pagano for reflecting on these difficult issues with me, and I hope he will reconsider his position in light of this response.

Dr Ronald Pies is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and editor in chief emeritus of Psychiatric TimesTM (2007-2010).