Primum Non Nocere

Palliative care is the interdisciplinary care of the patient and family intended to prevent and relieve suffering. All therapies are directed at sources of suffering and are guided by the patient’s goals of care. They are also guided by the traditional dictum to the physician to “primum non nocere” (first, do no harm). Physician-assisted suicide (PAS) and euthanasia both assume that the palliative interventions will not prevent or relieve the suffering and that the physician is relieved of the responsibility to do no harm. A patient’s refusal of treatment that is perceived by the patient to be futile and/or burdensome beyond benefit depends only on the patient’s action or non-action. Physician-assisted suicide and euthanasia require action on the part of the physician in addition to action by the patient. It is this involvement of a second person in the action and its outcome that creates the ethical dilemma. Does any individual have the right to demand such an action by another person whether or not the physician agrees with the decision?

In the spirit of “do no harm” and because the full, appropriate therapies for all sources of suffering are as yet unknown, requests for PAS and euthanasia by patients should be evaluated diligently as requests for help, and all available interventions for the prevention and relief of suffering should be offered to the patient making such a request. In earlier proposals supporting PAS, the arguments were often about “what if the pain cannot be controlled?” Now, even the most ardent supporters of PAS acknowledge that we can control pain. The use of opioids and sedatives in terminally ill patients is sometimes defended by the ethical doctrine of double effect, but current literature does not support the shortening of survival by these medications. Several studies have been done, involving more that 4,000 patients, that show no decrease in survival.

Palliative medicine is an emerging new specialty that focuses on the prevention and relief of suffering and is developing exciting new treatment methodologies to address psychosocial and spiritual issues as well as physical suffering.

Other issues arise when considering PAS. There are no studies about the long-term effects on survivors of PAS; it is known that survivors of people who complete a suicide have shown long-term harm and increased risk of suicide themselves. Any treatment by a physician should include an informed consent and recommendations for use. Acceding to a request for a prescription for suicide puts the physician in the position of using medications in unintended ways. If the physician “recommends” the suicide, he or she is then actively involved in the death of the patient.

The physicians and staff at San Diego Hospice & Palliative Care support the position that the California Medical Association has taken not to endorse any law promoting physician-assisted suicide.