The American Medical Association, and the entire profession of medicine in the U.S., stand at a crucial ethical crossroads. For two years the AMA has been considering the question of physician-assisted suicide (PAS): shall physician assistance with patient suicide now be considered permissible, or shall physicians hold fast to the ethic that a physician’s duty is to “to cure sometimes, to relieve often, and to comfort always,” but never to kill?
In 2016, AMA delegates from Oregon brought a resolution to the AMA House of Delegates (HOD), its policy-making body, to request that the AMA consider dropping its longstanding opposition to physician-assisted suicide in favor of a position of neutrality. The AMA’s ethical body, the Council on Ethical and Judicial Affairs (CEJA), spent 2 years of intensive study of the practice of PAS, gathering information from physicians, ethicists, U.S. states and foreign countries on the practice and implications of PAS, in an exhaustive, open and transparent process. In June of 2018 CEJA offered its report and recommendations to the AMA HOD for its consideration.
The CEJA report included a review of the European experience where PAS began with terminal patients, then progressed to healthy people with depression, then people “tired of life,” people unhappy after sex change operations, and so on. In Europe and now, frighteningly, in Canada, PAS rapidly progressed to active euthanasia (direct physician killing of patients). The CEJA report concluded that the AMA ethical position on PAS should not be changed, that PAS remains “fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.”
While recognizing the danger of PAS and the wisdom of keeping its ethical guidance unchanged, CEJA also recognized that physicians advocating for PAS do so from a conscientious belief that it is appropriate, therefore the CEJA report also referenced AMA’s position on conscience:
“Preserving opportunity for physicians to act (or to refrain from acting) in accordance with the dictates of conscience in their professional practice is important for preserving the integrity of the medical profession as well as the integrity of the individual physician, on which patients and the public rely. Thus physicians should have considerable latitude to practice in accord with well-considered, deeply held beliefs that are central to their self-identities.”
PAS advocates were dissatisfied by the balanced recommendations offered by the CEJA report, instead insisting that the report be reconsidered until CEJA agree to changing AMA medical ethics. But, increasingly, the AMA delegates are moving towards a rejection of the idea of PAS. At the AMA meeting in June of 2018, the HOD declined to endorse the CEJA report, referring it back for further study by a margin of 10% of votes cast. However, at the recent November 2018 AMA meeting, the CEJA report was nearly accepted, missing by only 3%. As the delegates hear the logical flaws in the arguments used to push PAS, these arguments are losing appeal. Among the pro-PAS arguments debunked by physicians defending the 2,400-year-old Hippocratic tradition that physicians “give no deadly medicine” are the argument of neutrality and the argument that patient autonomy should determine medical ethics.
PAS advocates claim that the AMA must adopt neutrality because there are divided views on PAS. Eminent bioethicist and physician from Georgetown University, Dr. Daniel Sulmasy, decisively debunked the neutrality argument in his recent article in the Journal of General Internal Medicine:
“Neutrality is not neutral. To change from opposition to neutrality represents a substantive shift in a professional, ethical, and political position, declaring a policy no longer morally unacceptable; the political effect is to give it a green light.
“Some might argue that neutrality is necessary because there are jurisdictions in which members of medical organizations can prescribe PAS legally. But exceedingly few physicians engage in the practice even in jurisdictions where it is legal, and the fact that some members do so does not require any professional body to be ‘neutral’ with respect to that practice. As a logical counter-example… to the thesis that professional neutrality is required if a medical practice is legal, consider the fact that physician participation in capital punishment is legal in 30 states. This fact does not affect the ethical opposition that the profession takes, nor has organized medicine felt compelled to give instructions on how to execute prisoners well for those few members who do this.”
Patient autonomy has been suggested as a justification for PAS. However, no physician would amputate a patient’s healthy limb just because the patient wishes it done. Physicians don’t give certain drugs or perform certain procedures that are absolutely contraindicated, even if the patient requests it, because physicians are required to use their knowledge to protect the patient. Patient autonomy is important, but never the only factor in a decision, and is never used to determine overarching professional ethics.
PAS advocates also want to “hide the ball” on PAS, obscuring the fact that it is suicide by giving it pleasant but unclear names like “physician aid in dying.” CEJA rightly rejected this, noting that “the term physician-assisted suicide describes the practice with greatest precision. More importantly, it clearly distinguishes the practice from euthanasia. The terms “aid in dying” or “death with dignity” could be used to describe either euthanasia or palliative/hospice care at the end of life and this degree of ambiguity is unacceptable for providing ethical guidance.”
The AMA is moving towards a reaffirmation of its historic and vital policy opposing PAS, which will best guide physicians and protect patients.
Shane E. Macaulay, MD, is a radiologist with Center for Diagnostic Imaging in Washington state, and twice selected as one of Seattle’s Top Doctors. He is an AMA Alternate Delegate from Washington state.