As you may have heard, the American Academy of Family Physicians’ (AAFP) Congress of Delegates recently voted during their annual meeting to change their Hippocratic position on assisted suicide to a position of “engaged neutrality.” When I communicated with CMDA’s family medicine physicians, they were shocked, to say the least. They had no knowledge this change of position was being seriously considered, and some of them wrote letters to the AAFP expressing their dismay. Each physician who wrote to the AAFP received a standard reply letter from Douglas E. Henley, MD, FAAFP (Executive Vice President/CEO of the AAFP), which is copied below:

The American Academy of Family Physicians is an organization made up of individuals who have widely disparate views on many issues, including this one.

• Both sides of the issue were passionately debated during reference committee testimony, and the reference committee drafted a resolution that considered all concerns.
• By rule, a vote at Congress of Delegates to change current AAFP policy on this issue required a 2/3 majority since such a change in position would be contrary to the AMA Principles of Medical Ethics (which currently opposes physician assisted suicide or medical aid in dying).
• It was passed by well more than the required 2/3 majority vote in the Congress of Delegates with remarkably little debate.
• Let’s be clear about what this resolution does and does not do.
  • It does not support medical aid in dying; it only moves AAFP policy to a position of “engaged neutrality” – neither for nor against this issue.
  • The approved resolution also asks that our AMA delegation advocate for neutrality in any debates on this matter when it might come before the AMA House of Delegates. 
• “Engaged neutrality” is not passive approval. Seven states and Washington D.C. currently allow medical aid in dying. AMA policy (and prior AAFP policy) creates and ethical conflict with our members in those states who perform a legal act in conjunction with an informed, autonomous patient, regardless of the circumstances. Engaged neutrality means the AAFP is not passively avoiding a stance, rather it means we are saying that we, as an organization, believe that the well-intentioned discussions and decisions between an individual and their long-term family physician should not be simplified to a black-and-white decision by those not involved in the clinical situation. 
• This is an issue that must ultimately be decided by the entire House of Medicine, state legislatures, and the American people.
• The resolution also requires that we reject the phrase “physician assisted suicide” in our own communications, using instead the phrase “medical aid in dying”.
• We are a member run organization and our decision-making body is the Congress of Delegates. This is why it is so important to be involved in your state chapter. 
• I very much appreciate and value your feedback, and I thank you for your membership in the AAFP.

I want to respond to Dr. Henley’s points:

• It is obvious there are disparate views on physician-assisted suicide. The question is, “Were ‘both sides of the issue’ adequately heard?” given that the vast majority of AAFP members had no idea a decision of this gravity was even being considered? Contrary to the official response, delegates who attended the reference committee meeting stated that no one testified in opposition to a neutral position. Does the decision of the Congress of Delegates really represent its membership?
• Compassion & Choices, the leading and generously funded proponent for physician-assisted suicide, has a long history of working behind closed doors to get the right people into positions of influence. They also lobby hard to get voting members to change their positions so they can accomplish their agenda accomplished. They strive to keep their efforts hidden and then spring votes with little or no notification, so that those opposing physician-assisted suicide have little time to respond. Of course, it is very difficult for busy physicians to change their schedule on short notice. This happens in legislatures and in professional organizations across the nation.
• The AAFP is the second largest professional physician organization in the U.S., after the American Medical Association (AMA). Its decision will significantly influence this issue in the AMA, state laws and referendums.
• If this issue was so passionately debated, why was it so quickly passed before members were even aware it was being considered? This issue is a cataclysmic shift in the foundation of the doctor-patient relationship. That foundation is trust. Over 2,000 years ago doctors both cured and killed. Because of that, patients were afraid to go to a physician. Hippocrates and his followers changed that by establishing a covenant, sworn to before God, that they would do no harm. Included in that covenant was a promise that, “Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course.” Those making that covenant were called “professionals” because they had “professed.” Western medicine prospered on this foundation because patients knew, among other things, that they would not be killed, their conversations would remain confidential and they wouldn’t be sexually abused. Unfortunately, professionals today are called “providers” and their relationships with patients are increasingly contractual rather than covenantal.
• In 1857, the U.S. Supreme Court ruled in a seven to two decision, in the Dred Scott case, that former slaves could not be U.S. citizens. The Chief Justice wrote in the majority opinion that, “Black Africans imported as slaves had for more than a century before been regarded as beings of an inferior order, and altogether unfit to associate with the white race, either in social or political relations; and so far inferior, that they had no rights which the white man was bound to respect.” This decision, made by greater than a two-thirds majority, stands first in legal scholars’ list of the worst Supreme Court decisions. I predict this decision by the AAFP will historically be seen in like manner. It will split family physicians into two camps, reduce membership and damage the AAFP. Worse than that, it will hurt patients and their families.
• Contrary to the AAFP’s claims, their decision does support physician-assisted suicide.
  • A decision to go “neutral” means they don’t care either way on this fundamental issue in the practice of medicine. Strange, isn’t it? The AAFP cared enough to take a stance on same-sex marriage and many other social issues that have little or nothing to do with the practice of medicine. Yet they are sending a clear message they have no ethical or moral position on a physician helping a patient commit suicide.
  • They also send a message that they believe laws passed by seven states have adequate safeguards, though:
    • It is impossible to always accurately predict a terminal patient will only live six months.
    • The vast majority of suicidal terminally ill patients are depressed, but only 3.5 percent receive psychiatric evaluations.
    • Under these laws, patients are considered terminal if they will die in six months without treatment, thus including patients who could live decades with their chronic disease if treated.
    • There is inadequate protection against greedy relatives or other elder abuse.
    • There is a remarkable short patient-physician relationship in many cases of physician-assisted suicide.
    • There is inadequate reporting and no independent review of how physician-assisted suicide is “working.” It is being done under a shroud of secrecy. Participating physicians and family members can’t be even surveyed and data can’t be verified. We don’t treat any other “intervention” in medicine like this.
    • Legalized physician-assisted suicide, widely practiced, is the quickest way to lower the cost of healthcare. The cheapest treatment for any serious disease is a legally sanctioned overdose.
    • All physicians are not ideal moral agents all the time.
    • No law requires specialty knowledge in diagnosing or treating the patient’s terminal disease or ruling out depression or determining competency.
    • No law requires a long-term patient-physician relationship. In fact, patients can “doctor shop” on the Compassion & Choices website to find a willing doctor.
    • Physicians normally refer for second opinions to other doctors that “practice like they do.” Studies in Switzerland showed that the second opinion is merely a rubber stamp.
    • And more…
  • Using the term “engaged” with neutrality is a feeble attempt to portray that physicians participating in physician-assisted suicide are not abandoning their patients. Does the AAFP really “believe that the well-intentioned discussions and decisions between an individual and their long-term family physician should not be simplified to a black-and-white decision by those not involved in the clinical situation” when a well-intentioned physician chronically over prescribes opiates at the request a patient suffering with chronic pain? Of course not, because that has the potential to seriously harm the patient. But doesn’t a physician enabling a patient to kill themselves represent the ultimate harm?
  • The AAFP is required by their resolution to use the influence of their 120,000 members to lobby the AMA to take a “neutral” position. If they are truly neutral, why would they care what the AMA’s position is? The goal of the proponents of physician-assisted suicide is to eliminate all organized professional opposition, and they are using the AAFP to accomplish their goal.
  • The AAFP claims they don’t want to make a “black-and-white” decision, yet they do that in many of their ethical positions. For example, the AAFP takes a black and white position on physicians having sexual relationships with their patients who are “autonomous, informed and consenting.” In fact, they consider it unethical for a physician to do so.
  • The number of physicians involved in physician-assisted suicide in the states where it is already legalized is very small. Of the five states (Washington, California, Oregon, Vermont and Colorado) reporting physician-assisted suicide data in 2017, only 485 physicians participated out of the 218,606 licensed physicians who practice in those states. That equals 0.22 percent of physicians. Not all of these physicians were specialists in family medicine. Think about this. The AAFP is changing an ethical position that has prohibited physician-assisted suicide for more than 2,000 years because they were concerned that less than one-quarter of 1 percent of physicians would feel bad.
    • Was this move by the AAFP a “solution” without a problem? Has any family medicine physician, in a state where physician-assisted suicide has been legalized, been brought up before any authority, much less the AAFP, for participating? Not that I have heard of.
  • The AAFP also decided to refer to physician-assisted suicide as “medical aid-in-dying” or the abbreviation “MAID.” It is the euphemism most recently pushed by Compassion & Choices since surveys showed it marketed well. “Suicide” has a negative connotation. Everyone, me included, want medical aid when I’m dying to control any troubling symptoms. MAID is deliberately conflating what all physicians should do with what has been prohibited in medicine for over two millennia. The AAFP is now promoting that confusion.
  • A similar term, “medical assistance in dying” was first used widely in Canada where their High Court said there was a constitutional right to MAID in 2015. Now, three years later, 95 percent of MAID is done via lethal injection (euthanasia) because there are fewer complications when you don’t ask the patient to consume the contents of a handful of lethal capsules dissolved in applesauce.
  • There is no logical place to draw the line when a legal right to suicide is based on subjective suffering.
    • In Ontario, physicians will lose their licenses if they don’t become morally complicit and refer patients who desire to be killed.
    • Hospices and hospitals are being accused of making their patients suffer if they don’t offer MAID.
    • Efforts are underway to allow “mature” minors to access MAID over their parents’ objections (or even without parental notification), to allow it for mental disease and to allow it to be an option selected in advance directives.
    • Patients with disabilities are being offered euthanasia.

I heartily agree with two-things in this response from the AAFP.

• Family medicine physicians concerned about this decision need to get more involved in the AAFP at the state chapter level. Their goal should be to replace the delegates who consented to this dangerous decision and reverse it to protect their profession and the patients we serve.
• Secondly, since they appreciate and value your feedback, let them know how upset you are over their decision. For resources to further educate yourself and others on physician-assisted suicide, please visit www.cmda.org/pas.

Thirdly, you should actively educate the public on the dangers of legalized physician-assisted suicide and work to improve authentic palliative care services.