Biomedical Ethicist Argues Assisted Suicide Is ‘Bad Ethics’

On May 3, 2018, Daniel P. Sulmasy, MD, PhD, MACP, offered the following testimony to the New York State Assembly Standing Committee on Health on proposed legislation that would legalize physician-assisted suicide. The following is Dr. Sulmasy’s written testimony:

My name is Dr. Daniel Sulmasy.  I am a general internist and a philosopher and I am the André Hellegers Professor of Biomedical Ethics at Georgetown University’s Kennedy Institute of Ethics. I am a native New Yorker. I served on New York State Task Force on Life and the Law under Governors Pataki, Spitzer, and Paterson, and on the Presidential Commission for the Study of Bioethical Issues under President Obama. I was not selected to give oral testimony, so I am submitting this written testimony to express my strong opposition to A.2383-A, the “Medical Aid in Dying Act.” This bill represents bad medicine, bad ethics, and bad public policy and should not be permitted to obtain the force of law.

First, a word on language and integrity.  This bill legalizes a form of suicide with the assistance of a physician. Proponents call it “aid in dying,” but that is merely a euphemism concocted to gain support. I aid lots of dying patients. It is my job to accompany them, care for them, treat their symptoms, and ease their dying. This bill does something different. In plain speech, it would enable patients to kill themselves by overdosing on medication prescribed by a physician. In more honest language, that means it legalizes physician assisted suicide. This dishonesty is compounded when physicians are forced to lie on death certificates, as this bill requires, making them state the cause of death as the underlying illness, not an intentional overdose.

Physician assisted suicide (PAS) is bad medicine. It subverts the meaning of healing to which medicine is dedicated. No patient is healed by being made dead.  PAS runs roughshod over the Hippocratic Oath which states, with good reason, “I will not give a deadly drug to any patient, even if asked, nor will I make such a suggestion.” It has been recognized since ancient times that profound trust is required to enable vulnerable patients to bare their bodies and their secrets to doctors. Everyone is a potential patient, and no one should ever fear that her doctor secretly wants to do her in.

PAS is also bad medicine since it should not be necessary. We can do more than has ever been possible in the history of humankind to heal the physical suffering of patients—drugs, electrical stimulation, complementary therapies. Studies from Oregon and Europe bear this out. The chief reason patients opt for PAS and euthanasia is not pain (which can be treated) but loss of control. They say they feel like burdens. Should we say yes, you are a burden? They say they are tired of life or lonely. Is the answer enlisting doctors to help them kill themselves? Do not be deceived into believing the false dilemma that patients have a choice of either being strapped to machines, poked with needles, and racked with pain, or they can seek assisted suicide. Hospice and palliative care can treat physical symptoms, even, if necessary, to the point of rendering a patient unconscious through invoking the rule of double effect and the careful practice of palliative sedation. Even shortness of breath can be treated (with lower doses of morphine than it takes to treat pain). This whole movement is about something else—a very small but vocal, forceful, and powerful group of people who want to have the freedom to kill themselves rather than depend upon other people to help them. They often enroll in hospice, but refuse its routine services, demanding that they be given the drugs with which to end their lives. Most patients, however, when they learn what palliative are and hospice are about, want these services and take advantage of them.

And if the health care system is not delivering such good, state of the art hospice and palliative care to the citizens of New York then fix your health care system, don’t legalize medical aid in suicide.

PAS is bad ethics. Not only does it undermine the trust that ought to undergird the patient-physician relationship, it gives state sanction (and medical sanction) to the notion that being dependent upon others is so awful a state that it makes life no longer worth living. That is why the disabled are so fearful of these laws. They do not expect to have their wheelchairs lined up so that they can be forcibly injected (at least not yet). What sends shivers down their spines is that through laws like this one the state formally declare that lives like theirs are so bad that they should be terminated. They know that once it is permissible for an individual to declare his own life is not worth living, it is a very short step to third party determinations that the lives of others are not worth living—the physically disabled, the cognitively and intellectually challenged, and so many other vulnerable groups that we physicians treat. The state has an interest in cultivating a medical profession that sees the sick and disabled as worthy of service.

You see, PAS flips the default switch. At present, patients are presumed to want to live until treatments become more burdensome than beneficial, and then we stop. Once PAS is on the table, however, the question becomes, “Why haven’t you done it yet? Why are you still burdening yourself and us by continuing? Here’s your prescription, just in case you want to use it.” That poisons medical ethics.

Personal autonomy is not absolute, and there is a difference between the negative right to be free of unwanted therapy and the positive right to receive whatever treatment one wishes, including suicidal medication. As Wittgenstein once observed, if suicide is allowed, anything is allowed. If we are to have ethics and the rule of law it must be based on the idea that all lives are worthy of respect and that no one, not the state, not the doctor, not the patient, should have the power to end lives deemed unworthy of living.

PAS is also bad public policy. PAS cannot be controlled by regulations and additional amendments. New York should not let this genie out of the bottle.  Abuse happens, and will happen. But the regulatory structures in this bill, modeled on Oregon, make it nearly impossible to detect abuse. The precise data to be collected will be specified by regulation, but restricted by legislative strictures about confidentiality and are therefore certain, as in other states, to be really bare bones. Moreover, the data will be collected through self-reporting by physicians, who are really smart. They know how to say what will keep them out of trouble, and they don’t want a lot of bureaucratic hassle. Only state officials have access to the data, and we can’t know what we don’t observe. We do know, however, that while, on average, about 40% of terminally ill patients can be expected to be depressed, in Oregon less than 5% of PAS patients (in some years no one) is referred for psychiatric assessment. There are disturbing anecdotes. Demented patients have used the law, even though patients are supposed to have decisional capacity. Family members have assisted patients who are too weak to self-administer, even though that constitutes euthanasia which is not permitted by the law.

Moreover, suicide of any form has a social contagion effect. We have an epidemic of suicide in this country, and data suggest that legalized PAS leads to more suicide in the general population.  That’s misguided policy.

The cost-constrained environment of contemporary medical care is a really unsuitable atmosphere into which to release PAS. There are a number of anecdotes describing patients who have been offered PAS by insurers who simultaneously denied overage for life-extending therapies. My colleagues and I have shown that there is a strong correlation between a cost-saving attitude and a pro-PAS attitude among physicians. And the Canadians have been bold enough to publish a recent cost-effectiveness analysis on how much their law will save for the health care budget.

Most importantly, assisted suicide is just the beginning. You see, once PAS is legalized, logic and law lead inexorably to euthanasia. It will be declared discriminatory to prevent patients who are paralyzed from equal access, and that requires active euthanasia for a person can’t take the pills. And what about the demented? Can’t one claim that grandma would have wanted to go if she knew she had become demented? That will require euthanasia by third party consent. In Belgium, 5% of all deaths are by euthanasia. The indications for euthanasia in Belgium and the Netherlands include psychiatric illness since psychiatric suffering is as great as physical suffering.  Euthanasia is prescribed for children and for infants born with genetic disorders. Pass this bill and you’ll end up in Brussels, not Portland.

Why has this not happened in yet in the US? Proponents have been very disciplined in not expanding their campaigns beyond asking for PAS until they have enough states on board. New York could be their tipping point. With a large northeast state legalizing PAS, proponents will be able to claim enough momentum to carry a few more states and then the calls will start.  Actually, a few such bills have already been discussed and/or introduced in Oregon and California. Defeated for now. But you know the real zealots don’t quit. How many PAS bills have already been introduced in New York? They will not stop with PAS.

So, be courageous leaders for the Empire State, and be careful. Bear in mind the law of unintended consequences. Look, for example, at another recent well-intentioned venture in bad medicine, bad ethics, and bad public policy—increased access to pain medication for the chronically ill led us to the present opioid epidemic.

I care deeply about compassionate care for the dying and have worked hard over my whole career to make that care better. Physicians and legislators can work together to do improve the care of the dying through expanding access to hospice and palliative care, expanding social work and chaplaincy services, and educating physicians to do a better job in care at the end of life. That’s what the vast majority of patients want and deserve. Assisted suicide plays no role in that care.

Don’t pass this bill, which will do far more harm than good.

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