Letters

• physician-assisted suicide
• ethics
• palliative care

Dear Editor:

In response to Dr. Anfang's editorial supporting physician-assisted suicide (PAS),¹ I offer these opposing comments.

Physicians have adhered to codes of ethics since the 5th century BCE. Included are the Oath of Hippocrates and the oath of the great physician Maimonides. The United States of America was founded in 1776. Thomas Percival introduced our country's first medical ethics standards in 1803. These codes, adopted by the American Medical Association in 1847, are revised continuously, most recently in 2008. What has never changed is the requirement that physicians focus 100 percent of their efforts on healing.

Physicians are terrible at predicting death. After six months, fewer than 33 percent of predictions are correct. PAS relies on the physician informing patients of their life expectancy. If we can't do that with even a 50 percent accuracy, how can we assume the role of physician-advisor in helping a patient decide to commit suicide instead of seeking additional treatment or compassionate palliative care?

The myth that physicians can provide a speedy and pain-free death needs to be confronted with reality. Nothing in our training teaches us how to help people kill themselves. There are no courses in medical school, no CMEs, no conferences, no journals, and no controlled experiments to guide us. We are trained to heal, not to harm, and certainly not to kill (as is done in veterinary school.)

The American “experiment” with PAS, begun in Oregon, shows that the average time to death is 2 hours, but has been as long as 140 hours. Of these individuals, 10 percent vomited up the drugs they took, 2 percent awakened from their comas, and 33 percent took 30 hours to die. Although 25 percent were depressed, only 2 percent were ever referred for psychiatric treatment.^2,3 And there is a “contagion effect”; Oregon's overall suicide rate is now 40 percent above the U.S. average.⁴ “Normalizing” suicide is not a message we should broadcast. More than 40,000 people kill themselves annually without involving physicians. Clearly, there is no great need to corrupt the medical profession by encouraging doctors to be handmaidens of self-inflicted death.

The most recent revision of the AMA Code of Medical Ethics states: “PAS occurs when a physician facilitates a patient's death by providing the necessary means and/or information to enable a patient to perform the life-ending act. Permitting physicians to engage in assisted suicide ultimately causes more harm than good. PAS is fundamentally incompatible with the physician's role as healer, would be difficult or impossible to control, and would pose serious societal risks.”⁵

Physicians must aggressively respond to the needs of patients at the end of life. Physicians should not abandon a patient once it is determined that cure is impossible; must respect patient's autonomy; must provide emotional support and communicate effectively; and must provide comfort care and appropriate pain control.

Helping people kill themselves is not and should never be part of a treatment plan. Death is not just a medical event. It is a life event with dimensions in the physical, emotional, psychological, and spiritual realms. Death is not a problem that can be solved with a prescription.

• © 2021 American Academy of Psychiatry and the Law