Debate Over Physician-Assisted Dying at 'Turning Point'

Zosia Chustecka

January 21, 2016

The debate over physician-assisted dying (PAD) appears to be at a turning point, with recent public polls showing strong support, comment two lawyers in an editorial in the January 19 issue of JAMA, a special edition on death and dying.

They also note that, for the first time, a 2015 poll in the United States found that more than half of physicians surveyed favored medical assistance in dying, even though the American Medical Association opposes PAD.

Four states now have legislation allowing PAD ― Oregon, California, Vermont, and Washington ― and a fifth state, Montana, allows PAD through a court decision, write Lawrence Gostin, JD, and Anna Roberts, LLB, MIPH, both from the Georgetown University Law Center, in Washington, DC.

But there is an ongoing, heated debate as to whether PAD is incompatible with the physician's oath to do no harm, the lawyers comment. Two opposing views appear in the same issue of the journal, as already reported by Medscape Medical News.

There is evidence to suggest that physicians who work closely with terminally ill patients are more likely to support PAD than their peers, the lawyers note. In addition, in jurisdictions where PAD is not available, physicians report using alternative methods to assist their patients in hastening dearth, they add.

"Furthermore, all states that have legalized PAD provide opt-outs to accommodate physicians who have a conscientious objection to PAD or simply do not wish to participate; these statutes protect physicians against civil or criminal liability for refusing to participate," the lawyers point out.

Coming Soon to Other States?

During 2015, a total of 23 states and the District of Columbia sought to codify the practice of physician aid in dying, and eight of these states have done so for the first time, note the authors of another editorial in the same issue of JAMA.

The legislatures of Massachusetts and New Jersey are slated to debate the issue later this year.

"This unprecedented legislative wave represents more than double the number of death-with-dignity bills introduced in any year since 1995 and a six-fold increase relative to 2014," write Ryan Clodfelter and Eli Adashi MD, both from the Warren Alpert Medical School, Brown University, Providence, Rhode Island.

They also believe that "the tide may be turning," and they suggest that "a national concensus may be emerging, as indicated by the unparalleled flurry of recent state legislation and of the legislative outcome in California" (which passed its law in October 2015).

They point out that opinions among the general public have changed, citing results from the latest Gallup Values and Beliefs survey.

"Nearly 7 of 10 people polled in the United States are now favorably disposed to the practice," they note. "This level of support increased nearly 20 percentage points over the last 2 years to its highest level in more than a decade."

In addition, the percentage of young adults aged 18 to 34 years who support physician aid in dying increased by 19% this year alone, to reach 81%, they note.

Both surveys posed the same question: "When a person has a disease that cannot be cured and is living in severe pain, do you think doctors should or should not be allowed by law to assist the patient to commit suicide if the patient requests it?"

"Climate Has Changed"

A shift in opinion has taken place, states another editorial in the same issue, this one authored by the journal editors, Howard Bauchner, MD, vice chairman of pediatrics at Boston University School of Medicine and editor-in-chief of JAMA, and Phil B. Fontanarosa, MD, MBA, adjunct professor at Northwestern University Feinberg School of Medicine and executive deputy editor of JAMA.

"Although discussions about death, dying, and end of life care were politicalized just a few years ago, the climate has changed and more intellectually honest and more informed conversations about these important issues are now possible," they write.

"Willingness to seriously and openly consider these important issues is reflected, for example, in the changing public opinion and legislative climate in the United States around physician- assisted dying," they state.

 
Physician aid in dying has received increased recognition and acceptance. Dr Howard Bauchner and Dr Phil Fontanarosa
 

"Although this practice previously was widely rejected on clinical and ethical grounds, physician aid in dying has received increased recognition and acceptance by some physicians, members of the public, and policy makers as a viable option for patients at the end of life," they comment.

"Virtually every physician has emotionally painful and poignant stories about how medicine failed their own family members, friends, or colleagues during the final stages of life," Dr Bauchner and Dr Fontanarosa write.

"It is concerning when physicians, who know the health care system far better than most patients and can use their knowledge to improve the provision of health services, relate these stories, often describing too much medicine at the end of life, failed discussions about prognosis, or the very late involvement of palliative care," they write. "Progress with respect to dying well will be evident when these stories become less frequent and more physicians and others can report that their colleagues, their friends, and their family members had a good death."

JAMA. 2016;315:249-250, 251-252, 270-271. Editorial 1, Editorial 2, Editorial 3

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