If there is any doubt that the legalization of assisted suicide has changed the ethos of medicine, that question should be settled by Craig and Dzeng’s article, “How Should Physicians Care for Dying Patients with Amyotrophic Lateral Sclerosis?” As psychiatrists and ethicists, we appreciate Craig and Dzeng’s attempt to highlight some central ethical issues involved in end-of-life care. However, we are deeply troubled by the article’s implicit message: namely, that physicians are acting ethically when they help patients kill themselves in such a way as to avoid legal liability. In our view, that self-serving calculation serves physicians’ interests—not patients’ well-being. We are also troubled by several critical omissions in the fictional Dr S’s evaluation and clinical management of “Donald”—a patient with amyotrophic lateral sclerosis (ALS) and extreme physical limitations who is requesting what the American College of Physicians rightly terms “physician-assisted suicide” (PAS).1
In the case, Dr S worries that despite these extreme physical limitations, Donald might somehow still be able to kill himself in a protracted or violent way, and he considers a lethal prescription to be an acceptable alternative means of death. Some proponents of assisted suicide assert that patients who seek medically assisted death are so determined to die that they will merely find another method if denied a prescription. Jones and Paton2tested this method-substitution theory and found, on the contrary, that having an assisted suicide law on the books did nothing to reduce the rate of “natural” (ie, nonassisted) suicides. States that offered physician-assisted suicide had no reduction in nonassisted suicides.2 Conversely, states without assisted suicide laws had similar increases in nonassisted suicides as states with the laws.2 However, having an assisted suicide law on the books does increase total state suicide rates by 11.79% when a range of factors are controlled for.2 Indeed, evidence from Oregon suggests there might be a “contagion” effect, owing to highly publicized cases of PAS, such as that of Brittany Maynard.3