Bioethics Forum Essay
Is Medical Aid in Dying a Human Right?
The Kings County Medical Society in New York recently hosted a brunch with New York State legislators. One of the guests was Richard Gottfried, chair of the New York State Assembly Health Committee, who is cosponsoring A2694, a bill legalizing medical aid in dying (MAID). As a medical oncologist with 30 years’ experience treating seriously ill patients, I have concerns about it, and I expressed them to Gottfried.
Once legalized, assisted death would become an accepted treatment option. A physician who cares for dying patients would then be obligated to discuss it with all such patients. Even if it were not directly raised, all patients with terminal illness speaking with their physicians about options would know that assisted dying is on the table. This might create subtle pressure on those already burdened with serious illness.
Advocates point out that in the states where MAID is legal, relatively few people have availed themselves of it. The majority of those who have are well educated men with cancer. What, then, is the harm? I am concerned that legalizing this practice would affect all dying patients and their relationship with their physicians, not only the small number who currently opt for it.
I also take seriously the warning that some have raised that there might be a connection between relaxed attitudes toward hastening death for the terminally ill and our nationwide epidemic of suicide and death from despair. This connection is impossible to prove, or disprove. A Wall Street Journal article notes that “recent studies have shown that people who have lost love ones to suicide have an increased risk of dying by suicide themselves.” The article quotes clinical psychologist Vanessa L. McGann: “There’s some sort of modeling, now you’ve seen this is how somebody else has coped with their pain.” Perhaps by renaming “assisted suicide” as “medical aid in dying,” controlling, and medicalizing it, we might avoid that problem. But perhaps not. Given the small number of people who choose MAID, why take the risk?
While several state societies have adopted positions of neutrality on the issue, and a few national medical organizations have expressed support for medically assisted dying, the major national organizations of physicians–the American College of Physicians and the American Medical Association–are opposed as is the New York State Medical Society. (All favor wider availability of palliative care and hospice services.)
Gottfried offered the following defense: if someone with a terminal illness is on life support, one can legally withdraw it even if the person shortly dies. What’s the difference between that and physician aid-in-dying?
In response, I said that a person with a terminal disease who is removed from life support is being allowed to die from an illness. With legal MAID, a patient would die because of a fatal dose of medicine. Though the patient must ask for the medicine and be able to administer it himself or herself, a physician must prescribe it.
Finally, Gottfried said of MAID, “It’s a human right.” His response, I believe, is at the heart of the disagreement. Is MAID a human right?
According to the Cambridge Dictionary of Philosophy, human rights “are possessed merely by virtue of one’s status as a human being” or “have been incorporated into legal systems by international agreements.” The United Nations states, “Human rights include the right to life and liberty, freedom from slavery and torture, freedom of opinion and expression, the right to work and education, and many more.”
MAID could fall into the category of “and many more.” We could imagine a human right to be free from unwanted medical treatment or to be provided pain relief if suffering from illness or injury. But the provision of a lethal prescription to a gravely ill patient, an action that alters traditional understandings of a physician’s role, seems more of a public policy issue, in which the wishes of some would need to be weighed against considerations of broader public interest.
MAID advocates such as Marcia Angell, former editor of the New England Journal of Medicine, have framed the issue partly in this way, writing in the New York Review of Books that it would be a public good if more people opted to have their lives directly ended with the help of a physician. This may reflect the fear of many that they will live “too long.”
But is MAID the right response to this understandable fear? Involving physicians and the medical system as a whole in solving this existential concern effectively sanitizes the practice of deliberately ending a human life by making use of the doctor’s skill and adding the doctor’s blessing. The terminology itself, medical aid-in-dying, is something of euphemism for an affirmative action to end a person’s life, while the proposed process has the effect of making it seem as if no one is really responsible.
Those who avail themselves of this option, should it become legal in New York, can say that the doctor said it was OK. The doctor can say, I’m just doing what the patient wants, and a consulting doctor providing a required second opinion approved it. The consulting doctor can say, this isn’t my action—it’s up to the treating doctor and patient. A person is suddenly dead, and everyone involved can point to someone else. Do we really want to start down this road? Developments in the Netherlands and Belgium, where the indications for medically assisted dying have gradually expanded, suggest that we ought to exercise extreme caution in eroding long-established safeguards.
Medicine is a heavily regulated practice in the public interest. As it considers adding physician aid-in-dying to the list of individual human rights, I hope that the New York State legislature will keep its attention focused on the larger public good.
Alan B. Astrow, M.D., is chief of hematology/medical oncology at New York-Presbyterian Brooklyn Methodist Hospital and professor of clinical medicine at Weill Cornell Medical College.