Physician-Assisted Suicide and the Medical Profession

 

BY G. KEVIN DONOVAN, MD, MA

Recently, Gov. Jerry Brown of California signed into law a bill authorizing physician-assisted suicide in that state. It now joins Oregon, Washington and Vermont as the only states that voted in such legislation. The legislation initially failed to pass, but was moved through by an unusual process in a special session of the legislature. It was clearly influenced by the Brittany Maynard case, a young woman from California who moved to Oregon for assisted suicide after being diagnosed with a brain tumor. She became the poster child for a campaign by Compassion and Choices to make physician-assisted suicide legal throughout the nation. It can be considered a huge public relations success, but a legislative failure for the most part.

In the past year, similar bills were introduced in 25 states plus the District of Columbia. So far, they have failed or stalled out everywhere, but California. When Gov. Jerry Brown signed the bill, his stated reason was that he did not want himself or other Californians to die in pain, and therefore they should have the option for suicide when terminally ill. As a rationalization, it was somewhat disappointing, not least from a moral perspective from this former Jesuit seminarian. At some point he must have learned that suicide violates the Commandments, and assisting someone else to do so is even more morally problematic, because diminished capacity is less likely to be a mitigating factor for the cooperator. Even if this were not all true, it would be disappointing that the chief executive of the state had such a poor grasp of the additional issues that argue against physician assisted suicide.

There are cogent reasons to avoid legalization of PAS, without reference to moral or religious arguments. Gov. Brown’s first mistake was failing to realize that such legislation was not needed for patients to be authorized to proceed with suicide whenever they wished. Since the past century, suicide has been decriminalized in all 50 states and the District of Columbia. Therefore, the model legislation introduced by Compassion and Choices offers no new protections to patients; it merely protects doctors who write the prescriptions for them. Moreover, as we shall see, uncontrollable pain is not really an issue that would require PAS, nor is it an actual motivator for those who seek it. In fact, PAS has deleterious effects on society, the medical profession, and particularly the patients that it should serve.

As documented by the Oregon experience, patients there who seek PAS are not motivated by issues of uncontrollable pain. They are typically privileged, educated, white males, most often with cancer, fearing loss of control, lack of ability to participate in their enjoyable activities, or a risk of being burdensome. These are not purely medical problems. As Steven Miles has recently pointed out:

Entrusting this profound existential problem to the physician-patient relationship is why this is a falsely premised medicalization. Ironically, the public has chosen a technological fix that illuminates the very problem of the depersonalized medical death that it challenges. California’s law will result in medically assisted suicides, but there is little reason to believe that it will advance the humanization of persons who are dying. The literature on patient suicides suggests that physicians who are most discomfited by disability, a patient’s fears, or the burden of chronic disease, enable a decision to suicide, in a counter transference reaction. Furthermore, few modern physicians have any interest or training in how to address existential concerns – suicide being the most profound existential issue.

Those patients who may face similar situations but have no desire for Physician Assisted Suicide also experience an increased sense of vulnerability when such laws are passed. To have certain lives designated as more deserving of death (when terminally ill) can easily be extended to the lives of the elderly, physically disabled, mentally disabled, and depressed. They will see their lives as less valuable to society, their care as devalued.

Such legislation can hardly be seen as an enhancement to the medical profession. To have physicians offer a medical death rather than treatment or support for seriously ill patients will produce a corrosive effect on the doctor-patient relationship. Although this offer may be welcomed by some, it will rightly instill fear and confusion in those who depend on their physicians to fulfill the traditional (and essential) role of healer. It will also decrease the physician’s motivation to learn and employ palliative care measures. End-of-life care is expensive, challenging, and emotionally draining. However, assisting suicide for those willing to do it is simpler, quicker, and cheaper. Nevertheless, it does not always bring satisfaction even to the physicians involved, as reports from Oregon demonstrate that 24% of physicians previously involved in PAS develop depression caused by their actions and an aversion to repeating them. This is probably why in Oregon, over a seven-year period, only three doctors wrote 23% of the prescriptions for PAS and a mere 20 doctors accounted for 84% of the prescriptions statewide, meaning 99% of Oregon doctors did not participate in the practice.

Society’s inability to monitor and control PAS may be its most frightening aspect. The reported data from Oregon is suspect because, among other things, doctors are forbidden to list PAS as a cause of death on death certificates, and after an annual collection of reports, all individual data is destroyed. In European countries that have more experience with the practice, it has become clear that the touted limitations for PAS do not and cannot restrict indications for PAS or euthanasia. In Belgium and the Netherlands they now include almost any chronic illness, including anorexia nervosa, senility and dementia, deafness/blindness, severe depression and mere advanced age. Such “indication creep” is logical and inevitable once the option of induced death is legitimated as a medical good. If PAS is good for patients, then restrictions will be seen rightly as arbitrary and discriminatory, a violation of autonomy, an unjustifiable withholding of a medical good. Physician Assisted Suicide or euthanasia become the “treatment of choice” for those who don’t want to feel that they are a burden or who fear abandonment. Is this the best we as a society have to offer to the sick and vulnerable?

 

G. Kevin Donovan, MD, MA is the Director of the Pellegrino Center for Clinical Bioethics and a professor in the Department of Pediatrics at Georgetown University School of Medicine.  

 

References:

Oregon’s Death with Dignity Act – 2014: HTTP://public.health.oregon.gov/Provider Partner Resources/Evaluation Research/Death with Dignity Act/year 17.PDF

The Advance of Physician Assisted Suicide in California, October 7, 2015: info@ncbcenter.org

MCW list serve: Steven Miles, October 2015

Image: Creative Commons

Keeping up with PCCB’s James Giordano, PhD

Photo of James Giordano, PhD from http://www.ccnelsi.com/
Photo of James Giordano, PhD from http://www.ccnelsi.com/

 

If you’re interested in current issues and topics in neuroethics, be sure to keep up with PCCB’s Professor James Giordano, PhD. 

One of his most recent posts on BioMed Central’s blog discusses the increasing influence of neuroscience on the “world stage,” and both the promises and problems associated with this rapidly growing field.  Professor Giordano advocates for the simultaneous progression of neuroethics and neuroscience, suggesting that “there should be no new neuroscience without neuroethics.”

Connect with us and stay tuned for more from Professor Giordano and PCCB!

Neuroethics: Responsibilities at the Intersection of Brain Science and Society

BY JAMES GIORDANO, PHD

 

The term “neuroethics”, although first coined to describe ethical issues of neurology and the brain sciences, has obtained broader meaning and use. Cognitive scientist and philosopher Adina Roskies has claimed that the field addresses both the “neuroscience of ethics “and the “ethics of neuroscience”. Let’s delve into the first, and leave the second for later…and for a bit of balance. I think that the “neuroscience of ethics” is a somewhat inaccurate description. I offer that what’s really being studied are the structures and functions of the brain that are involved in the ways that moral thoughts (including emotions) are developed and processed, and how these are engaged in various actions in different environmental circumstances and situations. Our group refers to this as “neuro-ecology”: not to add yet another “neuro-neologism” to the fray, but to more accurately describe both the ways that these neural processes function – and what the field is dedicated to studying.

What is becoming clear is that moral cognition and decision-making doesn’t seem to be much different from any other forms of judgments and actions – at least on a neurological level. Moral decisions and behaviors involve memories, relating to others, reinforcements, anticipation of and response to rewards and punishments, and emotions of pleasure, discomfort, and pain. There isn’t a “moral center”, some “nucleus moralis” in the brain.

Current evidence reveals that a number of brain structures can be involved in what are construed to be moral decisions. Every decision and action – whether considered to be moral or otherwise – involves a perception of the circumstances and actors involved, some orientation to a prior event that was similar or referential to the present situation, recall of actions – of self and others – and their consequences, and recollection of the emotions that the actions and outcomes evoked.

It’s also likely that we develop these functions as a result of interactions and experiences throughout our lifetimes. We possess sensitivity and capability to respond to cues, and learn from our environment and from others (barring of course, certain disorders, such as psychopathy, that render these processes dysfunctional). We have innate skills that establish a proto-moral groundwork, and enable us to acquire a sense of “good”, “bad” “right”, and “wrong” from an increasing circle of others (e.g.- family, friends, strangers and the not-so-friendly) and interactions with the communities in which we live, and formal and informal institutions, mores and norms we encounter.

The functional patterns of brain activity involved in moral-type thoughts – and resulting decisions and behaviors – appear to differ based on a number of factors, including age (i.e.- adolescents seem to be more self-centered, as if this were a great surprise), sex (i.e.- females appear to be somewhat more perceptive and responsive to others’ emotions… perhaps no great shock there either), group influence, first or third person perspectives , and outcomes (yes, it does seem that everyone appears to have “a price” that might make them change their mind about moral matters!) .

Although we tend to use “preferred” or learned cognitive patterns and beliefs in our intuitions, rationalizations and judgments, it appears that each of us actually employs a range of cognitive reasoning functions and abilities when faced with a problem or decision that we hold to be “moral” in its value and effect. In short, moral cognition involves reasoning and justification processes that are more of an admixture of ethical precepts. We are all ethical polymaths, at least to some extent.

Can “the neuroscience of ethics” tell us what is “good”, and how to live our lives? No, not really; but neuroscience can provide insights to how various circumstances, actions and effects influence the brain, and what and how brain functions are involved in various thoughts, emotions and behaviors. What’s more neuroscience affords tools to access and affect the brain, and the ways we think, emote and act.

And therein lies the interaction with – and need for- the “ethics of neuroscience”. Regardless of how we put neuroscience to work, it’s vital to address the ways that various techniques and tools are used in brain research, and how the results and products of brain science are used in larger contexts of medicine, individual and public life, and in social and political spheres.

There is great power in the capabilities of neuroscience. With power comes profound responsibility, and this responsibility is borne by the field of neuroethics. Thus, it will be increasingly important to develop, cultivate and sustain the field through supported programs of neuroethics education and training, at a variety of levels. Elsewhere, I’ve called for “no new neuroscience without neuroethics”, and un-apologetically do so again here. Indeed, what we do with neuroethics will be critical to what we do both in brain science, and with the knowledge and abilities it conveys – both now and in the future.

Dr. James Giordano is Chief of the Neuroethics Studies Program in the Pellegrino Center for Clinical Bioethics, Co-director of the O’Neill Institute-Pellegrino Center Program for Brain Science and Global Health Law and Policy, and Professor in the Department of Neurology at Georgetown University Medical Center.   To learn more about his work, go to: www.neurobioethics.org.

 

Image Source: Creative Commons

Meet Our Faculty

 

STAY TUNED

PCCB publishes new posts regularly. Topics and conversations will vary, but will always relate to ongoing and current issues in bioethics. Primary contributors will include our faculty, and occasionally other staff and visiting scholars.  Check back soon for more!

MEET OUR FACULTY

G. Kevin Donovan, MD Director
G. Kevin Donovan, MD
Director, PCCB
Kevin T. FitzGerald, MDiv, PhD, PhD Associate Professor David Lauler Chair for Catholic Health Care Ethics
Kevin T. FitzGerald, MDiv, PhD, PhD
Associate Professor
David Lauler Chair for Catholic Health Care Ethics
James Giordano, PhD Adjunct Professor Director, Neuroethics Studies
James Giordano, PhD
Professor, Department of Neurology and Department of Biochemistry
Chief, Neuroethics Program, PCCB

 

 

 

 

 

 

David G Miller, PhD Associate Director for Academic Programs
David G Miller, PhD
Associate Director for Academic Programs, PCCB

Building Community

PCCB is always trying to find new ways to promote ethical reflection and discourse. We are taking our discussion online, to engage new and old participants in the discussion and to bring new ideas to the table.

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Dr. Edmund Pellegrino: Our Founder

Portrait by Jerry Crowley
Portrait by Jerry Crowley

Dr. Edmund D. Pellegrino was Professor Emeritus of Medicine and Medical Ethics at the Kennedy Institute of Ethics at Georgetown University and founding director of PCCB. He served as Chairman of the President’s Council on Bioethics in Washington, DC, John Carroll Professor of Medicine and Medical Ethics and as director of the Kennedy Institute of Ethics, and the Center for the Advanced Study of Ethics at Georgetown University. He received his BS degree from St. John’s University and his MD from New York University. He served residencies in medicine at Bellevue, Goldwater Memorial, and Homer Folks Tuberculosis Hospitals, following which he was a research fellow in renal medicine and physiology at New York University. During Dr. Pellegrino’s more than 65 years in medicine and university administration, he was a departmental chairman, dean, vice chancellor and president.

Dr. Pellegrino authored over 600 published items in medical science, philosophy, and ethics, and served as a member of numerous editorial boards. He was the author or co-author of twenty-three books, and the founding editor of the Journal of Medicine and Philosophy. Dr. Pellegrino was a Master of the American College of Physicians, Fellow of the American Association for the Advancement of Science, member of the Institute of Medicine of the National Academy of Sciences, and recipient of 52 honorary doctorates in addition to other honors and awards including the Benjamin Rush Award from the American Medical Association, the Abraham Flexner Award of the Association of American Medical Colleges, and the Laetare Award of the University of Notre Dame. Dr. Pellegrino’s research interests include the history and philosophy of medicine, professional ethics, and the physician-patient relationship.

For more from our founding director and the opportunity to have a virtual dialogue with him, check out our main webpage.

 

B&W Image of Dr. Pellegrino Source: Washington Post, Georgetown University