The Point Blog ARCHIVE
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The purpose of this blog is to stimulate thought and discussion about important issues in healthcare. Opinions expressed are those of the author and do not necessarily express the views of CMDA. We encourage you to join the conversation on our website and share your experience, insight and expertise. CMDA has a rigorous and representative process in formulating official positions, which are largely limited to bioethical areas.
Council on Judicial and Ethical Affairs
May 24, 2018
by David Stevens, MD, MA (Ethics)
Compassion & Choices uses every trick in the book to get physician-assisted suicide legalized in individual states, and they never give up. They fund polling with leading questions in the vein of, “Would you like to die in terrible pain hooked up to a machine by doctors who won’t let you die or should physicians aid you in dying?” They then tout the results as overwhelming support for the legalization of physician-assisted suicide to the media and anyone else who will listen.
They have sponsored referendums, found legislators in almost every state to sponsor “right to die” laws and tried many times to get state Supreme Courts to find a constitutional right to physician-assisted suicide. (The last time I checked, everyone has the “right to die” and the death rate was holding steady at 100 percent.) The only state that came close to listing it as a constitutional right was Montana, which put in their ruling that for anyone prosecuted for physician-assisted suicide, the courts could consider that the patient gave informed consent as a part of their decision. The court didn’t say it would be a deciding factor, but Compassion & Choices still touts that physician-assisted suicide is legal in Montana.
Another one of their strategies has worked better than any other. Their supporters in state medical societies, sometimes using terminally ill physicians as their point persons, advocate that the society take a “neutral” position on legalization. In each of the states underlined below where this has happened, physician-assisted suicide has been legalized—California, Colorado, Maryland, Maine, Minnesota, Nevada, Oregon, District of Columbia and Massachusetts. The Hawaii Medical Association did not oppose its legalization last month, which is a de-facto neutral position. This strategy is batting 50 percent. Compassion & Choices even has a booklet online entitled Medical Aid in Dying: A Handbook for Engaging State Medical Associations to teach physicians how to advocate for a neutral position.
Taking a neutral position on physician-assisted suicide is like saying you are neutral on child abuse. You really don’t really care whether it is happening or not.
Some professional associations have caved on the issue as well. The largest one is the New York State Academy of Family Physicians with 120,900 members that endorsed physician-assisted suicide in 2016. Other larger groups advocating for physician-assisted suicide include the American Public Health Association with 50,000 members that endorsed it in 2008 and the American Medical Student Association (AMSA) with 30,000+ members that gave its support way back in 2007.
AMSA and the Oregon AMA Delegates have been the points of the spear to get the American Medical Association (AMA) to take a neutral position. Resolution 15-A-16 was referred by the AMA House of Delegates in 2016 to CEJA and was entitled “Study Aid-in-Dying as End-of-Life Option.” The resolution said:
That our American Medical Association (AMA) and its Council on Judicial and Ethical Affairs (CEJA), study the issue of medical aid-in-dying with consideration of (1) data collected from the states that currently authorize aid-in-dying, and (2) input from some of the physicians who have provided medical aid-in-dying to qualified patients, and report back to the HOD at the 2017 Annual Meeting with recommendation regarding the AMA taking a neutral stance on physician “aid-in-dying.”
The much-anticipated CEJA report was finally issued this month. Many individuals and organizations submitted oral and written testimony to CEJA, including CMDA and our members. The committee stated that “ethical arguments advanced today supporting and opposing ‘physician-assisted suicide’ or ‘aid in dying’ are fundamentally unchanged from those examined in CEJA’s 1991 report on this topic.” They instead considered “the implications of the legalization of assisted suicide in the United States since the adoption of Opinion E-5.7, ‘Physician-Assisted Suicide,’ in 1994” that explicitly opposed physician-assisted suicide.
Before addressing that issue, the committee looked at the euphemisms being used to sanitize and promote physician-assisted suicide such as “aid in dying,” “death with dignity,” “end of life options” and “patient choice and control at the end of life.” The report stated:
CEJA believes ethical deliberation and debate is best served by using plainly descriptive language. In the council’s view, despite its negative connotations, the term “physician assisted suicide” describes the practice with the greatest precision. Most 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.
That is a significant setback for proponents and will be advantageous in the future if the media can be persuaded to use the proper term: “physician-assisted suicide.” The staff and supporters of Compassion & Choices have already met with editorial boards and media groups and convinced some of them to use their euphemisms.
CEJA’s statement then states that people on both sides of the debate have “coherent, consistent, and deeply held beliefs “that “yield irreducibly different judgments about what is an ethically permissible course of action.” When I first read that, I thought it was a preamble to taking a neutral position, but fortunately it was not.
More disturbing to me was when CEJA seemed to agree with a statement by Canadian psychiatrist Harvey Chochinov who stated that “neither those who are strongly supportive nor those who are opposed hold a monopoly on integrity and a genuine concern for the well-being of people contemplating end of life. Equally true: neither side is immune from impulses shaped more by ideology than a deep and nuanced understanding of how to best honor and address the needs of people who are suffering.” That statement gives moral high ground equally to both those working to legalize physician-assisted suicide and those that oppose it and relegates the issue to a matter of personal opinion. Those on both sides of the debate can’t be morally and ethically right at the same time.
The report then comments that the present adequacy of “safeguards” are deeply contested and “current evidence from Europe does tell a cautionary tale.” The report then recommends more robust independent safeguards and quotes a recent commentary in JAMA Internal Medicine 2015; 175:1640-1641 that said, “part of the problem with the slippery slope is you never know when you are on it.”
After all that and more, CEJA recommended:
“That in its current form the Code offers guidance to support physicians and the patients they serve in making well-considered, mutually respectful decisions about legally available options for care at the end of life in the intimacy of a patient-physician relationship. The Council on Ethical and Judicial Affairs therefore recommends that the Code of Medical Ethics not be amended.”
Though that recommendation doesn’t change the AMA’s position that “physician-assisted suicide is fundamentally inconsistent with the physician’s professional role,” it is hard to reconcile that the same code “offers guidance to support physicians and the patients they serve in making well-considered, mutually respectful decisions about legally available options for care at the end of life in the intimacy of a patient-physician relationship.”
The battle is not over. The recommendation will be accepted or rejected at the House of Delegates AMA meeting on June 9-13 at the Hyatt Regency Chicago in Chicago, Illinois. If you are an AMA member, I encourage you to show up and support CEJA’s “no change” recommendation. If you are an AMA member, please testify at the Reference Committee Meeting on Sunday, June 10 at 8:30 a.m. If nothing else, please contact your AMA delegate or leave a comment on the AMA site. Here is the link to the full CEJA statement. Here is a link to the list of AMA delegates. Here is a link where you can give a commentary online. You will need to create a login if you are not an AMA member in order to leave a comment.
It is obvious to me that the AMA is just a razor’s edge from going neutral on this issue. If that happens, an avalanche of states will legalize physician-assisted suicide. You and I cannot be silent or trust, which is the foundation of the doctor-patient relationship, will be destroyed and, soon after, our profession will be destroyed as well.