Not the Time for Physician-Assisted Suicide!

Lawmakers in Maryland are again debating the legalization of physician assisted suicide (PAS), with bills proposed in both the State Senate and State House which are modifications of the original bills first proposed in 2019. It would have been the wrong move for Maryland four years ago, and it would be even more so now. The following are some reasons why I oppose PAS (SB 945 and HB 933).

Health insurance companies have profited handsomely by not spending money on healthcare. Significant obstacles to patient care already exist in the form of prior-authorizations and denials. Life-saving care is often expensive. Here in Maryland, the Total Cost of Care Model began in 2019, a model which incentivizes hospitals to lower healthcare costs. ACO models throughout Maryland are also incentivizing physician practice groups to achieve shared savings in healthcare. In other words, practices like mine are rewarded for reducing costs across a population of patients. This is not the time for the low-cost death option! To permit medically-prescribed death would be to open the way to an entirely unmanageable set of financial conflicts of interests for insurance companies, hospitals, and medical practices.

·         Because of financial conflicts of interest in healthcare, we must not allow the low-cost death option to be legalized in the State of Maryland.

This is no time for Maryland to legalize physician-assisted suicide. To cast this issue as “Compassion and Choices” is deceptive. What is being debated is a prescription for death. The medical profession is full of compassionate doctors who offer choices to our patients every day.  In primary care, we help our patients throughout their lives, even to the end. MAID (or Medical Aid in Dying) deceives the public as a term, since help is already available for terminally ill patients including home-based and inpatient hospice care.

·         Compassionate care centered on patient goals at the end of life already exists, within the limits of what is beneficial and not harmful.

Autonomy must be weighed against other medical ethics such as beneficence, non-malevolence, and social justice. Autonomy of an individual should not come at the expense of another person or group of people. If physician-assisted suicide were to be legalized in Maryland, the autonomy of the few would come at the expense of the many. The following individuals would be at greatest risk of harms: people unable to afford healthcare or medication, elders believing they are a burden, those wanting to avoid health costs in order to leave an inheritance, the lonely, chronically ill, patients with weary caregivers, and people living with disability.

·         Autonomy has limit where harm is involved.  PAS threatens vulnerable populations.

It is ironic that there is a push to enable physicians to prescribe death at a time when our great State of Maryland is reeling from opioid overdose death and suicide epidemics, both of which preceded but have worsened during COVID times.  The desire to end life is often a symptom of severe mental illness. The desire to die may be transient, as my clinical experience has taught me.

·         Amidst an opioid overdose epidemic, this is not the time to release more dangerous drugs into society.

·         Amidst a suicide epidemic, this is not the time to signal ending one’s own life as a favorable option.

The “Right to Die” is tied to this legislation. It is false to imply that this form of autonomy depends upon legalizing PAS. Autonomy already exists in the right to refuse medical treatment and the right to discontinue medical treatment. For physicians to stand out of the way of the natural dying process is fundamentally and unalterably ethically different than to act with the intent to prescribe death. Most physicians in states where PAS has been legalized have refused to participate. 

·         The “Right to Die” does not depend upon the existence of PAS.

·         Standing out of the way of the natural dying process is ethically distinct from actively prescribing or administering death.

Medical professional organizations oppose PAS. I am a member of the American College of Physicians (ACP), the largest organization in my profession, representing over 160,000 internal medicine specialists in the US. The ACP opposes physician-assisted suicide. I have attached our ethics paper on this topic.

·         The American College of Physicians opposes Physician Assisted Suicide.

Terminal illness remains difficult to define precisely. Patients whom I thought would die within months have lived for years. Some conditions like Parkinson’s disease have been used to push the case for physician-assisted suicide. Yet, degenerative conditions have a long disease trajectory. In other countries where PAS was legalized, euthanasia has followed. At which point, would terminal illness or even personal consent be cast aside as requirements? One should look to Europe for modern examples.

·         Defining terminal illness is inexact.

·         Voluntary PAS opens the door to euthanasia, including involuntary euthanasia.

What is good, or beneficent, at the end of life is to provide high quality, patient-centered care.  Hospice care should be available for all Marylanders. In my practice, we have increasingly supported patients and their family and caregivers at the end of life at home, with the help of home hospice. Hospice care needs ongoing investment to improve access and quality. This includes the need to study symptom management in terminal illness. We need to continue to improve the systems which help terminally ill patients and their families in the settings of their preference. Better hospice care should dissolve all demand for physician-assisted suicide by providing assurance to our society that physicians and other healthcare workers will labor to relieve suffering while shaping treatment plans around patient goals.

·         Hospice care makes Physician Assisted Suicide unnecessary.

What is just, what is good, what avoids wrong, what is safe, and what is wise must be at the forefront of every consideration in healthcare. Though other states have legalized physician-assisted suicide, this would not be good for Maryland.