Neutral Stance on Physician-Assisted Death Proposed by AMA: Blessing or Curse?

The AMA Principles of Medical Ethics: I,IV makes these statements: “permitting physicians to engage in assisted suicide would ultimately cause more harm than good. Physician-assisted suicide [physician-assisted death] is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks (Ch. 5, Opinion 5.7, AMA, 2016)”

However, there is an effort afoot within the American Medical Association (AMA) to switch its long-standing opposing stance on assisted suicide to one of neutrality. After the annual national AMA meeting this summer, its Council on Ethical and Judicial Affairs was instructed to study aid-in-dying as an end-of-life option. Response is already underway–the November interim meeting of the AMA’s House of Delegates in Orlando will feature a special breakout session on assisted suicide. Some believe a full debate by the AMA House of Delegates will occur next summer.

Physician-assisted suicide (PAS), physician-assisted death (PAD), or “death with dignity” as some like to call it, is the intentional death by medical means provided by a physician at the request of a patient or the patient’s surrogate decision maker. This issue continues to generate both ethical and legal controversy.  Purposefully ending a life presents an ethical dilemma that requires complex moral decisions from all parties involved.

Groups who object to physician-assisted death often argue for the sanctity of life.  Many religious and secular beliefs hold life to be sacred and disallow human interventions that end life early, attesting that no human has authority over who lives and who dies.  These people expect those who engage in the “healing profession” to promote and protect life, and they would generally disallow physician-assisted death as the logical next step when healing seems impossible or no longer desired.

Recently (Aug 2016) posted on The Health Care Blog — Ronald Pies, MD and medical ethicist, presented this scenario as analogy: a terminally ill patient asks to use the doctor’s gun he knew was in his desk so that he could shoot himself. Pies asks, “Would it be ethical for the physician to grant the patient’s request? I suspect most of us would be horrified at the thought.”

Would a change to neutrality lead to a slippery slope in compromising the professional integrity of a physician, whose commitment is to healing and avoiding harm?  Many physicians and ethicists see physician-assisted death as a direct infliction of harm on a patient.  Others fear the potential for abuses, specifically coercion or exploitation of the elderly, medically frail, and individuals with various disabilities. Some foresee its encouragement as a cost containment strategy.

Some support for physician-assisted death is based on the concept of compassion for those suffering, especially those diagnosed with a terminal illness that will cause them to suffer physically, mentally, and psychologically over time.  The concept of patient self-determination also enters the discussion, as those who support physician-assisted death argue that it respects the patients’ rights to autonomy and to direct their own health care, and honors the positive liberty to request death. Proponents often state that if patients have the autonomous right to direct their care, which includes withholding or withdrawing life sustaining treatment, then they should also have the right to request assistance to die.  Many believe its acceptance is long overdue and that it opens the opportunity for more honest and transparent discussions about death and end-of-life issues and options, aiding physicians and patients alike. (Keep an eye on Dutch law as they consider proposals allowing healthy elderly individuals to end their own lives with assistance for any personal reasons they choose—those will be interesting discussions.)

Truthfully, this shift in ideology of the AMA should come as no big surprise. Already twenty years ago, in 1997, a random sampling of approx. 1,000 American physicians (300+ from AMA House of Delegates) selected to take a survey on attitudes regarding legalizing physician-assisted suicide showed results that surprised me. According to the returns, many were more in favor than against: only 34% of rank and file physicians definitely opposed, while 62% of House of Delegates member respondents definitely opposed. Interestingly, over 50% of both groups preferred it to be a patient/physician “no law” decision (Whitney, S. N., et al. J Gen Intern Med. 16.5 (2001)).

As an ethicist, I clearly understand both sides of this issue and definitely have my own ideas of the ramifications of either allowing or prohibiting this practice. But what I really wonder is this: What do you think, readers?

Is legalized physician-assisted death really “a bridge too far” as Pies posits, which “radically undermines the traditional role of the physician as trusted teacher and healer”? Or is its legalization just a manifestation of the changing mores in American society that need to be reflected in the law? Also, what evidence and reasoning did you use to formulate your view

Regardless of one’s personal perspective, removing opposition to assisted death is a significant formal change for the AMA, one that should be made only after much unbiased input and discussion and with great transparency to the public.

Furthermore, we can all probably agree upon this: healthcare workers are going to need special training on how to competently and appropriately engage in these discussions with patients and families without their own biases prevailing – i.e., answering all questions with honesty and compassion, giving just the facts clearly, and genuinely listening. Helping patients to explore their own beliefs and preferences will be a challenge for many of the experienced and inexperienced alike!

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