Allowing physician-assisted suicide (PAS) would be a grave mistake for four reasons, as explained in a Heritage Foundation Backgrounder, “Always Care, Never Kill.” First, it would endanger the weak and vulnerable. Second, it would corrupt the practice of medicine and the doctor–patient relationship. Third, it would compromise the family and intergenerational commitments. And fourth, it would betray human dignity and equality before the law. Instead of helping people to kill themselves, we should offer them appropriate medical care and human presence.
This Issue Brief focuses on how allowing physician-assisted suicide corrupts the culture in which medicine is practiced. PAS corrupts the profession of medicine by permitting the tools of healing to be used as a technique for killing. It fundamentally distorts the doctor–patient relationship, greatly reducing patients’ trust of doctors and doctors’ undivided commitment to the healing of their patients. Lastly, PAS creates perverse incentives for insurance providers and the financing of health care.
Physician-Assisted Suicide Corrupts the Profession of Medicine
The heart of medicine is healing. Doctors cannot heal by assisting patients to kill themselves or by killing them. They rightly seek to eliminate disease and alleviate pain and suffering. They may not, however, seek to eliminate the patient. Allowing doctors to assist in killing threatens to fundamentally corrupt the defining goal of the profession of medicine.
In testimony before the U.S. House of Representatives, Dr. Leon Kass elaborated on this point:
The legalization of physician-assisted suicide will pervert the medical profession by transforming the healer of human beings into a technical dispenser of death. For over two millennia the medical ethic, mindful that power to cure is also power to kill, has held as an inviolable rule, “Doctors must not kill.”
Dr. Paul McHugh agrees that this inviolable rule is essential to the practice of medicine:
Since ancient Greece physicians have been tempted to help desperate patients kill themselves, and many of those Greek doctors must have done so. But even then the best rejected such actions as unworthy and, as the Hippocratic Oath insists, contrary to the physician’s purpose of “benefiting the sick.”
For this reason, the American Medical Association (AMA) code of ethics rejects physician-assisted suicide. The AMA states: “Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer.” As law professor O. Carter Snead notes, dozens of professional associations and groups representing vulnerable persons oppose physician-assisted suicide, including the American Medical Association, the World Health Organization, the American Psychiatric Association, and the American Association of People with Disabilities.
Medical professionals oppose physician-assisted suicide because practicing medicine is a not a morally neutral act of mere technical skill. Physicians do not practice medicine simply to fulfill the desires of consumer-patients, whatever those desires may be. Rather, medicine is a profession governed by its core commitment to healing patients. Dr. Kass explains that “the physician devotes himself to healing the sick, looking up to health and wholeness.” Dr. Kass adds: “Healing is thus the central core of medicine: to heal, to make whole, is the doctor’s primary business.”
Killing is incompatible with caring. Dr. Kass explains: “Can wholeness and healing ever be compatible with intentionally killing the patient? Can one benefit the patient as a whole by making him dead?… ‘Better off dead’ is logical nonsense.” Indeed, “to bring nothingness is incompatible with serving wholeness: one cannot heal—or comfort—by making nil. The healer cannot annihilate if he is truly to heal. The boundary condition, ‘No deadly drugs,’ flows directly from the center, ‘Make whole.’”
Dr. McHugh illustrates what happens when this boundary is crossed: “Once doctors agree to assist a person’s suicide, ultimately they find it difficult to reject anyone who seeks their services. The killing of patients by doctors spreads to encompass many treatable but mentally troubled individuals, as seen today in the Netherlands, Belgium and Switzerland.”
Physician-Assisted Suicide Distorts the Doctor–Patient Relationship
Physician-assisted suicide will not only corrupt the professionals who practice medicine, but also affect patients because it threatens to fundamentally distort the doctor–patient relationship, greatly reducing patients’ trust of doctors and doctors’ undivided commitment to the healing of their patients.
Our laws shape our culture, and our culture shapes our beliefs, which in turn shape our behaviors. The laws governing medical treatments will shape the way that doctors behave and thus shape the doctor–patient relationship. Legal philosopher John Finnis explains how a change in the law will lead to a change of heart on the part of doctors:
Now change the law and the professional ethic. Killing with intent becomes a routine management option. Oh yes, there are restrictions, guidelines, paperwork. Well meant. Not utterly irrelevant. But as nothing compared with our doctors’ change in heart, professional formation, and conscience.
On this point, Dr. Kass agrees:
Won’t it be tempting to think that death is the best treatment for the little old lady “dumped” again on the emergency room by the nearby nursing home? Even the most humane and conscientious physician psychologically needs protection against himself and his weaknesses, if he is to care fully for those who entrust themselves to him. A physician friend who worked many years in a hospice caring for dying patients explained it to me most convincingly: “Only because I knew that I could not and would not kill my patients was I able to enter most fully and intimately into caring for them as they lay dying.”
Dr. Kass asks us to consider the new normal that PAS would bring to patients:
Imagine the scene: you are old, poor, in failing health, and alone in the world; you are brought to the city hospital with fractured ribs and pneumonia. The nurse or intern enters late at night with a syringe full of yellow stuff for your intravenous drip. How soundly will you sleep? It will not matter that your doctor has never yet put anyone to death; that he is legally entitled to do so—even if only in some well-circumscribed areas—will make a world of difference.
Finnis dramatizes this new normal, highlighting how the change in law leads to a change in patients’ behavior:
A new zone of silence. Can I safely speak to my physician about the full extent of my sufferings, about my fears, about my occasional or regular wish to be free from my burdens? Will my words be heard as a plea to be killed? As a tacit permission? And why does my physician need my permission, my request?
The trust that patients place in their doctors will be seriously breached if patients fear that their doctors may encourage—and actively facilitate—their death.
Physician-Assisted Suicide Creates Perverse Incentives for Insurance Providers
Physician-assisted suicide will create perverse incentives for insurance providers and the financing of health care. Assisting in suicide will often be a more “cost-effective” measure from the perspective of the bottom line than is actually caring for patients. In fact, some advocates of PAS and euthanasia make the case on the basis of saving money.
Baroness Mary Warnock, a leading ethicist in the United Kingdom, has argued, “If you’re demented, you’re wasting people’s lives—your family’s lives—and you’re wasting the resources of the National Health Service.” Warnock went on to suggest that such people have a “duty to die.”
Derek Humphry, founder of the Hemlock Society, also points to the role of money, noting that “the pressures of cost containment provide impetus, whether openly acknowledged or not, for the practicalities of an assisted death.” He goes on to add that “the connections between the right-to-die and the cost, value, and allocation of health care resources are part of the political debate, albeit frequently unspoken.” Humphry, however, was one advocate willing to speak about that cost: “It is impossible to predict exactly how much money could be saved.… Conservative estimates, however, place the dollar amount in the tens of billions.”
Physician-assisted suicide has affected the financing of health care in the United States as well. Dr. McHugh notes:
When a “right to die” becomes settled law, soon the right translates into a duty. That was the message sent by Oregon, which legalized assisted suicide in 1994, when the state-sponsored health plan in 2008 denied recommended but costly cancer treatments and offered instead to pay for less-expensive suicide drugs.
Richard Doerflinger adds:
Last year, over half the patients who committed assisted suicide in Oregon relied on the government for their health coverage or had no coverage at all. Over three-quarters of those dying under Washington’s assisted suicide law were partly or completely dependent on Medicare or Medicaid.
This sets the stage for a perverse alignment of public financing and patient death, just as the New York Task Force on Life and the Law, established by Governor Mario Cuomo (D), predicted in its 1994 report:
Limits on hospital reimbursement based on length of stay and diagnostic group, falling hospital revenues, and the social need to allocate health dollars may all influence physicians’ decisions at the bedside.… Under any new system of health care delivery, as at present, it will be far less costly to give a lethal injection than to care for a patient throughout the dying process.…
Physicians who determine that a patient is a suitable candidate for assisted suicide or euthanasia may be far less inclined to present treatment alternatives, especially if the treatment requires intensive efforts by health care professionals.
These perverse financial incentives will exercise a subtle but profound pressure on patients as the advice from their physicians and the procedures covered by their insurance increasingly point toward PAS. Given the increasing number of elderly patients in modern societies, their increasing longevity, and the increasing cost of treating their chronic illnesses, PAS will increasingly be seen as a cost-effective option and one that the elderly should be encouraged to consider.
Physicians are to eliminate illness and disease but never eliminate their patients. Not every medical means must be used. Patients can refuse or doctors can withhold particular treatments that are useless or causing more harm than good. But in deciding that a treatment is useless, we must not decide that a patient is worthless. Doctors should not kill.
Instead of helping people to kill themselves, we should offer them appropriate medical care and human presence. We should respond to suffering with true compassion and solidarity. Doctors should help their patients to die a dignified death of natural causes, not assist in killing. Physicians are always to care, never to kill.—Ryan T. Anderson, PhD, is William E. Simon Senior Research Fellow in American Principles and Public Policy in the Richard and Helen DeVos Center, of the Institute for Family, Community, and Opportunity, at The Heritage Foundation.