Taking Requests, Doing Harm

Original Article

The “Hippocratic Oath” sniffed Dr. Sherwin Nuland dismissively in the February 24, 2000 New England Journal of Medicine, “has been embraced over approximately the last 200 years far more as a symbol of professional cohesion than for its content … Ultimately, a physician’s conduct at the bedside is a matter of individual conscience.”

What a frightening thought. When I tell audiences that only about 13 percent of physicians take the Hippocratic Oath – if that – invariably they respond with loud, shocked gasps of alarm. Patients believe that if doctors want professional cohesion, they should join the Rotary Club. They believe that doctors have certain ironclad professional obligations to patients that cannot be violated regardless of a physician’s individual beliefs. Indeed, patients rightly view the Hippocratic Oath as one of their primary defenses against the overwhelming power over our vulnerable lives that we, of necessity, place in the hands of our doctors. This obligation is summarized by the Hippocratic principle that a doctor “do no harm” to a patient – even if the patient may wish otherwise.

Nuland wrote in the context of an editorial favoring a right for physicians to engage in euthanasia – an act explicitly prohibited by the Oath. That is disturbing enough. But to see just how radical a departure Nuland’s proposed “individual conscience” standard could take medicine away from thousands of years of professional wisdom and tradition, just read “Costing an Arm and a Leg” written by Carl Elliott for Slate.

Elliott writes about a bizarre new mental illness called “Body Integrity Identity Disorder,” or as it is commonly known, “amputee wannabe.” Yes, you read right, we are talking about disturbed people who want their arms or legs cut off. Worse, there appear to be at least a few doctors whose “individual consciences” allow them to amputate these patients’ healthy limbs – most notably Dr. Robert Smith of Scotland – who has admitted to acceding to the desires of amputation-obsessed patients. According to Elliott, there are even psychiatrists willing to prescribe amputation as the “only” available therapy to their patients’ obsessions even though, “no formal research studies on treatments for wannabes have ever been undertaken.”

While it remains exceedingly rare for physicians to be willing to amputate healthy arms or legs, the idea of facilitating patient suicides – once just as beyond the pale as unnecessary amputations – has gained steam in the mental-health professions as well as among a minority of physicians. Indeed, there is a new theory being promoted in psychiatry, psychology, and social work known as “rational suicide.”

According to rational-suicide proponents, the mental-health professional’s duty to a suicidal patient is not necessarily to prevent death. Rather, if after exploring the reasons a patient wishes to commit suicide the mental-health professional believes that the decision “to suicide” – some advocates use the word as a verb – is “rational” and appropriate to the patient’s personal circumstances, then not only should the decision be accepted, but perhaps even facilitated. Indeed, once the professional decides that the reason for committing suicide is rational, his primary job is not to engage in prevention but to ensure that the patient goes through a proper decision-making process, such as ensuring that he has considered the impact of the planned suicide on loved ones, before doing the deed.

As far as I know, professional associations have not yet formally accepted rational suicide. Still, “model rules” for “permitted suicide” have already been published in the October 2001 Journal of Mental Health Counseling, in an article written by Elliot D. Cohen, Ph.D. According to Cohen, a “permitted suicide” exists when a “counselor validates the client’s decisions to commit [rational] suicide and obtains at least one independent qualified, confirmatory assessment.”

Providing the mental-health profession’s imprimatur to self-destruction does not end the duty of the permitted suicide practitioner, according to Cohen. Counselors are also required to become “knowledgeable about the various methods of self-administration, including types of drugs, lethality of dosages, and efficacy of methods” for suicide, so that the patient can be instructed on how to do the job right. Above all, mental-health professionals are urged not to be judgmental about suicide. Indeed, Cohen analogizes committing rational suicide to refusing life-sustaining medical treatment. Since the suicidal person can’t pull the plug in order to die, he asserts, the rational suicide “warrants the same legal protection afforded other groups of rational, competent persons against involuntary hospitalization, detainment, surveillance, and other forms of coercive practice.”

As if this anti-Hippocratic advocacy weren’t bad enough, the law seems to be drifting toward a libertarian view that would permit physicians to do almost anything that a willing patient desires. Indeed, in 1999 the supreme court of Montana, in striking down a law that would have required doctors to perform abortions, (James H. Armstrong, M.D. v. The State of Montana), ruled, “The Montana Constitution broadly guarantees each individual the right to make medical judgments affecting her or his bodily integrity and health in partnership with a chosen health care provider free from government interference.” Moreover, the majority decision ruled, only “a compelling interest … to preserve the safety, health and welfare of a particular class of patients or the general public from a medically acknowledged bona fide health risk,” warrants any state involvement in medical decision-making.

Think about the implications of this decision: Regardless of the individual or societal consequences, absent extraordinary exigencies such as preventing a plague, virtually anything may be allowable medically in Montana if it can be construed to involve obtaining “medical care from a chosen health care provider.” Indeed, the decision was so radical that two justices dissented. They worried that the court had stripped the Montana legislature “of any role in matters relating to health care to be provided to the people of Montana” and that rule of law enunciated in the case was so broad that it could “encompass and decide such issues as the right to physician-assisted suicide and other important health and medical-related issues.” If the dissenters were correct that almost anything goes medically in Montana so long as a patient wants it and a health-care professional is willing to do it – a reasonable interpretation considering the expansive language and philosophical thrust of the majority’s decision – then it could very well allow doctors to amputate healthy limbs upon request and permit psychiatrists to participate in the “rational suicides” of despairing patients.

If medicine and mental-health counseling are to remain truly professional, “anything goes,” cannot be their creed. Rather, health-care professionals need to energetically revive and defend the venerable Hippocratic principle that doctors are duty-bound not to harm any patient – even if that is what the patient desperately wants. To do otherwise is to abandon those who are least capable of protecting themselves to the horrors of self-abuse and destruction.

Wesley J. Smith is a senior fellow with the Discovery Institute and an attorney and consultant for the International Task Force on Euthanasia and Assisted Suicide. His revised and updated Forced Exit: The Slippery Slope from Assisted Suicide to Legalized Murder was recently released by Spence Publishing.

Wesley J. Smith

Chair and Senior Fellow, Center on Human Exceptionalism
Wesley J. Smith is Chair and Senior Fellow at the Discovery Institute’s Center on Human Exceptionalism. Wesley is a contributor to National Review and is the author of 14 books, in recent years focusing on human dignity, liberty, and equality. Wesley has been recognized as one of America’s premier public intellectuals on bioethics by National Journal and has been honored by the Human Life Foundation as a “Great Defender of Life” for his work against suicide and euthanasia. Wesley’s most recent book is Culture of Death: The Age of “Do Harm” Medicine, a warning about the dangers to patients of the modern bioethics movement.