Guest Column: Dying with Dignity: State v. Patient

Discussion about physician-assisted suicide and refusing end-of-life care has greatly dominated the public conversation recently. It can be seen in the media event that followed Brittany Maynard’s choice to die with dignity and in the countrywide surge of proposals for “right to die” legislation.

Polls show that there is support for allowing terminally ill patients to end their own lives, yet aid in dying is only legal in five states: Montana, New Mexico, Oregon, Vermont and Washington. The medical field also lags behind popular opinion with respect to end-of-life care. A significant number of physicians in practice and in polling admit that, in some circumstances, they have refused or would refuse to honor patients’ wishes regarding end-of-life care. While one may want to attribute this to a fear of legal liability, state statutes make it clear that physicians and other health care professionals are immune from liability when they comply with their patients’ wishes to refuse life-sustaining treatment.

The differences between what the people want and what doctors do and what the law allows are based on a conflict of values. Whereby patients seek to assert their autonomy in choosing how to live and die, doctors practice medical beneficence, and the state asserts its interest in preserving life.

For example, patient advocates claim that Brittany Maynard’s death demonstrates progress in medical ethics, since she was allowed to determine when and how she would pass, which preserved her dignity and quality of life. The American Medical Association, on the other hand, still upholds that their doctors should not participate in assisted suicide; instead, physicians must respond to the needs of patients even at the end of life. The AMA’s disapproval of physician-assisted suicide, despite its legality in certain locales, is due to the fact that the association sees the assistance as being fundamentally incompatible with the physician’s role as a healer. When doctors are reluctant to allow their patients to refuse care, they are (improperly?) extending what they think is their professional role as healers contrary to the patients’ wishes.

When patients sue doctors who override their wishes, such as in “wrongful life” suits, the courts are usually unwilling to provide recourse. This is based on the courts’ premise that “life is not a damage” upon which one can collect. Because of the courts’ decisions, despite legislation that protects the patient’s right to refuse treatment, legal scholars have called it an “illusory protection,” a “false promise,” and a “right without a remedy.”

While it is no longer a crime to commit suicide, courts oftentimes mention that prevention of suicide is a state interest, especially when there is a risk for undue influence or euthanasia. Yet, the state’s interest in suicide prevention also has played a direct role against legalizing aid in dying based on this same slippery slope. For example, in Sampson v. State, the court held that, while the Alaska statute prohibiting assisted suicide interfered with a person’s constitutional right to liberty, it nevertheless served a legitimate governmental purpose. The reason is that if the court permitted assisted suicide for competent patients, it might also provide an opening for incompetent patients who have an advance directive. In Washington v. Glucksberg, for example, the court states explicitly, “(p)hysician-assisted suicide is fundamentally incompatible with the physician’s role as healer.” Similarly, in Vacco v. Quill, the court cited the AMA position on physician-assisted suicide to differentiate it from withholding and withdrawing treatment.

These few examples should make us aware that the death-with-dignity movement is not solely a matter of individual rights. It also challenges the state’s views of its responsibility for its citizens and the doctor’s self-perception as healer. The state is, however, slowly giving its citizens the power to decide for themselves whether they want to die with dignity. Also, physicians are beginning to value the alleviation of suffering as much as healing. Acknowledging the current underlying concerns might allow for a discussion that finds a proper balance between the prerogatives of individuals and that of society at large.

Ira Bedzow is the Director of Biomedical Ethics and Humanities at New York Medical College and Senior Scholar at the Aspen Center for Social Values. Join him and top scholars July 20 for “When Life Nears Death: A Conversation of Medical & Social Values” 5:30 to 7 p.m. at 435 W. Main St. in Aspen. Open to the public.