Don’t confuse death with dignity with suicide

In 2008, the state legislature of Washington passed what was called the Death with Dignity Act, a law that legalized physician assisted suicide.  Under the law, terminally ill patients (predicted to have less than six months to live) can request prescriptions for lethal medications from their physicians, under a series of safeguards:  multiple requests for example, determination of competency, and the like.  Then, if the patients so choose, they can ingest the pills at the time of their choosing, thus controlling the manner and location of their demise, a last act of control in the face of an otherwise debilitating illness.

I have no beef with the letter or spirit of Washington’s law.  I have long contended that in rare circumstances, physician assisted suicide is a compassionate and morally appropriate policy.  Nor am I worried about the way the Washington law has worked in practice.  Indeed, a New England Journal of Medicine study demonstrates that patients have chosen assisted suicide sparingly, and without undue coercion from clinicians urging them to “off themselves”.

My beef is not with the letter of the Washington law, it’s with the name.  I think it is wrong-headed to equate assisted suicide with the concept of a dignified death.  Such a link unduly narrows the concept of dignity, and potentially undermines our ability as clinicians to help patients find other ways of achieving a dignified death.

According to dictionary.com, dignity is defined as “bearing, conduct, or speech indicative of self-respect or appreciation of the formality or gravity of an occasion or situation.”  By this definition, someone with dignity carries themselves in an impressive manner.  Think Helen Mirren as opposed to Jenny McCarthy.

In medical circles, the concept of dignity is a bit removed from this lay usage.  Dignity refers to people’s right to be valued and treated ethically.  Going back to Kant, dignity refers to the importance of treating people like ends, not means.  At times, dignity is lumped together with the right of self-determination.  Mainly, the word is used in medical contexts with very little clarity, often undefined by those wielding the word except to say:  “X would deny patient dignity, therefore we should be against X.”

I agree with supporters of Washington’s law that physician assisted suicide can be part of a dignified death.  But there are plenty of other ways for terminally ill patients to control the circumstances of their death, making it wrong to equate dignity with suicide.  For example:  How about more aggressive use of palliative care?  Too often, patients with advanced illness are treated aggressively with “salvage chemotherapy” or with “IV pressers”, when their quality or even quantity of life would be better served by aggressive palliative care.

I worry that patients suffering from terminal illnesses will perceive an unnecessary dichotomy, between continued aggressive care and death with dignity, a.k.a. physician assisted suicide.  Those who are morally opposed to suicide may then fail to pursue other dignified ways of controlling their destiny.

The Washington researchers point out in their New England Journal article that only 114 patients at the Seattle Cancer Care Alliance inquired about the Death with Dignity program, a tiny number compared to the number of patients who died of their cancers in the Seattle area over the time period the investigators studied.  In other words, people are not rushing to kill themselves.  But what the researchers could not comment on was the number of patients who unnecessarily suffered at the end of life because the death with dignity law misdirected their attention from palliative care to assisted suicide.

There are many ways to die with dignity.  Let’s not propagate the mistake of equating dignity with suicide.

Peter Ubel is a physician and behavioral scientist who blogs at his self-titled site, Peter Ubel and can be reached on Twitter @PeterUbel.  He is the author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together.

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  • Guest

    Suicide is suicide. You can’t change the definition of the word to make you or the patients you’re helping to kill “feel better” about it.

    If someone kills himself or herself, that’s a suicide, whether it’s by shooting himself or herself in the head or deliberately ingesting poisons that their trusted physician has handed them with the promise that that’ll “do the deed.”

    If you’re going to feel bad about leading someone to kill herself, DON’T DO IT. Whether it’s helping them hold a loaded gun to their head or handing them poison, if you’re doing it with the intention that it’ll kill them, that’s assisting a suicide. There’s really no way to pretty it up.

    • penguin50

      Guest, you seem to be comfortable only with black-and-white thinking. You seem to want to stay safely and squarely on the “pretty” side, not the “ugly” one. How lovely for you to stand by and preen yourself on your shining moral status while someone screams for mercy.

      Are you even aware of how complex these issues are in practice? Would you consider, for example, terminal sedation to be a form of “suicide,” as some do?

      If I were in utter, untreatable agony and would surely die within, say, 36 hours, I don’t want a doctor who is primarily concerned with preserving his or her own ego-infused sense of moral purity. I want a doctor who is willing to wade into the gray zone with me and help me out of my pain in whatever way necessary. If you are a doctor who works with terminally ill patients, I certainly hope that you let them know very early on where you stand on this issue so that, if they so desire, they have time to find a doctor who thinks more broadly.

      • meyati

        Since I was diagnosed with a caustic bone eating cancer by my nose, and it will take time, lots of time, until my brains fall out, I’d like help with pain control when it starts hurting. The CAT scans show that it is in remission. The ACS wanted to cut out about half of my face including bone, eye, upper teeth, nose-in several surgeries, wait a year for a prosthetic face-then have about 10 years B4 it comes back. The catch-I know a man that was promised 10, but had only 4 years, including the time waiting for prosthetics. then more surgery, then chemo and everybody says that it doesn’t work at all, then radiation-then wait out the time to be allowed to have palliative care–Surely the 6 week or 36 hour rule is sort of sick and sadistic to me and to my family. Would you like to see your mother’s or child’s brains fall out without any hope or pain relief?

        • penguin50

          Meyati, I have been very sorry to read of your situation in various KevinMD comments; it sounds horrifyingly difficult, and I wish you all the best as you cope with it. But I think you may have misinterpreted my comment above to Guest.

          In no way do I mean to suggest or impose a “36-hour rule” (I don’t know where your six-week reference comes from)—that was simply an amount of time chosen as a random example. I am very much in favor of maximum pain relief for anyone suffering for any length of time at all. I would not advocate for any predetermined time limit on a person’s pain before they are given pain medication or, if such is not effective in their case, before they elect to pursue physician-assisted suicide.

          I sincerely hope that better treatment options become available to you. Right now, it sounds like you are in a terrible bind with no truly good choice. I would want you to have the very best pain control possible the very second you need it. I’m glad you are in remission, but I also understand how nerve-wracking that can be.

    • Mengles

      When you have terminal cancer and are in utter pain, please tell us when you feel differently.

    • Observer

      It would be helpful if you read the post, seeing as the author is suggesting that patients be offered options OTHER than suicide in order to allow them to die with dignity.

      • Disqus_37216b4O

        I was just going to make the same observation, Observer. I think Mr or Ms Kneejerk up there missed this bit of the original post:

        “I think it is wrong-headed to equate assisted suicide with the concept of a dignified death. Such a link unduly narrows the concept of dignity, and potentially undermines our ability as clinicians to help patients find other ways of achieving a dignified death.”

        I am personally opposed to legalizing “assisted suicide”, but am a strong advocate for hospice care, and I thought this was a very thoughtful and considered piece.

        • meyati

          What if palliative care and hospice doesn’t work because of the type of cancer?

  • Victoria

    The problem would seem to me to be that the opinions of the doctor are often seen as being more important than the opinions and needs of the patient. In some cases payments to a hospital can be seen as more important than the best interests of a patient, as outlined in a recent review of a book just published by Katy Butler http://www.nytimes.com/2013/09/08/books/review/knocking-on-heavens-door-by-katy-butler.html?pagewanted=1&_r=0
    How often is a care plan dictated by what the physician thinks is right rather than what is in the best interests of the patient’s wishes? Cancer patients often think they should not be questioning what the doctor recommends, and can also be put under enormous pressure by their family to remain in treatment when that is not appropriate at that time. Patients can be taunted by accusations of ‘giving up’ when they actually just want to be allowed to accept what is inevitable. This is death with dignity because it is a considered and informed choice and not an act of desperation. Suicide is more likely to be the result of treatments that don’t work, but which the patient feels they can’t question because they are advocated by a doctor and or their family.

    • Disqus_37216b4O

      “Patients can be taunted by accusations of ‘giving up’ when they actually just want to be allowed to accept what is inevitable.”

      THIS. The whole “illness as a battle” paradigm, which implies that he/she who decides to stop fighting is necessarily some kind of loser, has a lot to answer for.

      It’s okay to battle to the end, IF that’s what someone wants, but we should do more to recognize the dignity and grace of those who have come to terms with the inevitable and just want to go out quietly.

      • meyati

        I truly hate this term “giving up” and “fight”. I’ve been told that I’m a quitter by nurses and doctors. My first baby was breech and I had high BP. I had a small tear in my uterus and I bled. The staff gave up on me. I heard the ward doctor was reading comic books. They sent in a young corpsman to see if I was dead yet. She went down to the delivery rooms and got doctors. I found a small cave somewhere in my mind, where I could go and hide, conserve my strength. When help came, I was able to crawl out of my hole. They couldn’t understand why I could answer questions.

        One time, when I was being put under for minor surgery, I began to aspirate. I told the doctors. They begged me to stay awake while they tubed me. I said-” No, I gotta get out of here”, and slipped into my cave.

        This fall I was diagnosed with an incurable cancer. Because of my cave, I was able to retreat from the bullying to reason things out, talk to my family about the options-basically I’d rather throw myself from a cliff than do the standard treatment. I seem to be in remission, according to the CAT scans.

        People don’t always have the same way of fighting-and doctors don’t have the right to close the door and sit in their office reading comic books, instead of monitoring a patient and waiting for that sweet spot to exam the patient without the patient hemorrhaging out. Another analogy, is that an oncologist doesn’t have the right to deny follow up, lab work, and refuse to allow the patient to get another doctor that’s willing to care for the patient. I wasn’t allowed to go into my cave, so I came out with my fangs on the so-called doctor’s jugular.

        The prognosis is that this will come back no matter what I do, eat through the roof of my mouth until my brains fall out. It’s very slow moving, and I’m told it is the most caustic of bone eating cancers.

        In this day of DEA micromanagement and limited pain relief-I’m allergic to Tylenol and nobody wants to dispense codeine-I fell off a ladder and sprained both knees-then was jogging with my hounds and jammed my arm into the rotator cuff-had to use self-hypnotism after I got out of the ER- why should I think that waiting til the very end to get palliative care or assisted suicide is a form of dying with dignity, and it will be very hard to crawl into my cave to finally die?

        If I don’t die from another cause-being struck by a lightning bolt, being run over by a drunk driver, etc, denying me pain relief if this comes back, will not stop any criminal from stealing and selling drugs and stop anybody from overdosing in the street.

  • Dorothygreen

    I just read the first few sentences of Katy Butler’s review in the NY times. Thank you Victoria.

    We aren’t a very dignified country relative to other countries he way we treat people at the end of life or how they wish to die to avoid an unnecessary painful death or be a burden to their loved ones.. This post is an example. Trouble with the word dignified. I have trouble with the words – Suicide is “illegal”. And someone taking offense with the use of the word in this setting.

    We don’t need all these gradations of the dying process and wouldn’t if we had a real health care system that is not for profit for basic care. Hospice should encompass so called palliative care and so called assisted suicide. A spectrum of comfort care with the rights of what the patients want and when they decide they want it. It should be supportive and help them prepare.

    The accounts of medication denial in this post and what I still hear happening in ICUs across the country. (probably all in the booK) makes me want to lie about having a sleeping problem or pain just to horde some medicine “just in case”. Problem is it would expire long before I could possible need it

    We have to do better as a country than this.

  • katerinahurd

    What are the features of aggressive palliative care? Since palliative care refers to the management of pain and suffering that terminal patients face, what is an aggressive pain? Do you think that the experience of an aggressive pain deprives a human of any dignity?