Why the Hippocratic Oath Prohibits Physician-Assisted Suicide

The Hippocratic Oath rightly prohibits doctors from giving deadly drugs, even if autonomous patients ask for them. By assisting in the suicide of a terminally ill patient who wants to determine the manner of his death, the physician inappropriately medicalizes mortality itself. He also jeopardizes the welfare of other vulnerable patients.

“Regimens I will use for the benefit of the sick according to my ability and judgment, but what is used for harm and injustice I will keep away from the sick. I will neither give a deadly drug to anyone, though having been asked, nor will I lead the way to such counsel; and, similarly, to a woman a destructive pessary I will not give. But purely and piously I will watch over my life and my art.” So swears a physician-in-training who takes the Hippocratic Oath. The new doctor straightforwardly pledges to employ beneficial therapies on behalf of the ill, and forswears those that harm patients. He specifically swears off two injurious kinds of treatment: lethal drugs and abortive pessaries. These do not benefit the vulnerable—they hurt and wrong them. In contemporary terms, the oath’s prohibition against deadly drugs forbids physician-assisted suicide (PAS) and euthanasia, for each in its own way commits the harm and injustice of giving a deadly drug to a patient.

In prohibiting PAS, the oath does not argue for a position, nor would one reasonably expect it to. After all, wedding vows commit one to fidelity, but they do not prove the soundness of monogamy. Instead, the oath endorses conclusions based on truths that are central to the practice of medicine—conclusions that were reached after lifetimes of therapeutic practice. Note that in rejecting requests for lethal drugs, the oath points to the principal reason that many offer for giving such drugs—in the parenthetical phrase “though having been asked.” One should provide such a drug, some would argue, if a patient asks for it, because the patient—an autonomous agent, who presumably finds the end of life burdensome—wants it. In the face of such a request, and because contemporary society gives exclusive control over such substances to physicians, why would a doctor not provide a deadly drug?

Falsely Medicalizing Mortality, and Jeopardizing Vulnerable Others

First, by assisting the suicide of a terminally ill patient, who wants to determine the time and manner of his death, the physician inappropriately medicalizes mortality itself. In the words of the poet Gerard Manley Hopkins, this is the “blight man was born for” that causes us to mourn even the falling of leaves, for in their falling we intuit our own evanescence. The object of medical therapy and of the physicians’ expertise, however, is physiological, not philosophical. The physician seems to answer Hamlet’s query by asserting: “‘tis nobler to end the sea of troubles.” Yet, while it perennially attends the human condition, “To be or not to be?” is not a medical question. Doctors should not presume that the question of life’s goodness has an obvious medical answer.

Second, by so responding to a request for PAS, the physician jeopardizes the welfare of other vulnerable patients—the doctor makes them susceptible to suicide as well. Consider two cases of such individuals: first, a patient in a medical condition similar to that of the patient that requests assisted suicide; second, an otherwise healthy person who is contemplating suicide.

Imagine Dr. Jones. She has two patients in similar medical situations, Al and Mary, who know one another’s medical status. Al opts for PAS; Mary does not. Dr. Jones assists Al’s suicide. How will Mary come to regard the question of continuing her own therapy upon learning that Al—her ill peer—requested death, and that Dr. Jones (her physician) assisted him? Given the momentousness of assisting a killing, Dr. Jones cannot assert that she did so simply because that is what Al wanted. Dr. Jones must have thought that her assisting Al was justified partially by the disease; Dr. Jones must have thought that it was reasonable that Al wanted PAS. She endorsed his view of his life and his choice of suicide, and on those grounds gave him the deadly drug. Moreover, it would be reasonable that others should think that she must have endorsed Al’s decision. By participating in Al’s PAS, Dr. Jones indicated to others that having Al’s disorder to that degree is a good reason to kill oneself. Thus, from Dr. Jones’s perspective, if the progress of Mary’s disease is similar to that of Al’s, then Mary has good reason to kill herself. This judgment—which is reasonably inferred from Dr. Jones’s actions—amounts to a further burden that Mary must carry.

Slightly farther afield, consider those among the general public who are contemplating suicide. We know that public awareness of suicides—especially when reported in detail, and without accompanying information about suicide prevention—tends to promote more, often similar, suicides. This is called “copycat suicide,” “suicide contagion,” or the “Werther effect,” from Goethe’s 1774 novel The Sorrows of Young Werther, in which the protagonist’s death by suicide leads to other suicides. Indeed, among the eleven main risk factors for suicide, the U.S. National Institute for Mental Health includes “being exposed to others’ suicidal behavior, such as [of] a family member, peer, or media figure.”

Given that being aware of another’s suicide increases one’s own risk of suicide, we would expect the legalization of PAS to increase the risk of suicide in the general public. Of course, if the general public is not made aware of actual instances of PAS (a policy that reminds one of the quip “everything’s fine; just don’t tell anybody”), or if the media can discover and abide by ways of describing PAS innocuously, perhaps few non-physician-assisted suicides will result from legalizing PAS. This remains to be seen. Yet our acceptance of the increased risk of suicide for others who are already in jeopardy is itself troubling. By pushing to legalize PAS, we show little concern for its effects on those in the general public who are contemplating suicide. This unconcern ultimately—albeit unconsciously—follows the same simple-minded, unimaginative, pessimistic sentiment that motivates recourse to PAS: that death is the solution to complex human problems.

Fortunately, we know better. Recently, I was walking along the beautiful San Francisco Bay. As I neared the magnificent Golden Gate Bridge, I noticed rescue personnel with boats, helicopters, and jet-skis looking for a person (requiescat in pace) who had just jumped from the bridge—a sorrowful event that occurs about forty times a year. To prevent such unnecessary loss of life, the Golden Gate Bridge District has begun to install a suicide-prevention net, at a cost of over 200 million dollars—and it is well worth it. This net will dramatically reduce, and perhaps even eliminate, suicides at the bridge. More remarkably, as we know from other experiences with installing such means to impede suicide, the people who will be prevented from committing suicide at the Golden Gate Bridge will probably not try again to commit suicide elsewhere. When people are prevented from killing themselves at a locale that is conducive to suicide, they typically do not try do so elsewhere, or by other means. Rather, when a society takes care to set up such obstacles to suicide, those who contemplate suicide hear the basic message that we need to hear when we are suicidal: “We care about you. Please do not kill yourself. You matter to us.” Legalizing PAS goes directly against this vital life-affirming, life-saving, suicide-preventing, and altruistic message.

Impeding Medical Progress, Advancing Killing More Generally

If we need a third and further reason to oppose PAS, consider its likely effect on medical innovation. PAS will tend to impede medical progress in the development of therapies and symptom management for those diseases that might lead patients to seek PAS. When advocates of PAS propose it as a fitting therapy, they would reduce the demand for alternative therapies. If they prevail, PAS—presumably one of the less expensive of alternative treatments—will itself become a therapeutic response to those diseases.

Fourth and finally, when she assists a killing even supposedly as a therapy, the physician undermines the medical profession’s ability to resist being suborned into killing more generally. If a deadly drug may be prescribed as therapy for a terminally ill patient, why not for other grim medical conditions? If a deadly drug may be prescribed to a terminally ill patient who can take the drug himself, why not to a similarly situated patient who cannot give himself the drug? If PAS is permissible, why not euthanasia? Today in most U.S. locales these questions are only rhetorical. Yet who that is familiar with the dynamics of contemporary society would think that we would permit PAS only for terminally ill patients, were PAS to become an accepted practice?

Society’s Constant Attempt to Turn Physicians into Killers

Further, if physicians participate in PAS, consider the ramifications this would have on killing outside the normal purview of medicine. As the anthropologist Margaret Mead noted, one important achievement of the Hippocratic Oath was to separate the social roles of healer and wounder: “[S]ociety is always attempting to make the physician into a killer—to kill the defective child at birth, to leave the sleeping pills beside the bed of the cancer patient. . . . [I]t is the duty of society to protect the physician from such requests.” Oddly enough, capital punishment illustrates Mead’s point. Joseph-Ignace Guillotin—the man who promoted the use of the guillotine for official executions during the French Revolution—was a physician. His colleague Antoine Louis—who played a larger role than Guillotin in the development of their lethal device—was a surgeon. Motivated by egalitarianism and a desire to reduce harm, they employed their medical training toward the end of efficient, speedy, almost pain-free killing. We are told that when Guillotin proposed his “killing machine” before the French Assembly, he was met with an immense burst of laughter. Presumably this was because his audience found the physician’s enthusiastic advocacy of killing “in the blink of an eye” incongruous. Physicians heal; executioners kill. A physician who is eager to kill is funny in an Abbott-and-Costello fashion, for he joins opposites. In the one case a tall, skinny man is paired with a short, fat man; in the other a doctor acts as a hangman.

Needless to say, the guillotine proved to be no laughing matter. Yet the dark sentiment behind it remains with us. In 2009 the Supreme Court of North Carolina ruled that the North Carolina Medical Board, which licenses physicians, cannot prohibit physicians from administering capital punishment under threat of revoking their licensure. Rather, as the legislature of that state mandated (in N.C.G.S. §§ 15-190), during the execution by lethal injection, a physician must “monitor the essential body functions of the condemned inmate and notify the Warden immediately upon his or her determination that the inmate shows signs of undue pain or suffering.”

By enlisting physicians to reduce the pain and suffering of one condemned to death, the state appears humane. Mead’s observation, however, pierces this apparently benign facade, for the state seeks to turn the healer into an agent of capital punishment. No matter how painless, punishment essentially involves inflicting damage, hurt, and harm. This role does not comport with the physician’s exclusive devotion (often) to heal, restore, revive, and always to care. Caring excludes killing, for caring sustains, while killing eliminates the subject of care. Aware of this primal truth, the Hippocratic Oath clearly draws a line that physicians ought not to cross, lest they become society’s most technically proficient executioners: “do not give a deadly drug.”

By respecting this venerable boundary, physicians can resist society’s chronic tendency to conflate the roles of healer and wounder. Moreover, by rejecting PAS, doctors ensure both that death will not become a therapy for grim diseases more generally, and that today’s PAS will not become tomorrow’s euthanasia. This honorable “No” to giving a deadly drug permits many “Yeses” to therapeutic progress and shields vulnerable others. Finally, doctors would do wisely to avoid the temptation to medicalize mortality by answering questions outside their competence—indeed, questions the answers to which bound human insight concerning “The undiscover’d country from whose bourn/No traveller returns” and allied matters of “great pith and moment.”

The Oath’s Concluding Blessing

Toward the end of the Hippocratic Oath, the new physician prays, “now, to me making this oath fulfilled, and not breaking it, may it be to share in life and art being famous according to all men for all time.” Having not taken life with his art, as he knows he readily could, he hopes to enjoy his life and his art and to be spoken well of into the ages. Certainly, in Hippocrates’ time as in ours, a life dedicated to healing that excludes killing has all the best reasons on its side and merits perennial admiration and praise.

 

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