Words matter

Words matter. Medical aid in dying (MAID or MAiD) is the term now widely accepted in law and medicine to describe the practice of a physician prescribing medication to a terminally ill, mentally competent, adult patient who may choose to ingest it to end suffering they find unbearable, and achieve a peaceful death. It is accurate language which should be used. Other terminology such as physician aid in dying may also be used, but increasingly there is a preference for the term medical aid in dying.

It is inappropriate and inaccurate to use the value laden, pejorative terms “assisted suicide” or “physician assisted suicide” to describe medical aid in dying. Opponents of the practice use this biased terminology to equate medical aid in dying with criminal acts, and imply a social stigma. It does not matter, in my view, that suicide may not be considered bad or wrong in certain situations. That is not relevant in this context. When death occurs by a dying person taking prescribed life-ending medications, it is simply not a suicide (even if courts have, I believe erroneously, considered it to be such). These are people whose disease is killing them. In the vast majority of cases they do not want to die but they will inevitably soon die. They are only controlling the time and circumstances of their dying in an acceptable medical, ethical fashion. We do not consider the death of a patient who has life-sustaining treatment withdrawn to be a suicide, even though that person might survive with such treatment for weeks or months (or even longer in some cases). So it seems inconsistent to characterize medical aid in dying as a suicide.   

Those who take prescribed medications to end their suffering are not committing suicide. Stark differences exist. Suicides are committed by those who can continue to live, but choose not to; are done in isolation, often impulsively and violently; and they are tragic. To the contrary, medical aid in dying is available only to terminally ill patients who will soon die; their disease is killing them. The process usually takes at least several weeks; it occurs after consultation with two physicians and almost always with family support; and it is empowering. The term “assisted suicide” is rejected by the American Public Health Association, American Academy of Hospice and Palliative Medicine, American Medical Women’s Association,  American Academy of Family Physicians, and American College of Legal Medicine, among others, and in the state laws which permit medical aid in dying. 

In 2017, the American Association of Suicidology issued this statement: “Suicide is not the same as physician aid in dying”.

The Executive Summary states: “The American Association of Suicidology recognizes that the practice of physician aid in dying, also called physician assisted suicide, Death with Dignity, and medical aid in dying, is distinct from the behavior that has been traditionally and ordinarily described as “suicide,” the tragic event our organization works so hard to prevent. Although there may be overlap between the two categories, legal physician assisted deaths should not be considered to be cases of suicide and are therefore a matter outside the central focus of the AAS.”

The Statement raises 15 points of difference between what it terms physician aid in dying (PAD) and suicide. Some of them are quoted below.

3) In PAD, the individual who is already facing death often experiences intensified

emotional bonds with loved ones and a sense of deepened meaning as life is

coming to an end; in suicide, by contrast, the individual typically suffers from a

sense of isolation, loneliness, and loss of meaning.

4) The term “suicide” may seem to imply “self-destruction,” and the act may be cast

that way in some cultural and religious traditions. Ending one’s life with the

assistance of a physician and with the understanding of one’s family is often

viewed more as “self-preservation” than “self-destruction,” acting to die while

one still retains a sense of self and personal dignity, before sedation for pain or

the disease itself takes away the possibility of meaningful interaction with those

around one.

5) Suicide in the conventional sense often involves physical self-violence, as in

gunshot wounding, self-hanging, jumping, self-cutting, self-drowning, and the

ingestion of substances or compounds that may cause painful death. PAD in

contrast is intended to provide the physically easiest, least violent, least

disfiguring, most peaceful form of death an already dying person could face.

7) In suicide, the person often “sees no way out” of their desperate situation. Under

the PAD statutes in the US, the physician is required to inform the patient of all

feasible alternatives for relieving their situation, including comfort care,

palliative care, hospice care, and pain control.

8) Suicide in the ordinary, traditional sense is much more common among those

with mental illness, where it may be a complex byproduct influenced by

anhedonia, impaired thinking, cognitive distortion and constriction, impaired

problem-solving, anxiety, perseveration, agitation, personality disorders, and/or

helplessness and hopelessness. Under the PAD statutes, in contrast, mental

illness that would affect the rationality of decision-making is screened out, and

where, as in some European jurisdictions, PAD is legal in cases of unbearable

suffering in intractable mental illness, heightened scrutiny is required. Evidence

of depression and other mental illness is, by statute in the US, subject to

evaluation by a psychiatrist or psychologist and, if it is determined to be

influencing the decision, the patient is not qualified under the law.

9) The conventionally suicidal person may be unable to assess his or her situation

clearly or objectively; the person considering PAD is typically able to balance the

choice of an earlier death against the loss of control and increased

medicalization they may experience as they enter the end-stages of a terminal

illness. According to studies from the Netherlands, the patient who dies with

physician assistance forgoes on average about 3.3 weeks of life.

10) The legal status and consequences of the two acts are different. In the United

States, the statutes in those states with “Death with Dignity” or “End of Life

Options” laws assert that such a death “shall not, for any purpose, constitute

suicide, assisted suicide, mercy killing, or homicide under the law.” Deaths under

these laws are not reported as suicide on death certificates, but as death from

the underlying terminal condition.

11) Studies from Oregon and the Netherlands show that the impact of PAD on

bereavement in family members tends to be less severe than in other deaths. In

contrast, those bereaved by suicide deaths have higher rates of complicated grief

and PTSD, and may be at higher risk for suicide themselves.

Below are excerpts from statements of some of the other organizations mentioned.  At the time when they were authored, some a decade or more ago, different terminology was used by different organizations.  

American Academy of Hospice and Palliative Medicine

The term PAD (Physician Assisted Death) is utilized in this document with the belief

that it captures the essence of the process in a more accurately descriptive fashion than

the more emotionally charged designation Physician-Assisted Suicide. Subject to

safeguards, PAD has been legal and carefully studied in Oregon since 1997.

American Public Health Association

In 2008, the APHA adopted the following policy:

[APHA] does not support the use of inaccurate terms such as ‘suicide’ and ‘assisted suicide’ to refer to the choice of a mentally competent terminally ill patient to seek medications to bring about a peaceful and dignified death.

The American Medical Women’s Association

In 2007, the AMWA stated that

The terms ‘assisted suicide’ and/or ‘physician assisted suicide’ have been used in the past, including in an AMWA position statement, to refer to the choice of a mentally competent, terminally ill patient to self-administer medication for the purpose of controlling time and manner of death, in cases where the patient finds the dying process intolerable. The term ‘suicide’ is increasingly recognized as inaccurate and inappropriate in this context and we reject that term. We adopt the less emotionally  charged, value neutral, and accurate terms ‘Aid in Dying’ or ‘Physician Assisted Dying.’” And, in 2018, the AMWA issued a revised statement stating, in part, “AMWA believes the physician should have the right to engage in practice wherein they may provide a terminally ill patient with, but not administer, a lethal dose of medication and/or medical knowledge, so that the patient can hasten his/her death. This practice is known as medical aid in dying.   

American Medical Student Association

Whereas there is increasing use of neutral terms like ‘physician-assisted dying,’

‘physician-assisted death,’ or ‘physician aid in dying’ to avoid the more emotionally

charged ‘physician-assisted suicide’ … therefore be it resolved that the Principles

Regarding Physician-Assisted Suicide, Number 1 (pg. 150) be AMENDED to read:

‘Physician Aid in Dying.’

American College of Legal Medicine

The term ‘physician-assisted suicide’ is arguably a misnomer that unfairly colors the

issue, and for some, evokes feelings of repugnance and immorality. The appropriateness

of the term is doubtful in several respects….ACLM rejects the term ‘physician-assisted

suicide.’

Conclusion

If we are going to have the most positive impact on those we are attempting to influence, we should use language which is most accurate and which is consistent with existing laws and pending bills. Medical aid in dying (MAID or MAiD) seems to be the best terminology. We should use it and we should encourage those whom we encounter on this issue to use it.  

 

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David C. Leven, JD, is the Executive Director Emeritus of and Senior Consultant to End of Life Choices New York (EOLCNY). He served as its Executive Director between 2002 and 2016. An expert on advance care planning, patient rights, palliative care and end-of-life issues, David has played a key leadership role in having legislation introduced and enacted in New York to improve pain management, palliative care, and end-of-life care. This legislation includes, among others laws, the Palliative Care Education and Training Act, the Palliative Care Information Act (PCIA), and a law on Continuing Medical Education (CME).

In addition to receiving numerous awards for his public interest work, David lectures frequently to diverse professional groups and the general public on health care decision-making and end-of-life issues, and has been a regular guest lecturer at Fordham Graduate School of Social Service and College of New Rochelle School of Nursing, the New York Academy of Medicine, the State Society on Aging of New York Conferences, the Hospice and Palliative Care of New York State Annual Meeting and at several medical centers, all of the New York City area law schools, as well as at Yale, Syracuse, and Albany law schools.