Doctors: Reasons to oppose physician-assisted death

In recently denying Dr. Roger Kligler’s request for medical aid in dying/physician-assisted suicide (MAiD/PAS), the Massachusetts Supreme Judicial Court acknowledged the complexity of the decision, noting that the state has legitimate interests in “preserving life; preventing suicide; protecting the integrity of the medical profession; ensuring that all end-of-life decisions are informed, voluntary, and rational; and protecting vulnerable people from indifference, prejudice, and psychological and financial pressure to end their lives."

Gov. Maura Healey has since expressed hopes for legislative action to allow MAiD/PAS with “appropriate guardrails,” following the lead of other jurisdictions in the United States, Canada and Western Europe. 

Fears of dying in distress or dependent on technology have understandably heightened the appeal of arguments for MAiD/PAS based on self-determination and the relief of suffering. Counterarguments are often perceived as unduly abstract or based in religion. However, as a psychiatrist at a cancer center and a psychiatrist-medical ethicist, we see compelling reasons to oppose legalization of MAiD/PAS:

First, cumulative experience with MAiD/PAS in Oregon has shown that the vast majority of individuals do not request assisted death because of intractable pain and suffering. Rather, most are motivated by the fear of “losing autonomy” (90.6%); or being “less able to engage in activities making life enjoyable” (89.1%). Some also fear a “loss of dignity” (74.4%); becoming a “burden on family, friends/caregivers” (44.8%); or “losing control of bodily functions” (44.3%).

These fears, while understandable, are amenable to good palliative care. Helpful resources include meaning-centered therapy; dignity therapy; psychiatric, spiritual and hospice care; and the wisdom contained in books such as "The Lost Art of Dying" by Columbia physician Lydia Dugdale, who reminds us that to be human is to be contingent and interdependent with others.  

A crucial resource in dying well is a relationship with a physician who appreciates the psychological, personal and existential aspects of the doctor-patient relationship – one who can reassure patients that their final days can have meaning, that their burdens will be shared, and that their physical or emotional pain can be made more bearable. To offer MAiD/PAS is to convey that the end of life lacks intrinsic meaning or purpose, and to renege on the physician’s mandate to “cure sometimes, treat often and comfort always.”

We are also troubled by the European and Canadian experience, in which the availability of MAiD/PAS or euthanasia (the active termination of the patient’s life by the physician) has led to increasing numbers of individuals dying by these means. Although patient-administered MAiD/PAS in the United States has not resulted in similar numbers, in 2021 more than 10,000 people died by euthanasia in Canada, an increase of about a third from the previous year.

Moreover, there is an ever-expanding list of reasons, in some jurisdictions, for allowing MAiD/PAS or euthanasia. For example, the Netherlands and Belgium include mental disorders, and Canada has done so with a recently announced delay. In the Netherlands, the criteria have expanded to include advance directive-based, now incompetent individuals; infants; and those who are simply “tired of living.” Once MAiD/PAS is allowed – usually initially for the terminally ill – it becomes difficult for a society to contemplate life-affirming alternatives.  

Many in the disability community question whether MAiD/PAS can be equitable. Those pressing for MAiD/PAS are overwhelmingly white and privileged, but the law applies to all. Even Oregon has acknowledged that its “Death with Dignity Act” has not adequately protected patients with mental illness from receiving lethal drugs.

Notably, last February, after pleading unsuccessfully for affordable housing, a disabled Canadian woman ended her life under Canada’s euthanasia laws. In such instances, MAiD/PAS compels individuals who may already fear being a burden to justify their existence, and legitimates rather than discourages deaths of despair.

Finally, MAiD/PAS prioritizes the patient’s “autonomy” over the physician’s Hippocratic duty to “first do no harm.” Massachusetts lawmakers considering legalizing MAiD/PAS should recognize that “guardrails” cannot prevent this practice from distorting the physician’s role; cheapening individual life; and abandoning the most vulnerable people to the “right” to end their lives. Surely as a society we can do better, by providing optimal, accessible psychiatric and palliative care.

Dr. John R. Peteet is a psychiatrist at Dana-Farber Cancer Institute and an associate professor of psychiatry at Harvard Medical School. Dr. Ronald W. Pies is clinical professor of psychiatry at Tufts University School of Medicine, and professor emeritus of psychiatry and lecturer on bioethics and humanities at SUNY Upstate Medical University. The views expressed in this column are their own and not necessarily those of their affiliated institutions.