During the 1990s Dr. Jack Kevorkian drove his Volkswagen van through an unmet need in American medicine euthanizing 130 patients who felt death was the only solution to their suffering. He euthanized his “patients” with devices he named the “Thanatron” and the “Mercitron.” The former allowed his patients to administer IV barbiturates and potassium while to latter delivered carbon monoxide. When convicted of manslaughter, he told the court, “Dying is not a crime.”

Seven-hundred years before the Thanatron, Thomas Aquinas formulated an ethical doctrine called “The Principle of Double Effect” that stated if your intention is for a good but a harm occurs you are not liable for the harm. Aquinas’ writings on what is called “intentionality” are the ethical underpinnings for comfort care of patients at the end of life.

So what does a medical doctor who was dubbed “Doctor Death” have in common with a Dominican friar who was called “Doctor Angelicus?” There are interesting parallels. Kevorkian’s euthanasia reign was considered ethically heretical. Aquinas was reviled as a heretic for being an Aristotelian by a church steeped in Neoplatonism. The Angelic Doctor’s reputation was rehabilitated, Dr. Death’s was not. However, advocacy for physician-assisted suicide (PAS) has increased following Kevorkian’s imprisonment. Once illegal in all states, PAS is now legal in seven and in the remaining 43 it is either illegal or “legally uncertain.”

Although Kevorkian and Aquinas are dead, PAS is very much alive. However, as PAS is increasingly legal, it is also increasingly controversial. Physicians, courts, and legislators continue to debate it. Medical journals over the years have spilled a lot of real and electronic ink on this topic. The latest spillage was on September 19, 2017, when the ACP published a position paper taking the “position” that based on “substantial ethics” it could not support the legalization of PAS. The ACP expressed concerns that legalizing PAS would “fundamentally alter the physician’s role in society.” The paper is well researched, well written, and free. While the position paper took one side of the argument, the ACP published accompanying editorials providing arguments for and against PAS.

In one editorial, Dr. Timothy Quill expressed concern over “ACP’s rigid opposition” to PAS and argued for the need to continue “to debate the ethical and moral implications of permitting or prohibiting potential life-ending medical practices.” The other editorial expressed an opposite concern stating PAS was a “euphemism” which served only to make “a distasteful subject palatable.” However, both editorialists emphasized the need to compassionately and completely as possible to relieve the anguish of the dying. Both agreed that when taking steps either to allow to die or to cause to die, rigorous adherence to medical ethics is paramount. But they disagreed about what is ethical: opponents of PAS consider it to be “harm” while proponents of PAS advocated the reverse.

Those who find PAS unacceptable are guided by Aquinas’ theory of double intent to aggressively relieve pain and suffering. Those for whom PAS is an option are also guided by Aquinas — but only to a point. They believe there is a point in the spectrum of suffering at the end-of-life at which you can go beyond Aquinas’ “double-intent” and have a “single intent” — to cause to die. But PAS advocates are not 21st-century Jack Kevorkians who in the 1990s ignored all the standards of end-of-life care — he did not screen for depression and he did not attempt to maximize relief of suffering before turning on his Thanatron. Where it is legal, PAS has rigorous safeguards to prevent its misuse.

So we have a PAS predicament. In some states, it is legal; in most states, it is not. Some compassionate physicians believe PAS is ethical, other compassionate physicians believe it is not. Some feel it is a right role for a doctor to cause a patient to die, others feel it is a wrong role. However, both sides acknowledge the absolute obligation to relieve the suffering of patients at the end of their lives.

Why should you care? Because if you are reading this, you are going to die.

Some of us will die suddenly: some softly in a slumber, others violently in a trauma. Most of us, however, will watch our death approach like a black hole swallowing our universe. And like a black hole, the closer it gets, the more it will affect us physically, emotionally, and spiritually — causing us to suffer. It will pull at us, it will distort us, and it will pull away bits of us until finally what is left of us is perched on the rim knowing we must go in.

Both sides of the PAS quandary want to do everything possible to alleviate the pain of those on the edge of their death. Those who oppose to PAS see their duty as doing all that is humanly possible to relieve their suffering as they slip into the end of living. Those who propose PAS see their duty as doing all that is humanly possible to relieve their suffering but, if necessary, to gently push them into their end.

Suicide whether self-inflicted or physician-assisted is an act of hopelessness — the loss of hope that the pain can be relieved, that meaning in their life can be restored, that being alive is better than being dead. But what if this hopelessness could be relieved? What if medicine treated suffering like it treats ischemic heart disease? What if pain in a dying body received the same attention that pain in a beating heart gets? What if the same resources were put into palliative care as are put into cardiology? What if physician-assisted suicide is a sign of the need for more widely available, much earlier and more aggressive palliative care?

More palliative care wouldn’t hurt; in fact, it would hurt a whole lot less.

Michael A. Salvatore is a palliative care physician.

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