Notes from a presentation by Daniel Sulmasy, MD,
at the Catholic Medical Association
Annual Educational Conference

We all agree that as a minimum:
1.  We want good care.
2.  We do not want excessive care - we should be able to decline treatments that are burdensome and disproportionate.
3.  We realize that some treatments to relieve our suffering may shorten our life, and that is okay, so long as their use is not intended to shorten our life. (Principle of "double effect")
4.  Hospice and palliative care, administered properly, are good things.
5.  We want to be treated as a whole person, with compassion.  We want to be valued and cherished up until our last breath.

Why should we not remain neutral or silent about Assisted-Suicide ? 
1.  Matters affecting the public create a need for us to take a position.  It is not a private matter.
2.  Neutraility is not neutral.  According to logic, one can take 3 positions regarding a proposition: 1) permitted 2) prohibited 3) required.  Neutral = Not, not permitted = permitted.  So being neutral, is the same as permitting or allowing a practice.  Neutrality drops opposition to a practice.  Abraham Lincoln recognized this - in the Lincoln-Douglas debates he strongly opposed neutrality w/r/t slavery for the new states added to the union, because that would mean that slavery would be permitted there.
3.  Legality does not require neutrality. For example - capital punishment.
4.  Disagreement about a practice does not require neutrality - we can take a position about health care reform.

9 Inadequate Reasons for Physician Assisted Suicide
1.  Patients want this. 
This arguments emphasizes patient autonomy, but autonomy is not without limits.  All law limits liberty to some extent, and rules are present to enable us to flourish as individuals within a society.
2.  Patients need this.
Not for symptom control.
Primary reasons given by patients for PAS: control, fatigue, being burdensome, fear of poor symptom control (not actual poor symptom control).
3.  People have spoken.
Polls can be manipulated by methods, and by the complexity of the questions asked.
Polls do not establish "right" and "wrong".
Laws can be unethical; e.g., apartheid.
Legislators should not practice medicine.
Idea of a profession -to have ethics independent of the state.
4. I am personally opposed, but I don't want to judge or restrict others.
All laws and ethics make similar restrictions and require similar judgements.
Judgements about right or wrong ARE NOT judgements about or the value of another person.
One shows real respect for a person when one cares enough to argue with them.
"Whatever" is very dismissive and indicates a lack of caring.
The Am. Psychological Assn. used to be neutral about the use of torture; now they are opposed.
5. Suicide is a private act and government shouldn't restrict or interfere.
Suicide is never a private act.  It impacts the family of the person committing suicide.  It affects the physicians involved.  It may stimulate copy-cat suicides.  The rate of suicides can increase as a contagion.
Making suicide legal validates the argument that some lives are not worth living. It implies that dependence on others makes life lose its value.  It validates the idea that a life of dependence is one that is not worth living.  This exposes the sick, vulnerable and disabled, who are all dependent, to being devalued, and creates pressures for suicide or euthanasia.
Suicide is a social act, not an individual act. It affects others. It affects society.
6.  Suicide should be safe, legal and rare.
In Oregon, no official stats are kept.  Very few psych referrals.  Rates appear to be increasing.
In Belgium/Netherlands, 5% of all deaths are now by suicide or euthanasia.  There is euthanasia of neonates, psychiatric patients, and demented people. There are euthanasia vans which will come to you!
7.  Not providing PAS abandons patients, and we cannot abandon patients.
It is not abandonment to refuse bad treatment, or every patient wish. Non-abandonment is instead accompaniment and commitment. We validate a person's value as a human being.
8.  There is no difference in killing vs. allowing to die.
The US courts recognize this difference.  The key is the intention or aim. Allowing to die aims at ending a treatment; death may ensue (Karen Ann Quinlan).  The intention of PAS is the death of the patient.
9.  All arguments against PAS are religious, and therefore should not be considered. 
The foregoing arguments are not religious.

Why ban Physician-Assisted Suicide
It is bad medicine.  It is bad ethically.  It is bad public policy.  PAS for symptom control is a failure.
1.  PAS for existential reasons (loneliness, despair, despondency, angst) is hubris (arrogance, excessive pride or excessive self-confidence).  It is medicine going beyond the scope of medicine. Rather than being killed, patients need holistic care.  Death is not a treatment.  PAS is not comfort or healing, which is what physicians are called to render.
2.  To maintain the patient-physician relationship, which is built on trust.
At a minimum a physician commits:
I will not kill you.
I will not have sex with you.
I will not divulge your secrets.
Physicians need to be VERY careful about counter-transference.  Caring for the terminally ill is very hard work. At times, the physician may develop subconscious (or possibly even a conscious) wish to be rid of a patient, of this burden. The patient may internalize what he hears from a doctor or caregiver, and then report it back, as his or her own autonomous wish.
Prohibiting PAS creates a limit or a boundary - that way getting rid of a patient cannot happen.
3.  PAS violates the fundamental principle of all ethics - the dignity of the human being.
MLK - Everybody is a somebody.
PAS - Takes a somebody and reduces him/her to a nobody.
Wittgenstein - If suicide is allowed, anything is allowed.
Suicide is autonomy run amok.
4.  PAS opens us up to the possibility of abuse.
There will be under-reporting and skirting of the rules.
5.  Slippery slope
     PAS will lead to euthanasia.
     Questions will arise about discrimination something to do, some:
          a.  What about people who want PAS but cannot take pills?
          b.  What about people who have lost their decision making capacity but would have wanted PAS in this circumstance (substituted judgement)?