Death be not proud, but Life, be not selfish

This blog post is about a very sensitive topic – “physician assisted death”. I expect that some people will be so emotionally invested in this issue that they will be hurt, just from the discussion. My intent is not to incite or enrage, but rather, to openly share my (very personal) views on this critical topic. Please do not read any further if this hits “too close to home”.

The following two quotes come from the most recent JAMA edition. As you can plainly see, this is a forum for opposing opinions in regards to whether physician assisted death is justifiable/moral/merciful/within the purview of a physician. Please read the quotes and my comments follow afterwards.

Is physician-assisted death ever justifiable?—Yes.
Both the lived experience of a person with a serious illness as well as commonly recognized ethical principles provide guidance in answering this question. A woman in her 40s faced her ovarian cancer with great courage, sought available new oncologic treatments, and carefully researched how to relieve potential end-of-life pain, dyspnea, nausea, and other physical or psychosocial distress should it occur as she became sicker. She considered the possibility of physician-assisted death and received a prescription from her physician in Washington because it gave her “a way out” if her existence became intolerable. She was not certain she would use the medication, and she made sure her family supported her plan. In the end, with help from hospice, family, and clinicians, she felt the last part of her life was “surprisingly okay,” and she died comfortably, in her home, the medications potentially intended to hasten death unused.

Is physician-assisted suicide ever justifiable? —No.
Physician assisted suicide is fundamentally inconsistent with the physician’s professional role,” according to a long-standing position of the American Medical Association.1 That we are debating this question of whether physician-assisted suicide (or “physician-assisted death”) is ever justifiable shows how far medicine has shifted toward redefining the role of physician. If the medical profession accepts physician-assisted suicide, it will be declaring decisively that “physicians” are mere providers of services, to be guided only by the desires of the individual patient, the will of the state or other third parties, and what the law allows. The idea of medicine as a profession, which embodies a shared commitment to care for persons who are sick and debilitated so as to restore their health, will quickly fade into memory. Those made vulnerable by sickness and debility, to whom physicians owe their solidarity as physicians, will have much less reason to entrust themselves to physicians’ care.

I first must declare that I am heavily biased in this discussion. I am a strong proponent of physician assisted suicide. I am also a strong proponent of changing the term to medically assisted end-of-life. The very use of the word suicide invokes far too many emotions, and simply is a misuse of the term. Admittedly, any time someone takes their own life, you can refer to this as suicide. But as in cases of murder, there are a number of sub classifications. There is premeditated murder, criminally negligent homicide, vehicular manslaughter and the list goes on.

Therefore, suicide should be granted the same respect. There is psychologically driven suicide in an otherwise young and healthy patient, there is suicide secondary to long-standing uncontrollable pain from a terminal disease, and so on. People, including many doctors, like to classify  everything as suicide, when speaking about medically assisted end-of-life. It makes the argument much more black and white. At that point, the doctor only needs lift his chin and straighten his back, invoke some platitude related to a doctor’s commitment to treatment rather than murder, and – who can argue with that.

I hope it is already clear that this simplification is intended to free doctors from difficult decisions. It is far easier to pretend to be morally superior to anyone in favor of medically assisted end-of-life, rather than actually argue the issue. In the challenge to allowing “suicide”, the author effectively argues that physicians should be both the enablers of the suicide, yet also be the judge of whether the request for suicide is legitimate. A first year law student would point out the be obvious conflict of interest. I certainly hope that the author who speaks out against physician-assisted suicide recognizes this obvious conflict.

Not that long ago, physicians were the ones who decided whether a woman could have an abortion. I know of physicians who refuse to give patients contraceptives. In one case, a woman presented to another physician asking for a morning-after pill. The physician who initially saw her, was an individual who I greatly respected until that day. His personal beliefs were more important than the patients. Assisting the patient in getting a morning-after pill does not reduce the doctor to a simple service provider, as is argued in the negative opinion. Assisting the patient is what a doctor is supposed to do. Sometimes the rules and even the morality are not well-defined. But, by what right should a doctor be the one to make the decision whether a person should receive a morning-after pill, or life ending injection.

It’s well known that doctors have tremendous egos and control issues. The concept of anything being taken out of their hands leads them to lash out with arguments about the doctor-patient relationship and the deterioration of medical care. Most of these arguments are pathetically simple and small minded, which is actually quite frightening given that the same doctors are the ones who are deciding on the welfare of patients on a daily basis.

The author of the counter opinion argues that medicine has changed drastically and that the role of the physician is also changing to such an extent that it might become unrecognizable in the near future. How this relates to the issue of respecting a person’s right to choose how and when they die is simply unclear to me. But I do agree with the fact that physicians are facing a future full of uncertainty. My mother used to say to me all the time that physicians never starve. Quite simply, she was saying that there will always be a need for doctors, such that they will always be able to support their family, financially. Considering that  both my parents were survivors of the Holocaust, I can definitely understand why this was such a major issue to them.

At the same time, we are on the verge of a new world where the role of the classic physician is shrinking away. There are surgeons who have recently finished their training who have never opened an abdomen with a scalpel. Their entire training has been in the use of laparoscopic surgery. In a couple of generations from now, there will literally be no one around who has any training in opening a belly. Admittedly trauma surgeons are a special class, as they have to deal with anything that comes through the door, including someone with an abdomen that has been opened during an accident.

But many of the skills that are considered basic for any physician are being lost. New smart stethoscopes and bedside handheld ultrasound will fundamentally change the way patients are assessed. Rather than wait for radiological studies or for specialists to come down to the ER to evaluate a patient, all of the information will be collected by the on-site physician and transferred to the online electronic medical record. Despite all of the negative press that computerization of medical care has received in the last few years, things are improving all the time and it is just a matter of years until medical technology simplifies and improves patient care far beyond that of what humans can provide.

Perhaps, in fact, this will be another area in which future physicians are specifically trained. When computers truly do the vast majority of medical care, humans will still be needed to help with the art of medicine. And part of that art will be helping a patient decide if they wish to live or die, by their own choice. Rather than spouting doctrine that “all suicide is wrong”, maybe future doctors will spend the necessary time to learn to be compassionate and caring, in order to help patients with THEIR choices about how they wish to live and end THEIR lives.

Thanks for listening

About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.