Gatekeeping vs Safeguarding

A doctor's duty to dysphoric or dying patients

Reminder that I’ll be speaking at the Portsmouth Institute Summer Symposium next week on their Healthcare and Christian Anthropology panel. If you live in New York and oppose doctor assisted suicide, you can use this call to action script to call state reps and the governor.

Photo by Online Marketing on Unsplash

Last Sunday, the New York Times Magazine ran a vivid, reported piece on Paula Ritchie’s quest to receive a doctor’s help in dying. Ritchie, a Canadian, did not have a terminal illness, and she had been told by prior doctors she was ineligible for MAiD, even under Canada’s expansions to non-terminal patients. However, Canada places no limit on how many doctors you can ask for a lethal injection. It only takes one yes.

Paula had called the region’s MAID coordination service every day, sometimes every hour, demanding to be assessed again, until the nurse on the other line had practically begged Wonnacott and his colleagues to take Paula off her roster.

Ritchie got her yes from Dr. Matt Wonnacott. He volunteered to see patients other doctors found difficult to assess. It wasn’t that he had greater expertise than other doctors in untangling depression from pain or loneliness. He felt he was better suited to meet with these patients because the details of their medical history mattered less to him.

In the beginning, Wonnacott said, he could get hung up on a patient’s complexity — even distracted by it. He would try to map out the contours of a request: the shape and scope of different kinds of suffering. He learned to stop doing that. It was an impossible exercise that produced meaningless conclusions. Also, it didn’t matter. “The phrase I find myself saying a lot is, ‘I’m not going to judge people for why they’re suffering,’” he told me. “In some jurisdictions, you have to meet specific criteria for suffering, and I think it’s good that in Canada, you don’t. I don’t particularly care why you’re suffering. If you tell me that you’re suffering, who am I to question that?”

If a doctor isn’t applying his or her medical judgement to assess the cause of a patient’s suffering and whether it could be remedied, it’s not exactly clear why there is a doctor in the loop at all. In Canada, MAiD is frequently administered by the doctor, via lethal injection. In America, the states that allow MAiD require that a patient take lethal drugs him or herself. No doctor is needed at the very end.

The doctor is needed to legitimate the desire to die, not to effect the death. Without a meeting with the doctor, dying because life does not seem worth living would be suicide. With the meeting, the patient’s judgement is validated. Even when, as with Wonnacott, the doctor disclaims applying his own philosophical or medical judgement.

The case in the Times reminded me of one of the central questions in Skirmetti, a Supreme Court case on youth gender medicine whose decision is expected any day in June. I covered the oral argument for Fairer Disputations.

Tennesse banned puberty blockers, cross-sex hormones, and surgery when prescribed to minors for the purposes of transition. The plaintiffs seeking to overturn the law attacked it as an example of sex discrimination. If you would prescribe puberty blockers to a natal boy with whose breast buds were swelling, but you wouldn’t prescribe them to a natal girl who also did not want to grow breasts, you were treating boys and girls differently in a way the law must not allow.

But, as I wrote for Fairer Disputation, it is odd to assume the doctor would simply dispense medicine to a natal boy to curb growing breasts without being curious why the symptom had errupted. (The natal girl prompts no such curiosity). The patient’s role is to surface a symptom that troubles him or her, but it is the doctor’s role to intermediate between the desired body and the body as it exists.

This distinction is key to both the sex-discrimination claim and the deeper questions of medicine. Can “developing breasts” or “a treble voice” be considered a medical problem—the same medical problem for natal boys and girls—simply because a child does not want them? If so, the child—not the doctor—supplies the diagnosis, and medicine has little to say about the origin of either the breasts or the disgust the child experiences when contemplating signs of womanhood.

On this view, the role of medicine is to harmonize the actually-existing body with the desired body. There is no consideration given to medicine’s role in the integration of the body as a functioning, ordered system. Because it is not working as desired, it is not working, period. There is no question about whether the wrong things are being asked of the body…

A doctor, practicing their art well, sometimes advocates for the patient by speaking up for his or her body. It begins with curiosity. What set this person and his or her body at odds? Is there a deficiency in the body that can be mended to restore its integrity? Or has the patient asked something of the body that it cannot give? Is it the patient’s expectation (and that of his or her parents) that must give way?

In both these cases, the patient’s autonomy and the doctor’s judgement are set at odds. The patient needs access to medical tools to be able to master her body. She does not need a doctor’s alternative interpretation of what is happening in her body.

That distrust of a doctor’s opinion (especially applied to women’s bodies) is partially rooted in the real ways the medical establishment has minimized women’s pain and treated healthy female bodies as in need of medical suppression.

But we lose a lot if we simply try to sidestep doctors rather than form better ones. I’m reminded of this quote from Edmund Burke, explaining why, as a member of Parliament, his votes sometimes diverged from his constituents’ preferences:

Your representative owes you, not his industry only, but his judgment; and he betrays, instead of serving you, if he sacrifices it to your opinion.

My worthy colleague says, his will ought to be subservient to yours. If that be all, the thing is innocent. If government were a matter of will upon any side, yours, without question, ought to be superior. But government and legislation are matters of reason and judgment, and not of inclination; and what sort of reason is that, in which the determination precedes the discussion; in which one set of men deliberate, and another decide; and where those who form the conclusion are perhaps three hundred miles distant from those who hear the arguments?

When (if ever) has an expert won your trust such that you trusted their judgement over your preferences? How was that trust won?

When have you felt that an expert actively sought your testimony of your experience to inform their judgement?

When have you seen your trust broken? How did you decide the judgement was in error, despite the gap of expertise?