Revisiting Physician-Assisted Suicide: Reaffirming the Christian Hippocratic Legacy

Download PDF: Coming Soon

Abstract

Support for physician-assisted suicide is growing as a result of ever-expanding cultural pressure. Healthcare professionals should oppose this trend and recognize that physician-assisted suicide is a misguided answer to human suffering. For 25 centuries, the Hippocratic Oath has served as the ultimate credo of the medical professional, and serves as a more trustworthy guide for professional ethics than contemporary culture. In this essay, I reflect on the Hippocratic Oath from a Christian perspective and reaffirm that physician-assisted suicide, despite growing in cultural acceptance, remains a misled answer to human suffering and as such is dangerous for the profession of medicine. Physician-assisted suicide corrupts the medical profession, relies on a distorted view of autonomy, and subverts true compassion. The way forward for the medical professional, in contrast, is an ethic of a “good death” comprised of healing, palliative care, and true compassion.

Keywords: physician-assisted suicide, euthanasia, Hippocratic Oath, autonomy, compassion, palliative care, medicine, suffering

Introduction

In the face of expanding cultural pressure to adopt physician-assisted suicide, it is timely to reflect on the opposition to active euthanasia in the oldest versions of the Hippocratic Oath. Drawing on the Oath, this essay does not aim to blaze new trails of argumentation but to re-affirm the well-worn and historic path of physicians protecting the lives of the patients entrusted to them. Before embarking, I will define several terms and provide a brief history. Physician-assisted suicide (PAS), medical aid-in-dying (MAD), and physician aid-in-dying (PAD) are often used interchangeably to describe the same thing: namely, the act of a physician giving a patient life-ending medication that the patient then self-administers.[1] The preferred terminology is controversial. Sometimes, PAD is used as an umbrella term to include both PAS and euthanasia. Euthanasia, in contrast to PAS and MAD, is the act of a physician directly administering a life-ending medication to a patient; this is currently illegal in every state, prohibited under general homicide laws.

The history of PAD is extensive. In brief, the Oregon “Death with Dignity Act” was passed in 1994. In 1998, Dr. Jack Kevorkian, a guest on 60 Minutes, administered a lethal injection on national television to Thomas Youk, a man suffering from ALS. He was convicted of murdering Mr. Youk and sent to prison the following year. In 2008, Washington and Montana followed Oregon by legalizing PAS. Vermont joined in 2013 and California in 2015. At the time of this essay, ten states and the District of Columbia have legalized PAS. Globally, assisted suicide performed by a non-physician was legalized in Switzerland in 1942, which then became infamous for “suicide tourism.”[2] Subsequently, both euthanasia and PAS were legalized in the Netherlands and Belgium in 2002. Currently, nine countries have legalized PAS in some form.

Notably, the widespread adoption of PAS and euthanasia has been a frequent theme in dystopian novels. In Aldous Huxley’s novel Brave New World, the elderly are sent to the Park Lane Hospital for the Dying.[3] Once there, they are given increasing doses of soma—a drug that causes rapturous hallucinations—until their respiratory centers shut down. Dr. Shaw comments on how ideal it is that “[the elderly] are most conveniently out of the way.”[4] He continues, “Of course, you can’t allow people to go popping off into eternity if they’ve got any serious work to do. But as [they] haven’t got any serious work.” In Lois Lowry’s book The Giver, the elderly are “released” when they no longer contribute to the society.[5] Jonas, the protagonist, is aghast when he discovers that being “released” is a euphemism for being given a lethal injection.

Could this dystopian future be ours? A 2015 Gallup Poll revealed that nearly 70% of Americans were supportive of PAS among the terminally ill.[6] For the first time in American history, over half of all physicians also agreed.[7] We live in a country where the commonly accepted position increasingly says that, in certain circumstances, it is allowable for a physician to assist in their patients’ self-killing.

Having provided a short history of PAS and an overview of our current state, I now propose to demonstrate the misguided nature of PAS and contrast PAS with a better path forward. Specifically, PAS is misguided because it: (1) over-relies on the moral and clinical competence of practitioners to determine when life is worth living, (2) corrupts the medical profession by undermining trust and turning the physician into a subjectivist, (3) is upheld by a distorted view of radical autonomy, and (4) relies on false instead of true compassion. The way forward for the medical professional, in contrast, is an ethic of a “good death” comprised of preparation, avoiding the over-medicalization of death, and affirming the roles of healing, palliative care, and true compassion.

Despite More Common Acceptance, PAS and Euthanasia Remain Misguided

PAS over-relies on the moral and clinical competence of practitioners to determine when life is worth living. I once heard a physician lecturing about PAS pose the following question to a group of medical students: “How many of you have classmates to whom you would not trust the care of a dog of yours?”[8] Most of the hands in the room went up. Though anecdotal, this reflection represents something we all know: medical professionals are human; many are moral and virtuous, but many are not. This fallibility of medical professionals should make us think twice before bestowing them with the power to actively assist in the death of another. Physicians are not able to determine when life is worth living and when life is worth ending. To believe that they are is to over-rely on their moral and clinical competence.

Reckoning honestly with the imperfect nature of medical professionals, the Hippocratic Oath served as the ultimate credo of the medical profession for 25 centuries. In one section of the oath the physician swears:

I will use treatment to help the sick according to my ability and judgment, but never with a view to injury or wrong doing. Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course.[9]

Anthropologist Margaret Mead commented on the revolutionary nature of this oath:

For the first time in our tradition there was a complete separation between killing and curing. Throughout the primitive world, the doctor and the sorcerer tended to be the same person. He with power to kill had power to cure, including specially the undoing of his own killing activities. . . . With the Greeks, the distinction was made clear. One profession, the followers of Asclepius, were to be dedicated completely to life under all circumstances, regardless of rank, age, or intellect—the life of a slave, the life of the Emperor, the life of a foreign man, the life of a defective child. . . . [T]his is a priceless possession which we cannot afford to tarnish, but society always is attempting to make the physician into a killer—to kill the defective child at birth, to leave the sleeping pills beside the bed of the cancer patient. . . . [I]t is the duty of society to protect the physician from such requests.[10]

Humans are fallible and occasionally untrustworthy, including physicians. However, by adopting a professional pledge to not poison—intentionally kill—another human being, and by banishing those who violate this stipulation, the medical profession has engendered patient trust for centuries. This trust undergirds the doctor-patient relationship. As a patient, I trust that my doctor is committed to my healing and will not take my life or maliciously harm me.

PAS undermines this trust and thereby corrupts the medical profession. When a physician embraces PAS, the fundamental nature of the doctor-patient relationship changes. Suddenly, the physician is placed in the position of providing, or not providing, a life-ending “medication.”[11] The patient may be a voluntary moral agent requesting the medication, but the physician ascends to a seat of power in determining whether or not to provide the medication and, therefore, whether or not to participate in ending the patient’s life. Rather than esteeming life as a near-absolute value, life becomes valuable only under certain circumstances, and the physician is the ultimate judge. Trust is compromised. Instead of being wholeheartedly committed to the life, healing, and palliation of their patient, the physician instead becomes an arbiter of life and death.

This also turns the physician into a subjectivist. For the physician consenting to PAS, the value of the patient’s life is not sacrosanct. PAS acknowledges that there are certain conditions whereby it is right for the physician to assist in killing their patient. These conditions are necessarily subjective and influenced by the country, culture, and worldview that surrounds the physician. To illustrate this point, one only needs to consider the varying acceptable criteria and safeguards for PAS around the world, including in Belgium, where assisted suicide is available even for those who are not terminally-ill.[12] The Hippocratic physician, in contrast, upholds an objective oath. She will not administer a poison to intentionally harm or kill her patient. She is unashamedly committed to the life and healing of her patient, and to palliation in the face of natural death. This is an objective ideal that has upheld the medical profession for centuries and protected the doctor-patient relationship.

It is dangerous and corrupting to turn fallible physicians into subjectivists concerning the value of their patient’s life. Consider the logic of bioethicist Jonathan Glover, who in his essay, “The Sanctity of Life,” argued that to destroy life or conscious life is not inherently wrong—it is only wrong to destroy life worth living. He notes:

For these reasons, someone’s own desire to live or die is not a conclusive indication of whether or not he has a life worth living . . . . If we are to make these judgements, we cannot escape appealing to our own independent beliefs about what sorts of things enrich or impoverish people’s lives.[13]

While recognizing the incredible danger of one person determining whether or not another’s life is worth living, Glover nonetheless justified some subjective determinations about the value of another’s life. I hope that the peril of such subjective determinations is obvious. We should oppose PAS because it moves the value of a patient’s life, and the physician’s duty toward that life, from the realm of the objective to the subjective and relies on morally flawed physicians to make these subjective determinations.

PAS is also deeply misguided because it presupposes a distorted view of autonomy. In medicine, one of the primary strategies for resolving ethical disputes is that of principlism, which analyzes an issue within the framework of four principles: respect for patient autonomy, beneficence, non-maleficence, and justice.[14] Beauchamp and Childress, in their seminal work on principlism, define autonomy this way:

Personal autonomy is, at minimum, self-rule that is free from both controlling interference by others and from limitations, such as inadequate understanding, that prevent meaningful choice. The autonomous individual acts freely in accordance with a self-chosen plan.[15]

The idea of respect for patient autonomy has to do with self-governance. Patients should be free from external controlling influences that limit their agency, they should be informed, and they should be able to make choices in-line with their values. This notion of respect for patient autonomy should be supported.

However, PAS relies on a distorted view of patient autonomy. Rather than relying on respect for patient autonomy, arguments for PAS rely on “radical” autonomy. By radical autonomy, I mean a notion of autonomy that does not recognize limits on patient autonomy. It is completely consistent to say that the Hippocratic physician respects patient autonomy by ensuring their patients are free from undue controlling interference and values their individual choices while simultaneously recognizing limits to patient autonomy. Just because a patient desires something as an autonomous agent—such as medications to end their lives—that does not mean that they should have their desire satisfied out of respect for autonomy. That assertion misconstrues radical autonomy with respect for autonomy, is dangerous, and should be rejected.

The emergency room patient with chronic back pain and a substance abuse history should not be given a prescription for opioids just because they request it. A football game would not function if the first rule was “Do whatever you think best,” with only secondary suggestions to not go out of bounds. In life, autonomy flourishes only when properly constrained. But in the debate over PAS, autonomy is given a preeminent moral seat; the physician should give the cancer patient a lethal prescription if that is what the patient has determined is best for them. The age-old boundaries of medicine are secondary considerations. In the words of Leon Kass, this turns the physician into “a highly competent hired syringe.”[16] The professional, committed to an ethic of life and healing, is replaced by the provider beholden to radical patient autonomy.

PAS is also misguided because it relies on false compassion instead of true compassion. If autonomy functions as the moral club to squash other ethical considerations, then a false sense of compassion is the underlying driving force or proverbial arm behind the club. What do I mean by false compassion? Philosopher J. Budziszewski discusses the difference between true and false compassion: “In compassion we feel with the sufferer, but there is a right and a wrong way to act upon this. The right way relieves his suffering, the other relieves what I suffer for him; one gives him what he needs, the other merely gives him what he wants—or just puts him out of sight.”[17]

It is incredibly painful to watch the suffering of another. Not that long ago, I lost my mother to a two-year battle with pancreatic cancer. As the cancer invaded her body, her suffering was incredible. First, intense pain racked every step as bony metastases overwhelmed her spine and pelvis. Then, she became too frail to walk or even hold up her own head. Horrible chemotherapy ulcers cracked her lips and filled every corner of her mouth. Her hair fell out and her legs swelled with fluid as the rest of her body withered. Her mouth became so dry she could only speak after we helped her suck on a moistened sponge. Night-black cancerous tumors covered her skin, eventually breaking through the skin and bleeding like angry ulcerated craters.

It is one of the most horrendous experiences imaginable to watch someone you love so dearly suffer so gravely. True compassion sits at the bedside as a comforting human presence, as a hand to moisten the lips and administer medications, as a voice to speak and read stories, as a source of encouragement that reflects on the value of the beloved’s life. False compassion can bear it no longer and slips the terminal sedative onto the bedside table. The 1980 Vatican Declaration on Euthanasia states:

The pleas of the gravely ill people who sometimes ask for death are not to be understood as implying a true desire for euthanasia; in fact it is almost always a case of an anguished plea for help and love. What a sick person needs, besides medical care, is love, the human and supernatural warmth with which the sick person can and ought to be surrounded by all those close to him or her, parents and children, doctors and nurses.[18]

Mother Teresa is lauded as a paragon of humanity because she gave true compassion—tears, food, and a human presence—to the destitute and ill of the slums of Kolkata. Her legacy would be very different if she had merely provided terminal sedatives to those who did not want to live anymore. It has been said, “Suffering is not a question which demands an answer, it is mystery which demands a presence.” PAS provides a misguided answer to human suffering.

I have asserted that PAS should be rejected because it over relies on the moral and clinical competence of fallible physicians to determine when life is worth living. Further, it corrupts the medical profession by turning the physician into a subjectivist and fracturing the sacred trust that undergirds the doctor-patient relationship. Lastly, PAS relies on unsound notions of radical autonomy and false compassion, instead of the superior guides of respect for autonomy and true compassion.

After rejecting PAS, how should the medical profession address the depths of human suffering? The charge of 17^th century physician Thomas Sydenham rings clear: “The physician should be diligent and tender in relieving his suffering patient, knowing that he must one day be a like sufferer.”[19] What is the Hippocratic physician to do in the face of natural death? How can we address the suffering that so many of our patients (and ourselves) are sure to face? Bioethicists Scott Rae and Paul Cox write:

Caring well for the dying is a moral obligation for professional caregivers and loved ones who take care of dying family members. . . . Good care for the dying does what is possible to create the possibility of a “good death” for the patient and his or her family.[20]

Throughout history, much attention has been devoted to this question of what comprises a “good death.” After the bubonic plague devastated 14^th century Europe, the Catholic Church offered a guide on how to die well. This guide, first published in the early 15^th century, was known as the Ars moriendi or “The Art of Dying”[21] and consisted of texts and woodcut reliefs that contrasted good and bad deaths. Those dying were encouraged to avoid the temptations of unbelief, despair, impatience, pride, and avarice. Instruction was offered for those who attended the bedside of their dying loved ones. Two centuries later, Jeremy Taylor, a cleric in the Church of England, wrote “The Rule and Exercises of Holy Dying,” a similar manual that exhorted its readers to strive for a pious and God-honoring death.

Lydia Dugdale comments on the valuable examples of these works:

The Ars moriendi of the late Middle Ages was successful precisely because it addressed a universal need in a manner that fit a particular culture and was easy to understand and apply. Such a tool today would need to accommodate a vast array of belief systems while remaining easy to use. The deathbed must again become a place of community, a place for the dying to forgive and receive forgiveness, to bless and to receive blessing, and a place for the attendants to anticipate and prepare for their own deaths.[22]

Her point is apropos—we should re-imagine the deathbed. From the outset, it should be acknowledged that medicine does not bestow the answers for what comprises a good death; the deathbed is in such a sorry state because for too long we have assumed that it does. As a Christian Hippocratic physician, however, I would espouse an ethic of a good death as one that is: prepared for, not overly medicalized, and comprised of healing, palliative care, and true compassion.

In my work as an emergency physician, I recently cared for a woman in her forties who had recurrent stage IV breast cancer. Her skin was yellowed. Her bilirubin, a marker of liver function, had climbed every visit for the past two months. The metastatic breast cancer was overwhelming her bile ducts, despite chemotherapy, and her abdomen was protuberant with a sickly, yellow fluid that was requiring drainage twice per week. She was listed as full-code and had future aggressive therapies scheduled. As I sat in the room with the patient and her husband, I was convicted to ask a difficult question: “Do you want to know, from a medical outlook, how much time you may have left?” I assured her that only God knows the day and the hour of the end, but my experience as a physician has prepared me to anticipate the final stages of life. Also, as a son who watched his mother die of cancer, I knew how difficult it was to reckon with the end—we always want more time. But, I wanted to give her the gift of preparation. The patient and her husband both assented, and I told her, “Days, possibly weeks.” There were tears, and I grieved with them. I encouraged them to leave nothing unsaid.

Two days later her liver shut down to the point of coma, and the following day she died. After our conversation, she had opted to avoid ventilators and CPR. I pray that her final days were meaningful, that she reminisced of her love for her husband and said goodbye to family while she was still cogent. I hope that this was a better death than the alternative, of dying in the ICU, sedated, having let one’s final moments of cognition and communication slip away, with no chance to bless or be blessed, still holding onto the delusion of more time. Death often comes sooner than expected—this is especially true for those fighting long battles with chronic illnesses and cancer. We know death lurks in the future; we refuse to believe that it is coming tomorrow. Medical professionals often feel like they are failing when they bring up the possibility of impending death. Surely our armamentarium of technology can buy a little more time? Like those bailing a deluged boat with cup, refusing to look up at the swelling waves, too often we clinicians reach for ventilators and vasopressors and rob our patients of the gift of preparation. We must do better. We must humbly and sensitively give our patients the gift of preparation, and not overly medicalize death.

From a Christian perspective, it is helpful to recognize that the avoidance of pain and the avoidance of death are relative goods, but not absolute goods. This means that it is good for the medical profession to seek to alleviate the pain of a suffering patient and leverage their expertise and resources to forestall death. If healing is possible at a tolerable cost, it should be pursued. It is also important to not confuse healing and curing. A patient may not be able to be cured of their terminal cancer or their kidney failure, but the role of physician as healer is still valuable. Skin maladies of the suffering and bed-bound colon cancer patient can be alleviated even if the underlying disease cannot be cured. Respiratory ailments can be mitigated through diuresis or antibiotics even if the cardiomyopathy is irreversible. The physician can still be a healer and comforter, even in the face of death. The aphorism is true: “To cure sometimes, to relieve often, to comfort always.”[23]

To seek comfort and relief, but not cure, is the definition of palliative care. Palliative care is a medical discipline that takes a multi-faceted approach to challenging medical illnesses with the goal of improving quality of life and not seeking a cure. Palliative care recognizes the limits of human health and longevity and focuses on improving quality of life for those who are suffering. When death appears imminent, palliative care transitions to hospice care. Medical professionals can help their patients achieve a good death by focusing on palliative and hospice care, especially when a cure is no longer possible or likely. In this setting, the responsibility of the medical professional transitions from cure to care. Ira Byock notes the following about the effectiveness of palliative care:

In more than 35 years of practice I have never once had to kill a patient to alleviate the person’s suffering. When other measures fail, palliative sedation for alleviation of physical suffering is reliably effective. Alleviating suffering is different than eliminating the sufferer.[24]

Finally, perhaps most importantly, a good death looks like true compassion. It looks like the family sitting at the bedside of the dying cancer patient. It looks like teamwork between medical professionals, family, friends, and community supports such as the church to keep the suffering patient comfortable and surrounded by human love and care. This often requires an incredible amount of work. It can be unfathomably difficult and distressing to help the dying patient with simple tasks such as having a bowel movement, eating, or bathing. The same amount of effort and care expected in welcoming a newborn home is necessary in helping a loved one die well—often more. However, true compassion looks like engaging in this work out of love for the dying father, mother, or friend. This opportunity celebrates the dignity of the dying patient, and is often meaningful to family and friends.

In summary, PAS is misguided and should be rejected, as it corrupts the medical profession by threatening patient trust and turning physicians into subjectivists, disregarding the wisdom of the Hippocratic Oath that has guided the medical profession for centuries. PAS stands on the shaky foundations of radical autonomy, as opposed to respect for autonomy, and false compassion, as opposed to true compassion. The better way forward for the medical profession, and society writ large, is to embrace an ethic of a good death: we should help our patients prepare for death, avoid the over-medicalization of death, and focus on healing, palliative care, and true compassion. We would do well to heed the words of the late bioethicist Daniel Callahan, who said, “Consenting adult killing . . . is a strange route to human dignity.”[25] Let us reject that misguided route, and follow the well-worn path of the Hippocratic Oath.

References

[1] Helene Starks et al., “Physician Aid-in-Dying,” Ethics in Medicine, University of Washington Medicine, 2013, http://depts.washington.edu/bhdept/ethics-medicine/bioethics-topics/detail/73.

[2] Penny Sarchet, “Tourism to Switzerland for Assisted Suicide Is Growing, Often for Nonfatal Diseases,” The Washington Post, September 22, 2014, https://www.washingtonpost.com/national/health-science/tourism-to-switzerland-for-assisted-suicide-is-growing-often-for-nonfatal-diseases/2014/09/22/3b9de644-2a14-11e4-958c-268a320a60ce_story.html; Sarah Mroz et al., “Assisted Dying Around the World: A Status Quaestionis,” Annals of Palliative Medicine 10, no. 3 (2021): 3542, https://apm.amegroups.com/article/view/50986.

[3] Aldous Huxley, Brave New World (London: The Albatross, 1947), 198.

[4] Huxley, Brave New World, 155.

[5] Lois Lowry, The Giver (Boston: Houghton Mifflin, 1993), 139–45.

[6] Andrew Dugan, “In U.S., Support for Doctor-Assisted Suicide,” Gallup, May 27, 2015, https://news.gallup.com/poll/183425/support-doctor-assisted-suicide.aspx.

[7] Leslie Kane, “Medscape Ethics Report 2014, Part 1: Life, Death, and Pain,” Medscape, December 16, 2014, slide 2, https://www.medscape.com/features/slideshow/public/ethics2014-part1#2.

[8] John Patrick, “Physician Assisted Suicide and Abortion” (CMDA 2019 Conference, Colorado, 2019), https://www.johnpatrick.ca/audio/.

[9] Michael North, trans., “The Hippocratic Oath,” History of Medicine Division, National Library of Medicine, National Institutes of Health, February 7, 2012, https://www.nlm.nih.gov/hmd/greek/greek_oath.html.

[10] Quoted in Rita Marker et al., “Euthanasia: A Historical Overview,” Maryland Journal of Contemporary Legal Issues 2, no. 2 (1991): 257–98.

[11] It is worth noting that the word “medication” derives from the Latin, medicatio, meaning “to heal” or “to cure,” neither of which are accomplished by PAS “medications.”

[12] Mroz et al., “Assisted Dying Around the World,” 3542–47.

[13] Jonathan Glover, “The Sanctity of Life,” in Bioethics: An Anthology, 3^rd ed., ed. Helga Kuhse, Udo Schüklenk, and Peter Singer (Malden, MA: Blackwell, 2015), 232.

[14] Tom Beauchamp and James Childress, Principles of Biomedical Ethics (New York: Oxford University Press, 1979).

[15] Beauchamp and Childress, Principles of Biomedical Ethics, 58.

[16] Leon Kass, Leading a Worthy Life: Finding Meaning in Modern Times (New York: Encounter Books, 2017), 204.

[17] J. Budziszewski, What We Can’t Not Know: A Guide, rev. ed. (San Francisco: Ignatius Press, 2011), 204 (emphasis original).

[18] Congregation for the Doctrine of the Faith, “1980 Declaration on Euthanasia,” in Bioethics, ed. Kuhse, Schüklenk, and Singer, 236.

[19] Thomas Sydenham, “The Doctor,” in On Moral Medicine: Theological Perspectives in Medical Ethics, 2nd ed., ed. Stephen E. Lammers and Allen Verhey (Grand Rapids: Eerdmans, 1998), 145.

[20] Scott Rae and Paul Cox, Bioethics: A Christian Approach in a Pluralistic Age (Grand Rapids: Eerdmans, 1999), 231.

[21] K. Thornton and C. B. Phillips, “Performing the Good Death: The Medieval Ars Moriendi and Contemporary Doctors,” Medical Humanities 35, no. 2 (2009), 94–97, https://doi.org/10.1136/jmh.2009.001693.

[22] Lydia Dugdale, “The Art of Dying Well,” The Hastings Center Report 40, no. 6 (2010): 23, https://doi.org/10.1002/j.1552-146X.2010.tb00073.x.

[23] The source of this aphorism is controversial, but it is often credited to 19^th century physician Edward Livingston Trudeau, founder of a noted tuberculosis sanitarium. Mark David Siegel, “To Comfort Always,” Yale School of Medicine, June 24, 2018, https://medicine.yale.edu/news-article/to-comfort-always/.

[24] Ira Byock, “Op-Ed: We Should Think Twice About ‘Death with Dignity,’” Los Angeles Times, January 30, 2015, https://www.latimes.com/opinion/op-ed/la-oe-0201-byock-physician-assisted-suicide-20150201-story.html.

[25] Daniel Callahan, “When Self-Determination Runs Amok,” The Hastings Center Report 22, no. 2 (1992): 52, https://doi.org/10.2307/3562566.

Download PDF: Coming Soon