Guy Micco, MD, is clinical director, emeritus, of the UC Berkeley-UCSF Joint Medical Program and former director of the Academic Geriatric Resource Center, where he teaches a course called “The Death Course.” He also works as a palliative care and hospice physician. California recently joined Oregon, Washington, Vermont, and Montana in legalizing physician-assisted suicide. Death, like taxes, is inevitable. But should we be able to turn to doctors to help us die? Micco explores the complex ethical and legal issues involved.
First, what exactly do we mean by the term physician-assisted suicide?
Assisted suicide is the act of intentionally killing yourself with the aid of someone who provides the knowledge or the means to do so. Many people prefer the term “physician aid-in-dying” simply because the word suicide has negative connotations. (Suicide isn't illegal, but some people consider it immoral.) Physician aid-in-dying is distinct from euthanasia. In states that have approved physician aid-in-dying, doctors can provide patients with the medications that will end their lives, assuming they meet certain strict criteria, but physicians can’t administer the medication. A patient has to be able to take it on his or her own. Euthanasia is where a doctor, or another person, administers the medication. That’s illegal in the United States, although euthanasia is legal, with certain restrictions, in the Netherlands, Belgium, and Luxembourg.
In states that allow physician-assisted suicide, which patients qualify?
Patients have to be terminally ill, which by definition means their doctor believes they have six months or less to live. They have to be able to take the drug themselves. They must have the mental capacity to know what they are doing and what the consequences are. They have to make two verbal requests, 15 days apart, and one written request with two witnesses. And two doctors—an attending physician and a consulting physician—must verify that the patient meets all the criteria. There are a lot of hoops to jump through. It’s not an easy process. The rules are there to try to make sure patients aren’t coerced, and that they know what they are doing.
What are the main arguments for allowing doctors to hasten a patient’s death?
The basic question is one of autonomy. It’s my life. I should have the right to take my life when that seems like the proper and best thing to do. Suicide isn’t illegal. Doctors control the means—drugs that end life painlessly. Why should they be able to withhold them from me?
What about the arguments against assisted suicide?
Some people fear that it will become an ethical slippery slope. Once we allow physician-assisted suicide for competent people who are terminally ill and can take the medication on their own, it opens the way to offering it to people who are no longer mentally competent. And then to people who are in distress but not terminally ill, such as the 24-year-old depressed woman in Belgium. Where does it stop? However, I’m not so concerned about the slippery slope. I think we can put safeguards in place, as we’ve done with the laws that have been passed.
The disabled community, through organizations like Not Dead Yet, offers another argument. They insist that people should be given the right to live well before they are given the right to die with assistance. They worry that people may want to end their lives because they aren’t getting the help and support they need. That’s a legitimate concern that we should try to guard against. One way is to offer more and better support to people with disabilities so they may live life more fully. But there’s no evidence that people with disabilities are more likely than others to access physician aid-in-dying.
Another argument comes from people who work in palliative care and hospice. Many say that if good palliative care—controlling pain, shortness of breath, or nausea—were widely available and offered, patients wouldn’t choose physician-assisted suicide. And it’s true that palliative care medicine is very good at controlling these symptoms. But the experience in Oregon shows that nearly all of the people who received a prescription for aid-in-dying were in hospice at the time, and had access to palliative care. Most people who seek out aid-in-dying don’t do it because they are in pain or have other physical symptoms. They do it because they want to have control over how and when they die.
Lastly, there are religious arguments against suicide. The main idea here is the “sanctity of life”—the belief that life is precious and death should never be hastened. I can understand this point of view, but I think it should apply only to believers. Why should the rest of the population be held to this standard?
Do the strict guidelines for physician aid-in-dying prevent some patients from getting the help they want at the end of life?
Absolutely. Consider the example of patients with ALS, commonly called Lou Gehrig’s disease. Slowly but inevitably they lose all motor function, eventually including the ability to swallow or breathe. Along the way, they lose control of their arms. Physically, they can’t take a drug to end life. Someone would have to give it to them. That would be euthanasia, and that’s illegal. Or consider people with Alzheimer’s disease. They may decide that they don’t want to live beyond a certain point—say when they can no longer recognize loved ones. But by the time they reach that point, they don’t have the mental capacity to make an informed decision to end life. Many people with a legitimate reason to want aid-in-dying can’t get it.
Does that pose an ethical dilemma?
There are all kinds of ethical questions to wrestle with. Why should someone who can move his or her arms be able to get physician aid-in-dying and someone who can’t be denied it? For that matter, why should someone have to be terminally ill? Why should someone who is suffering horribly, unremittingly, not have a right to physician aid-in-dying? Those are difficult questions to answer.
The legal issues are just as complicated. In the 1970s and 1980s, courts ruled that a patient (or his or her proper surrogate) has the right to say, “I don’t want this feeding tube or this ventilator” and those wishes have to be followed, even if it means the patient will die. We can make those wishes known in an advance directive, and even at a time when we’re no longer able to speak or move, they still have authority. But refusing treatment, even treatment that will keep you alive, is different than taking a medication that will end your life. You can’t ask for physician aid-in-dying in an advance directive. Your spouse can’t say, “He wouldn’t have wanted to live like this” and ask a doctor to give you a medication to end life. Currently, that doesn’t fly.
We hear about some doctors prescribing pain medication that has the effect of hastening a patient’s death. How is that different?
Ethicists and theologians call that the double effect. If a patient is suffering, a doctor can administer medication, in whatever doses are required to obtain relief. This might hasten that patient’s death, but the intention is to ease symptoms, not to kill someone. Ethically, giving good symptom relief is appropriate and right. If symptom relief leads to an early death, that’s an unfortunate second, unwanted effect; it wasn’t the intention. Among virtually all medical ethicists, including Catholic ones, that’s considered acceptable. And it is legal. But that’s distinct from giving a patient a medication specifically with the intention of ending life.
Oregon was the first state to legalize physician-assisted suicide. What have we learned from the experience there?
Under Oregon’s Death with Dignity Act, 155 prescriptions were written for physician aid-in-dying in 2014. That’s the most ever, but it’s still not a lot. Typically, between 27 and 42 percent of the prescriptions are never taken. So a very small percentage of dying people in Oregon choose physician aid-in-dying—around 3 out of 1,000. Most are white, well-educated, and over 65. In 2014, 90 percent died at home. Ninety-three percent were on hospice care.
Why did they choose physician aid-in-dying? More than 91 percent said the reason was fear of losing autonomy. More than 86 percent said the reason was decreasing ability to participate in activities that make life enjoyable. More than 71 percent said they wanted to die with dignity. Significantly, pain and other symptoms do not top the list. Even less important are depression, financial issues, and lack of social support.
As a medical ethicist, what are your personal feelings about physician aid-in-dying?
I’m ambivalent. There are strong arguments on both sides. I voted for the first California ballot measure for assisted suicide in 1992, but I definitely had misgivings. If we were to vote on it again, I probably would vote yes, with the same misgivings. I’m especially concerned about the arguments made by the disability community.
What do you say to people who fear being kept alive when they are terminally ill?
It’s become more and more clear that one way to hasten your own death is to voluntarily stop eating and drinking. That’s the way we naturally die most of the time. If I were suffering and dying, and it was time to hasten the process, I would stop eating and drinking, assuming I had the mental capacity to make the decision. You don’t have to implicate a physician, or anyone else, in your death. And unlike taking a medication that kills you, you can change your mind, up to a certain point.
But I also know that life is precious. I was diagnosed with acute myeloid leukemia about 13 years ago. I am among the lucky 30 percent who survive the disease. But I came very close to dying. I’m grateful to be alive. But it’s also good to know that when the time comes, I can have some control over how life ends.
This opinion does not necessarily reflect the views of the UC Berkeley School of Public Health or of the Editorial Board at BerkeleyWellness.com.