The Goals of Medicine for a New Century

In the mid-1990s the Hastings Center convened a distinguished international panel of experts and charged it with the task of examining the goals of medicine in light of the remarkable advances in medical science and technology that had taken place over the last 30 years. The overarching question was whether these advances, and the new therapies (each with its own inherent benefits and risks), warranted any fundamental changes in the conceptualization and articulation of the goals. Given the formulation of goals that emerged from this process, it would appear the response of the panel was that a radical restatement of the goals was neither warranted nor appropriate. The following goals, the panel stated, represented the core values of medicine as we entered the twenty-first century:

• • The prevention of disease and injury and promotion and maintenance of health.

• • The relief of pain and suffering caused by maladies.

• • The care and cure of those with a malady, and the care of those who cannot be cured.

• • The avoidance of premature death and the pursuit of a peaceful death.^{Footnote 5}

There is a subtle yet exquisite symmetry permeating these four ostensibly simple and straightforward goals. Unlike modern medicine, in which the curative (disease-directed) model of patient care predominates and overwhelms the palliative model, the Hastings Center panel has placed them in a synergistic balance, in recognition of our ultimate mortality and the limits of even the most sophisticated medical science and technology.

Both the second and the fourth goals are relevant to our inquiry, but of particular concern is the subtle and elusive distinction implicit in the fourth. It calls to mind the mantra of hospice philosophy—we neither hasten nor prolong the dying process. The choice of the word “peaceful” is significant, in particular as an alternative to the d word: dignity. The term “dignity” in the context of dying and death has become highly controversial of late, with multiple warring camps contesting not only its meaning but also its relevance and significance. Decades ago the prominent theologian and ethicist Paul Ramsey wrote a provocative article entitled “The Indignity of ‘Death with Dignity,’” in which he challenged the very idea that there could be such a thing as a “good death.” There may be dignity in caring for the dying, he contends, but most certainly not in dying itself.^{Footnote 6} Similar attitudes have been expressed more recently by scholars such as Yale law professor Robert Burt, who insists:

Burt has further refined this perspective in the wake of the Terry Schiavo saga into an ethical stance that directly challenges the idea that ultimate decisions about dying and death should be left to the person who is dying or those who have been designated to speak for him or her. In a piece with the provocative title “The End of Autonomy,” Burt insists:

1. 1) No person should be socially authorized to engage in conduct that directly, purposefully, and unambiguously inflicts death, whether on another person or on oneself.

2. 2) Decisions that indirectly lead to death should be acted upon only after a consensus is reached among many people. No single individual should be socially authorized to exercise exclusive control over decisions that might lead to death, whether that individual is the dying person, the attending physician, or a family member acting as health care proxy.^{Footnote 8}

In a previous issue of this journal, I offered a sustained critique of Burt’s thesis and therefore will not elaborate on its many concerning implications here.^{Footnote 9} Finally, there are those such as bioethicist Ruth Macklin who insist that dignity is a “useless” concept, perhaps even a source of hopeless confusion in the context of discussions and debates about the ethics of end-of-life care, because it has been used in conflicting ways, and in most instances is merely a proxy for respect for individual patient autonomy.^{Footnote 10}

Returning to the second and fourth goals of medicine, certain questions call out for closer analysis. Might there be times when efforts to avoid a premature death undermine or conflict with the pursuit of a peaceful death? Indeed, in the context of a terminal condition, what would constitute a premature death? When a patient is confronted with a terminal diagnosis and an exceedingly grim prognosis (however long or short), can a means of ensuring a peaceful death such as palliative sedation or lethal prescription ever be said to be the cause of a premature death? Is there a material distinction with a genuine moral difference among declining life-sustaining interventions, requesting interventions that remove consciousness, or taking medications that result in death? How we answer these questions will depend in part on perspectives being offered by those on the boundaries of mental health and palliative care. For reasons that hopefully will become clear by the conclusion of this article, we would do well to follow the lead of the Hastings Center panel in eschewing an obsessive focus on dignity in favor of tranquility and peace. Too many strangers at the bedside, as well as political and social commentators, have conflicting opinions about what can and cannot legitimately be considered a dignified death, thereby causing us to lose sight of the interests and preferences of the patient who is actually dying. By contrast, if comfort is the medical focus and goal, then only the patient or the person duly designated to speak for her is in a position to declare with authority whether the dying patient is at peace.

The Rise of Palliative Care Psychiatry

One need only survey the recent second edition of the Handbook of Psychiatry in Palliative Medicine to appreciate the extensive growth and development of the literature in this field.^{Footnote 11} Special concerns running as common themes through the handbook include suffering, depression, dignity, and meaning. As I hope to elucidate, major figures who are promoting the rise of palliative psychiatry would have a field day with the opening quote from Joseph Conrad’s classic novel. The sentiments of the narrator would likely be interpreted as redolent of psychosocial, spiritual, and existential distress and thus as a target rich environment for psychiatric intervention. In fact, in the story, the narrator is facing imminent death, but not from chronic or terminal illness. Nevertheless, the sentiments expressed are those of what a reasonable person might view as a natural and quite understandable desire to avoid prolonged and unnecessary suffering. There is, indeed, as the author of the book of Ecclesiastes (3:2) declares, “a time to be born and a time to die,” but that begs such questions as whether the individual involved can have any legitimate role in the determination of when that time has arrived and whether there can be authentic and inauthentic ways of confronting death that are of moral concern. The late Ronald Dworkin certainly thought so, prompting him to forcefully assert: “Making someone die in a way that others approve, but he believes a horrifying contradiction of his life is a devastating, odious form of tyranny.”^{Footnote 12}

Others have raised concerns about an authoritarian streak, or a form of hard paternalism, in the philosophy and practice of hospice. Those concerns denote a perception that some in the hospice movement maintain a rigid and monolithic view of death: one size fits all; it’s the hospice way or the highway. More recently, a softer and perhaps more legitimate perspective on paternalism in hospice and end-of-life care has surfaced.^{Footnote 13} A similar concern arises from a survey of the palliative psychiatry literature, to which we will turn shortly.

Noting both the challenges and opportunities, Billings and Block observe that “palliative medicine and psychiatry are natural allies, yet have not leveraged their intrinsic affinity to optimize patient care.”^{Footnote 14} Developing and implementing that collaboration is the primary goal of this “movement.”^{Footnote 15} Interestingly, in this subspecialty literature of recent origin, there are repeated references to the work of Victor Frankel, most notably his widely read book Man’s Search for Meaning, first published in 1959. Three primary contributors to this literature in particular—David Kissane and the two editors of the handbook, Harvey Chochinov and William Breitbart—draw on Frankel in their work with patients whose experience of terminal illness at some point includes expression of a desire for a hastened death. It is important to consider their beliefs and clinical approaches in the context of two particularly controversial issues in palliative medicine: palliative sedation for refractory distress and lethal prescriptions (where allowed by law) in response to requests by terminally ill patients. What is also intriguing is the conspicuous absence from such discussions of patient decisions to decline life-sustaining interventions. Clearly the afflictions that plague the gravely ill and motivate them toward palliative options of last resort are also highly likely to be factors in the decisions by patients undergoing life-sustaining interventions to insist on their discontinuation.

Victor Frankl and Man’s Search for Meaning

In Man’s Search for Meaning, which he wrote in a mere nine days in 1946, Frankl, a Viennese psychiatrist who survived a Nazi concentration camp, provides a layperson’s introduction to his “logotherapy,” a form of existential psychoanalysis.^{Footnote 16} A much more sophisticated explication of logotherapy and its role in patient care is provided in Frankl’s The Doctor and the Soul.^{Footnote 17} Frankl’s logotherapy is inextricably linked to his experience in the concentration camp and his fundamental belief in the capacity of the human person to survive the most oppressive and demoralizing conditions by finding meaning in suffering that is truly inescapable. Frankl states: “It is one of the basic tenets of logotherapy that man’s main concern is not to gain pleasure or to avoid pain but rather to see a meaning in his life.” Most importantly, however, for purposes of the care of the dying, in the very next paragraph he goes on to state: “But let me make it perfectly clear that in no way is suffering necessary to find meaning. I only insist that meaning is possible even in spite of suffering—provided, certainly, that the suffering is unavoidable.”^{Footnote 18} In The Doctor and the Soul, Frankl further emphasizes the caveat that suffering must be unavoidable, for “to suffer unnecessarily is certainly masochism rather than heroism.”^{Footnote 19} As we shall see, this distinction between avoidable and unavoidable suffering is critical in the application of logotherapy to efforts directed at the relief of suffering in the terminally ill.

Demoralization Syndrome, Suffering, and the Desire for a Hastened Death

The recent initiatives in palliative care psychiatry by the individuals mentioned appear to be grounded on a core belief that clinical depression, or something much more amorphous (and potentially pervasive) that David Kissane characterizes as “demoralization syndrome” (DS), afflicts patients whose suffering appears to be of a primarily nonphysical origin (even though these patients have a terminal prognosis with lesions and other symptoms or side effects of treatment that would be obvious physical sources of distress). He describes it in the following terms: “In the clinical setting of hospice or palliative care, demoralization syndrome is a useful category of existential distress in which meaninglessness predominates and from which profound hopelessness and a desire to die may result.”^{Footnote 20} In a more recent book chapter Kissane coauthored with Breitbart, Chochinov, and others, demoralization is said to be “characterized by loss of meaning and purpose, with helplessness, hopelessness, inability to cope, sense of personal failure, and social isolation becoming prominent.”^{Footnote 21} So described, they characterize DS as a maladaptive response. They would, one might expect, take issue with the American Medical Association’s (AMA) dismissal of such suffering as “nonclinical” and hence not the responsibility of the physician to address, though not necessarily for the same reasons as I have presented in an earlier issue of this journal.^{Footnote 22} Rather, they would likely argue, it is a type of suffering that calls for primarily psychotherapeutic interventions rather than pharmacological ones. The very interesting element here is that if, as Kissane proposes, DS were officially recognized as a new Diagnostic and Statistical Manual of Mental Disorders condition, according to the AMA policy it would then be considered a form of “clinical” suffering of a psychiatric nature, rather than “nonclinical” suffering, and thus should it prove refractory to psychotherapeutic measures, palliative sedation would become an acceptable option of last resort.

The major concern of Kissane, and what appears to have prompted him to formulate DS, is the hypothesis that there are terminally ill patients who do not meet the more rigorous criteria for clinical depression but whose repeated expressions of a desire for a hastened death—or perhaps its more generally acceptable and legal alternative, sedation to unconsciousness and discontinuation of nutrition and hydration—are not genuine and authentic expressions of autonomous patient choice, but rather manifestations of “a morbid form of mental distress.”^{Footnote 23} The implications of a general recognition of the legitimacy of such a syndrome are not merely clinical but ethical and legal as well, for Kissane believes that those afflicted with DS may often lack, indeed might reasonably be presumed not to possess, decisional capacity. Here it is important to note, contrary to the belief of even some clinicians, that the diagnosis of clinical depression does not necessarily indicate that a patient lacks decisional capacity. It is at best a warning flag that should prompt the clinician to make a full capacity assessment and perhaps request a psychiatry consult.^{Footnote 24} Without compelling evidence to support the argument, it would be unreasonable to deprive patients of their presumed authority to make major decisions about medical treatment merely because they are believed to manifest indications of DS.^{Footnote 25}

DS potentially afflicts all patients whose decisions may lead to an earlier death, including those who decline or discontinue chemotherapy, renal dialysis, mechanical ventilation, artificial nutrition and hydration, or even those who simply decide to voluntarily stop eating and drinking. If other clinicians were to accept the legitimacy of DS, it would exponentially expand the population of candidates for Breitbart’s meaning-centered psychotherapy and Chochinov’s dignity-conserving care, to which we will turn shortly, each of which appear tailor-made as psychotherapeutic responses to terminally ill patients who express a desire to assert control over the time and manner of their approaching death. Implicit in the formulation of this syndrome and of psychotherapies purporting to treat it is a presupposition that a desire to escape profound and otherwise unrelieved suffering associated with terminal illness is by its very nature pathological. Or alternatively, drawing on the work of Frankl, that the experience of suffering is pathological because of the patient’s failure to find dignity and meaning at the end of life despite the physical and emotional suffering and distress that it entails. This view appears to comport with a prominent segment of the palliative care professional community that, almost without exception, maintains that patients who receive state-of-the-art palliative care, including psychosocial and spiritual interventions, almost invariably cease and desist from their desire for a hastened death.^{Footnote 26}

DS has been subjected to an extensive and cogent critique by Malcolm Parker.^{Footnote 27} Parker astutely observes the strong normative assumptions built into Kissane’s concept of demoralization. These assumptions epitomize the enduring antipathy of medicine in general and psychiatry in particular toward attitudes and practices that in any overt manner might hasten death. According to Parker, “given that the proponents of DS appear to pathologize all requests for assistance to die as maladaptive and harmful, the proposed category would then effectively and ‘scientifically’ define out of contention what many people now see as a matter of social choice and the subject of a social debate.”^{Footnote 28} Parker also notes that nowhere in the discussions of demoralization syndrome and expressions of a desire for a hastened death is refusal of life-sustaining measures discussed, thereby telegraphing the implicit moral distinction that presumptively deems this practice acceptable but assisted dying by means of a lethal prescription categorically unacceptable. In a subsequent section we will further consider arguments supporting the reasonableness under certain circumstances of the choice of an earlier death as a means to escape unbearable suffering.

Meaning-Centered Psychotherapies

As noted previously, the focus on meaning and its relationship to dealing with the experience of suffering draws heavily on Frankl’s logotherapy. The theoretical premise is that persons have the capacity to find meaning not only in their lives, their personal and professional pursuits, and their intimate relationships, but also in even the most grave or terminal illness, extreme suffering, and imminent death. Indeed, so the theory goes, it is in the process of finding or infusing meaning in these ultimate threats to one’s continued existence that one can transform suffering through the sheer force of one’s will.^{Footnote 29} Breitbart has developed and tested a model of meaning-centered group psychotherapy (MCGP) for cancer patients that involves eight sessions pursuing the following themes: concepts and sources of meaning, cancer and meaning, meaning in the historical context of life, attitudinal values, creative values, and experiential values.^{Footnote 30} More recently, Breitbart and colleagues published pilot data from a randomized controlled trial comparing MCGP with supportive group psychotherapy (SGT).^{Footnote 31} A detailed description of the two interventions compared in this study is beyond the scope of this article. The major distinction between the two appears to be that MCGP’s eight-week sessions were heavily focused on a range of issues concerning meaning in the lives of the group members and how confronting advanced cancer and approaching death alters the nature and sources of meaning. By contrast, SGT focused on coping skills and resources necessary to deal with the rigors and stresses of their cancer. Analysis of the data indicated that MCGP produced much greater improvement in spiritual well-being and a sense of meaning than SGP.

From the perspective of this article, several points must be made. First, many dying patients, particularly in the most advanced stages of terminal illness when suffering may be most severe and difficult to relieve, are unable and/or unwilling to engage in any form of group psychotherapy. Second, some patients may out of personal conviction reject the hypothesis that their suffering is the product, in whole or in part, of a failure to find meaning. A nontheological view of human life and one’s place in the cosmos might simply suggest that meaning is an artifact of human imagination, and so too would be any meaning imputed to one’s illness and approaching demise. For persons holding this point of view, pursuit of a peaceful death at a time and in a manner of one’s own choosing is a reasonable choice and not an indication of suicidality or another psychopathology. On this very point the late Supreme Court justice William Brennan had the following apt observation, one that appears very much in the spirit of the opening passage from Lord Jim: “Dying is personal. And it is profound. For many, the thought of an ignoble end, steeped in decay, is abhorrent. A quiet, proud death, bodily integrity intact, is a matter of extreme consequence.”^{Footnote 32}

Dignity-Conserving Care

Harvey Chochinov, the most prominent and prolific proponent of dignity-conserving psychotherapeutic interventions for terminally ill patients, seeks to shift the primary focus of the term “death with dignity” from physician aid in dying or euthanasia to palliative care, especially nonpharmacological psychotherapeutic interventions. Whereas Breitbart’s special concern, invoking Frankl, is the role of meaning—or more particularly its loss as a major contributor to suffering, spiritual distress, and a desire for a hastened death—Chochinov’s focus is on dignity. In his recent book on the subject, he describes his model of dignity in the terminally ill as derived in large measure from questions posed to a cohort of fifty Canadian patients who were near death. The questions asked them to provide instances in which their sense of dignity was supported or undermined as well as the more philosophical question, “How does your sense of dignity relate to the essence of who you are and the extent to which you experience life as still worth living?³³ From these responses Chochinov distilled three primary categories into which his model of dignity is divided: illness-related concerns, dignity-conserving repertoire, and social dignity inventory. Illness-related concerns encompass one’s level of independence (cognitive acuity and functional capacity) and symptom distress (physical and psychological). The dignity-conserving repertoire includes elements identified as integral to one’s sense of dignity, for example, continuity of self, role preservation, and legacy recognition, as well as such dignity-conserving practices as living in the moment, maintaining a sense of normalcy, and seeking spiritual comfort. The third and final component of the model, the social dignity inventory, considers privacy boundaries, social support, and burden on others as well as additional items.^{Footnote 34}

Based on the model outlined previously, Chochinov and colleagues developed the therapeutic intervention they call “dignity therapy.” Although described by Chochinov and those who have been trained to administer this intervention as an “empirically supported, individualized psychotherapy,” it consists primarily of a series of thought-provoking and reflective questions, the oral responses to which are made into audio recordings that are transcribed and utilized to produce a formalized “legacy” document for the patient to provide to designated family and friends.^{Footnote 35} With all due respect to the clinical credentials and good intentions of Chochinov and those who have undergone training in its methodology, the process appears much more like a potentially worthwhile exercise that might reasonably be offered to patients who are undergoing a profoundly debilitating chronic illness as well as those confronting a terminal condition. After all, serious illness can render living with dignity as much of a challenge as dying with dignity.

Refractory Suffering and Palliative Options of Last Resort

As previously noted, Frankl took the position that suicide is never justifiable, regardless of how horrendous and irremediable are one’s circumstances. Indeed, he maintained that it is in just such situations in which logotherapy challenges the sufferer to find meaning in the ordeal and thereby seize control in the only way possible, by changing one’s attitude to the suffering one must endure, because there is no escape route that can legitimately be taken. For purposes of this discussion, let us assume that Frankl would, as do many of his contemporary devotees, reject the provision of a lethal prescription as an acceptable palliative option of last resort, because of the still-pervasive attitude among clinicians, as exemplified by the AMA policy, that it is a form of suicide and that participation by physicians in the practice is inconsistent with their role as healer.^{Footnote 36} This assertion, however, begs the fundamental question, which is what exactly is the physician’s role as healer when one’s patient is terminally ill and experiencing profound refractory suffering—refractory even to dignity- or meaning-centered psychotherapies if the patient has been willing and able to pursue them?

As for the alternative, only somewhat less controversial last resort option of palliative sedation, Frankl’s position becomes ambiguous. Suffering that can be relieved, but only at the cost of consciousness, is not unavoidable in a strict and narrow sense. The question then becomes, how rigorous and exhaustive must be the process the physician and patient are expected to undertake before the suffering can be genuinely characterized as refractory?

Still more challenging are the circumstances when the source or nature of suffering is viewed not as physical in nature but rather as emotional, spiritual, or existential. These are the aspects of suffering that are the focus of the Frankl-inspired interventions. Indeed, in the most recent edition of the Handbook of Psychiatry in Palliative Medicine, Drs. Kissane, Breitbart, and Chochinov, along with two other coauthors, have contributed an extensive chapter on such existentially grounded therapies.^{Footnote 37} The authors identify four existential domains posing challenges for palliative medicine: (1) the self (loss of dignity, alienation, and isolation), (2) free choice (loss of control and dependence on others), (3) meaning (loss of purpose for living, spiritual doubts, and desire for death), and (4) anxiety (fear, grief, and dread).

Those who insist that the only ethically acceptable role for the physician in such circumstances is to “remain present and suffer with the patient in compassion” offer cold comfort to the patient.^{Footnote 38} When they choose to withhold sedation to unconsciousness out of some moralistic and unscientific notion that the patient’s suffering is nonclinical in nature, and when they categorically reject a lethal prescription even when the law of the jurisdiction allows it, they are in effect abandoning the patient to her avoidable suffering. It is difficult to escape the strong suspicion that inherent in such attitudes and practices on the part of certain healthcare professionals is a covert religious notion about the redemptive power of suffering or a belief in the moral obligation on the part of all persons to stoically bear the afflictions to which the mortal flesh is heir as an inescapable aspect of the human situation.

Many philosophical arguments about the immorality of causing death in order to escape suffering draw on the work of Immanuel Kant, particularly his admonition to “act in such a way that you always treat humanity, whether in your own person or in the person of any other, never simply as a means, but always as an end.”^{Footnote 39} From this flows the duty to preserve one’s life even when one might believe that the personal benefits of doing so are significantly outweighed by the burdens. However, even strong Kantian moral philosophers have acknowledged that circumstances of severe refractory suffering provide a principled basis for euthanasia. When a person’s pain and suffering have essentially commandeered her life, eclipsing all other aspects, then her dignity has been irretrievably lost. At that point, bringing about the end of someone’s life to end his or her suffering becomes acceptable even from a Kantian perspective.^{Footnote 40}

The Rational Choice of Death over Suffering

In a provocative article, John Hardwig called for an ars moriendi (art of dying) for the twenty-first century that is consistent with the secular-pluralist, highly diverse, and individualistic nature of contemporary Western society.^{Footnote 41} The need for this, he argues, arises out of the advances in medical science that have extended human longevity, but not health, so as to extend life, borrowing the late Ronald Dworkin’s apt phrase, “life past meaning.”^{Footnote 42} Although his use of that phrase is in the context of a discussion of persons with advanced dementia, the spirit of his work would permit its application to the circumstances Hardwig describes, of those frail and debilitated individuals, like his own mother, for whom, in their own judgment, “death will come far too slowly and too late.” Consequently, he maintains, “learning how to go to meet death is . . . one of the basic tasks of our time.”^{Footnote 43}

Although there may seem to be a decidedly contemporary flavor to this approach to life or death—that is, my life, my death, my way—in fact its roots are sunk deeply into ancient philosophy. Consider, for example, the sentiments of the Roman stoic philosopher Seneca: “For mere living is not good, but living well. Accordingly, the wise man will live as long as he ought, not as long as he can. . . . It is not a question of dying earlier or later, but of dying well or ill. And dying well means escape from the danger of living ill.”^{Footnote 44}

In the early 1990s, a study was conducted of “patient assessments of states worse than death.” These would be paradigm circumstances in which rational actors might choose to, in Seneca’s words, “slip the cable” or, in Hardwig’s parlance, “go to meet death.” The most frequently mentioned include unconsciousness, dementia, severe suffering, complete dependence on other persons or on life-sustaining interventions, and an extremely poor prognosis.^{Footnote 45} Based on their findings, the authors strongly urge clinicians not to conclude from such representations by patients that clinical depression or suicidality is the source of the patient’s sentiments, rather than a legitimate personal evaluation of the circumstances.

Linda Ganzini and colleagues have written extensively on those who choose to secure and utilize a lethal prescription in jurisdictions such as Oregon and Washington. The chief reasons included loss of independence (inability to engage in activities or provide self-care), a desire to control the time and manner of death and to die at home, and the prospect of increasing pain or diminution of the quality of life.^{Footnote 46} In an earlier commentary coauthored with Anthony Back, an oncologist and palliative medicine specialist, Ganzini, whose clinical specialty is psychiatry, observes that the Oregon Death with Dignity Act (ODWDA) data do not support the contention that patients who die from the self-administration of a lethal prescription are clinically depressed. The commentary authors note that there is a practical dimension at work here, in that patients who are genuinely clinically depressed “have difficulty marshalling the energy, focus, and determination needed to persevere through the requirements of the law.”^{Footnote 47} The best way to understand these patients, they suggest, is as persons who value control, dread dependence on others, are ready to die, and assess their quality of life as poor.

Another important consideration is whether the quality of dying and death is significantly different for patients who choose to hasten their death through medical means than those who receive traditional palliative care and die from their underlying terminal illness. The research here too indicates that exercising this kind of control in determining the timing and manner of one’s own death does not have a deleterious effect. Indeed, patients who actually took the lethal prescription were reported by their families to have a higher-quality death than those who secured a lethal prescription but were, for whatever reason, unable or elected not to take it.^{Footnote 48}

There is a distinct minority of mental health professionals who believe in the possibility of a rational suicide and who advocate for the rights of those who choose to be free from societal (legal or moral) constraints against it. Any discussion of this controversy should be preceded by some mention of the dramatic changes in public and healthcare professional attitudes toward the semantic aspects of these issues. Over the last decade, a number of prominent organizations in the health professions have issued policy statements or position papers asserting that “assisted suicide” is not an appropriate term for the provision of a lethal prescription at the request of a decisionally capable, terminally ill patient.^{Footnote 49} This trend reflects the adjustment of public attitudes away from the view expressed by the U.S. Supreme Court in the cases of Glucksberg ^{Footnote 50} and Quill ^{Footnote 51} that use of a lethal prescription by a terminally ill patient constituted suicide, and toward the position taken by the Ninth Circuit Court of Appeals that such conduct was most appropriately characterized as the exercise of a protected liberty interest in determining the time and manner of one’s death from a terminal condition.^{Footnote 52}

Proponents of the idea that ending one’s own life, with or without the assistance of another, can under some circumstances be a rational act unencumbered by clinical depression, any other form of mental illness, or materially compromised decisional capacity have offered criteria by which to evaluate such a decision. An early and often-cited version is minimalist in its requirements: “1) the individual possesses a realistic assessment of his situation; 2) the mental processes leading to his decision . . . are unimpaired by psychological illness or severe emotional distress; 3) the motivational bases of his decision would be understandable to the majority of uninvolved observers from his community or social group.”^{Footnote 53} Other versions are more demanding than even the ODWDA, in that they call for a mental health professional consultation in all instances:

1. 1. The person suffers from an unremitting hopeless condition, for example, a terminal illness, severe physical or psychological pain or suffering, a physically or mentally debilitating condition, or an unacceptably low quality of life.

2. 2. The person makes the decision as a free choice.

3. 3. The person has engaged in a sound decisionmaking process characterized by the following:

   1. a. Consultation with a mental health professional to rule out impaired decisionmaking capacity.

   2. b. Nonimpulsive consideration of all alternatives.

   3. c. Consideration of the congruence of the act with one’s personal values.

   4. d. Consideration of the impact on significant others.

   5. e. Consultation with those who may be impacted by the action.^{Footnote 54}

Over the years since these criteria were proposed, thoughtful clinicians on both sides of the debate have articulated their concerns about the implications of both legitimizing a chosen death under certain circumstances and categorically condemning it under all.^{Footnote 55} Notably, criteria have been proposed by some prominent palliative medicine professionals under which assisting a terminally ill and suffering patient in her pursuit of a peaceful death would be appropriate.^{Footnote 56} These criteria were developed before we had the benefit of a decade and a half of experience with the ODWDA, which if anything has borne out the position of its proponents and those clinicians who provide this option to their patients consistent with the act. More particularly, since the enactment and implementation of the ODWDA, the provision of hospice and palliative care in the state has flourished rather than been undermined, and there has been no evidence of a slippery slope toward expansion of its reach to patients who lack decisional capacity, who cannot ingest the lethal medication without assistance, or who do not have a terminal prognosis.^{Footnote 57} Another stated concern of opponents of aid in dying—that it would seriously undermine patient trust in physicians—has also been shown to be unfounded.^{Footnote 58}