Physician as Healer or Harmer? The Ethical Context of Aid in Dying

by: Elizabeth Dzeng, @LizDzeng

As ethicists like to point out, what is the law is not always ethical and what is ethical is not always the law. Passage of the End of Life Options Act in California does not imply that we’ve resolved the debate on aid in dying, nor should it define our moral stance.

However, it does provide us with new opportunities to find common ground. The energy and passion that motivate advocates on both sides, have always been rooted in the same desire to improve the way we die. The perspectives of those who oppose aid in dying will be especially critical, to give voice to vulnerable individuals for whom we must insure ethical responses with proper safeguards and support systems in place. This is an opportunity for us to critically evaluate and rethink our approach to improving end of life care as a whole.

Aid in dying is controversial precisely because it exemplifies the many ethical dilemmas our society has grappled with – concerns of injustices that predominantly affect the poor, the need to protect vulnerable populations, and the tensions between patient choice and control, versus the role of the physician as a healer.

Indeed, aid in dying is controversial because questions physicians’ fundamental professional identity as a healer. The American health care system is geared towards healing people when something can be fixed – and does a very good job of it. The problem is that this healer ethos falls apart when the patient can no longer be physically healed. We don’t do a great job of helping patients die peacefully, in part because clinicians are often uncomfortable when they can no longer heal. Medical culture too often sees death as a failure and physicians find it challenging to discuss death.

Aid in dying also forces us to confront a professional code to first do no harm. However, lines have already been blurred between the Hippocratic Oath’s mandate and the potential for harm in the treatments we provide at the end of life. Arecent study for example, demonstrated that chemotherapy does not confer survival benefit nor improves quality of life near death, and even more alarming, worsens quality of life for those with a high performance status. Atul Gawande, Sharon Kaufmann, and others remind us that medicine’s technological imperative and other structural incentives drive us towards interventions that do not help, and frequently harm. And Katy Butler eloquently reminds us of the havoc the process plays on caregivers who support the dying.

The calls for legalizing aid in dying thus reflect our broader concerns about medicine’s failure to facilitate a good death. As such, a successful, ethical response must also shine a light on how we generally care for the dying. To start, we must broaden our understanding of what healing means, and recognize that even when the physical cannot be healed, that we must still play a role in the psychosocial, spiritual, and holistic healing needed to prepare for death.

This blog is an extended version of the introduction to the ethics panel at the End of Life Options Act Response Conference