Updated on: October 5, 2017

Physician-Assisted Suicide: Dr. Jack Kevorkian and St. Thomas Aquinas

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Original story posted on: October 4, 2017

The physician assisted suicide predicament is seen in an historical context. 

During the 1990s, Dr. Jack Kevorkian fulfilled an unmet need in American medicine and society, euthanizing patients who felt that death was the only solution to their suffering.

Before being sent to prison, he “assisted” in the deaths of 130 people. He euthanized his “patients” with devices he named the “Thanatron” (from the Greek “thanatos,” meaning death) and the “Mercitron.” These contraptions allowed his patients to ‘self-administer’ IV barbiturates followed by IV potassium or inhaled carbon monoxide. After four trials, he was convicted of manslaughter. When sentenced, Dr. Kevorkian told the court, “dying is not a crime.”

Seven hundred years before the “Thanatron,” St. Thomas Aquinas, a 13th-century Dominican monk, wrote his masterpiece, Summa Theologica, which addressed the philosophical needs of the medieval church and society. Foremost among his achievements was his ethical doctrine called “The Principle of Double Effect.” Briefly, this simply states that if your intention is for good, but harm occurs, you are not liable for the harm as your intention was to achieve a good. It is not murder if a patient with intractable pain from metastatic cancer dies from narcotics-induced respiratory failure if the intent was to relieve their pain. Aquinas’s writings on what is called “intentionality,” although more than seven centuries old, remain the ethical underpinnings for comfort care of patients at the end of life.  

So, what does a medical doctor who was dubbed “Dr. Death” have in common with a Dominican friar who was called “Doctor Angelicus?”

There are interesting parallels. Kevorkian’s euthanasia reign was considered heretical by almost all physicians in the mid-1990s. Aquinas was reviled for several decades in the High Middle Ages as a heretic for being an Aristotelian, demonized by a church steeped in Neo-Platonism. The Angelic Doctor’s reputation was rehabilitated in the late medieval period, and his writings remain fundamental to Catholic theology.

Dr. Death has had no similar restoration of reputation. But the advocacy for physician-assisted suicide (PAS) has grown significantly in the 20 years after Kevorkian’s imprisonment.

Once illegal in all states, PAS is now legal in seven states, containing one-sixth of America’s population. In the remaining 43 states, it is either illegal or “legally uncertain.” Several states are considering its legalization.

Although Kevorkian and Aquinas are gone, PAS is very much alive. Although it is becoming increasingly legal, it is also becoming 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 the topic. The latest spillage was in the September 2017 issue of The Annals of Internal Medicine, a widely respected and widely read medical journal published by the American College of Physicians (ACP).

The ACP issued a position paper buttressed by 81 references taking the position that based on “substantial ethics,” it could not support the legalization of PAS. The ACP expressed grave concerns that legalizing PAS would have deleterious results, affecting trust in the physician-patient relationship and “fundamentally alter(ing) the physician’s role in society.” The paper is well-researched, well-written, and well-argued. It is also free to non-subscribers at http://annals.org/aim/article/2654458/ethics-legalization-physician-assisted-suicide-american-college-physicians-position-paper.

While this position paper took one side of the argument, however, the ACP published three accompanying articles providing arguments for and against PAS.

In an accompanying editorial, Dr. Timothy Quill, a PAS advocate, 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.” A second editorial expressed an opposite concern, opining that PAS was a “euphemism” that serves only to make “a distasteful subject palatable.” Lastly, in a special article Oregon’s 20-year experience with its “Death with Dignity Act” (DWDA) was detailed.

In their journal, the ACP balanced four articles, two for PAS and two against. However, these were not just two “pro” and two “con” articles; in fact, there was a lot of overlapping “pro” among the four articles. Specifically, all the authors, no matter their position on PAS, emphasized the need to compassionately and completely as possible relieve the anguish of the dying. Both sides agreed that when taking steps either to allow one to die or taking steps to cause one to die, rigorous adherence to medical ethics is paramount.  However, they disagree about what is ethical. Opponents of PAS consider it to be “harm,” and feel that patient autonomy does not allow the choice of PAS to end suffering, while proponents of PAS take the opposite stance.

Those who find PAS unacceptable are guided by Aquinas’s theory of double intent to aggressively relieve pain and suffering. Those for whom PAS is an option are guided by Aquinas, too, however – 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’s double intent and have a single intent – to end a life.

Practitioners of PAS, however, are not 21st century Jack Kevorkians, who in the 1990s ignored all the standard standards of end-of life care – he did not screen for depression, did not screen for psychopathology, and did not attempt to maximize relief of suffering before turning on his Thanatron. Where it is legal, PAS is surrounded by 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 it is ethical, other compassionate physicians believe it is not. Some feel it is a proper role for a doctor to cause a patient to die, others feel it is not. But 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 invading our universe. And like a black hole, the closer we get to it, 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 its 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 PAS see their role as doing all that is humanly possible to relieve suffering as patients slip into the end of living. Those who endorse PAS see their role as doing all that is humanly possible to relieve suffering – but, if necessary, to gently push such patients into their end. 

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

More palliative care couldn’t hurt. In fact, it could a lot less hurt.

Michael A. Salvatore, MD, FACP

Dr. Michael Salvatore was a pulmonary medicine/critical care physician for 35 years. Since 2012 he has been the physician advisor and medical director of the palliative care team at Beebe Healthcare in Delaware. After earning his MD at the University of Arizona, he trained in internal medicine and PULM/CCM at Duke University. Dr. Salvatore is a member of the RACmonitor editorial board.

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