ACP Affirms Opposition to Physician-Assisted Dying

Tara Haelle

September 18, 2017

Ethical arguments against the legalization of physician-assisted dying remain more compelling than those in support of the practice, the American College of Physicians (ACP) states in an updated position statement published September 18 in the Annals of Internal Medicine.  

The statement reaffirms the ACP's opposition to physician-assisted dying as originally issued in 2001, but support for it is not universal.

"Since then, there's been a lot of interest in the subject, and several more states have legalized physician-assisted suicide," ACP President Jack Ende, MD, told Medscape Medical News, explaining the reason the ACP revisited the issue. "We also felt there wasn't enough attention given to patients with terminal illness to be sure they were receiving the best possible care, with hospice care and palliative care."

The statement authors cite a study finding that 90% of US adults don't know the meaning of "palliative care." Hearing the definition, however, more than 90% of them said they would want it for themselves or a family member during severe illness. 

Dr Ende emphasized not only the thorniness of the issue but also the diverse beliefs of ACP members on the topic. The College encouraged robust discussion to ensure all voices were heard, he said.

"There was not uniform enthusiasm for this," Dr Ende told Medscape Medical News. "The College really does acknowledge the wide range of views on the subject, but in the end, the position of the College is that physician-assisted suicide breaches the first duty of the physician to do no harm."

The position paper reviews ethical arguments for and against doctors' participation in helping patients choose to end their lives and ultimately concludes that "society's goal should be to make dying less, not more, medical."

"The emphasis by medicine and society on intervention and cure has sometimes come at the expenses of good end-of-life care," Lois Snyder Sulmasy, JD, from the ACP's Center for Ethics and Professionalism in Philadelphia, Pennsylvania, and colleagues write in the statement. "Although medicine now has an unprecedented capacity to treat illness and ease the dying process, the right care in the right place at the right time has not been achieved."

The authors acknowledged that respecting patient autonomy is important but not absolute.

"We believe physicians need to be healers, and part of the role of the physician as a healer does not include assisting the patient with suicide," Dr Ende said. "We are very strong proponents of patient autonomy and also recognize that patient autonomy has limits."

The argument that physician-assisted dying interferes with the role of being a healer was one of three arguments the ACP cites to support their position. The others are that the practice risks undermining the physician-patient relationship (an "inherently unequal" relationship) and potentially jeopardizes trust between physicians and both their patients and the public.

"Physicians need to be present, [be] part of the dying process, and provide all the services, including palliative and hospice care," Dr Ende said. "We felt it would be comforting enough to allow patients to go forward with a natural death, to allow illness to take its natural course, rather than accelerate the process or take control of the process."

Dr Ende reiterated concern that the medical community does not appreciate the importance of hospice and palliative care and that doctors may hesitate to recommend them, lest the suggestion imply the physician is "giving up" on the patient. Yet surveys show families and patients value those services, he said.

Semantics Play Role in Debate

Development of the ACP statement, which stretched from September 2015 to March 2017, was first discussed and drafted by the ACP Ethics, Professionalism and Human Rights Committee (around a dozen members), followed by review by multiple boards and councils within the ACP and members as a whole. After revision and additional review, the ACP Board of Regents approved the paper on March 27.

The authors are careful to define terms and distinguish between different practices. The ACP uses the term "physician-assisted suicide" throughout its statement and in two accompanying editorials for the stated reason of consistency, though not all editorialists prefer that term.

The ACP defines "suicide" as "killing oneself intentionally." It defines "physician-assisted suicide" as a physician's participation in "advising or providing, but not directly administering, the means" for a person to end their life, a practice legalized first in Oregon in 1997 and most recently in Colorado and the District of Columbia in 2016. Four other states with legal physician-assisted dying include, chronologically, Washington, Montana, Vermont, and California. "Euthanasia," which remains illegal everywhere in the United States, is actively, intentionally ending another person's life to end suffering, such as a physician directly injecting a patient with a lethal dose of a substance.

Word choice offers insight into a person's position on this topic, and all four physicians interviewed for this story stressed the importance of using language purposefully.

William G. Kussmaul III, MD, associate editor of Annals of Internal Medicine, and author of one of the accompanying editorials, emphasizes the potential for language and shifts in public discourse to influence social attitudes toward the practice. "Words mean something, and if someone wants to say that not assisting a patient to [commit] suicide is abandoning them, that's a use of language that tends to cast a dim light on someone who does not want to participate," Dr Kussmaul, a retired physician, told Medscape Medical News.

Physician-assisted "dying" or "death" is a euphemism for suicide, Dr Kussmaul argues. Patients die all the time, and physicians provide the best assistance to patients as they can by "caring, making them comfortable, and accompanying them along the road all the way to the end." Equating "physician-assisted suicide" with "caring for patients" isn't fair to doctors who care for their patients but don't support suicide, Dr Kussmaul said.

The position statement asserts that the term "suicide" is "neither disparaging nor a judgment" despite "cultural and historical connotations." Further, conflating terms such as "physician-assisted suicide," "medical aid in dying," "physician-assisted death," and "hastened death" risks "obscuring the ethics of what is at stake and making meaningful debate difficult," the ACP authors write.

A coauthor of the other editorial, Timothy E. Quill, MD, from the University of Rochester Medical Center in New York, notes that many other languages have different words for different situations in which a person chooses to die. "Heroic suicide," such as a soldier shielding a bomb to protect others, differs from suicide resulting from mental illness or "rational suicide," resulting from an "unacceptable situation," he told Medscape Medical News.

"That's why there's a few of us who prefer to use 'physician-assisted death and dying,' because conflating it with mental illness is just not correct," he said. "If you are an opponent of this practice, you are going to be adamant about using the word 'suicide' because [public] support for the practice, when you use that word, goes down about 10%."

Discussions of Care and Patient Choice

The ACP position paper particularly emphasizes the "distinction between refusal of life-sustaining and physician-assisted suicide." The former is ethical, even if the result — but not intention — is death, the ACP says, because it withdraws a medical intervention that hindered an illness's natural course. Patients have the right to refuse any treatment, even life-sustaining, as the literal and philosophical effect is no different than if they had not initially consented to the treatment.

Similarly, increasing medication to relieve pain in terminally ill patients retains strong ethical support despite the potential for shortening life because the intention is to provide a benefit.

ACP opposes physician-assisted dying because its express intent is to end a patient's life.

"When it comes to relieving suffering, we have great many ways to do that, and ending life seems to be a poor substitute for actually caring," Dr Kussmaul told Medscape Medical News.

The ACP statement cites four major pillars of physicians' ethical care of patients: "beneficence (acting in the patient's best interest), nonmaleficence (avoiding or minimizing harm), respect for patient autonomy, and promotion of fairness and social justice."

The authors outline the key ethical arguments supporting physician-assisted dying as respecting patient autonomy and maintaining a physician's responsibility to relieve suffering without abandoning their patient. Yet the practice violates "duties of beneficence and nonmaleficence" when a physician should be providing care and comfort and it conflicts with a doctor's role as "healer and comforter," the ACP argues.

"Vulnerable communities and individuals raise strong concerns that legalization leads to attitudinal changes, subtle biases about quality of life, and judgments that some lives are not worth living," the authors write. "Some individuals might view themselves as unproductive or burdensome and, on that basis, as candidates for assisted suicide, especially if a physician raises it or validates a request."

The position statement also includes 12 steps physicians should take to ensure that patients and their families are receiving the most informed and best possible end-of-life care. Dr Quill praised those steps and similarly emphasized the importance of palliative care, but he said those steps and palliative care may not be sufficient for a tiny percentage of patients.

"What we're talking about is being much more open and forthright when palliative care has been tried in its best sense and it's inadequate," Dr Quill told Medscape Medical News. "If you've redoubled and redoubled and redoubled your efforts, [the statement] doesn't give a lot of guidance about how you should approach a patient who is asking for your assistance."

Simply "saying no" is not enough, Dr Quill said. Thus, physicians need to look for common ground with their patients, including other potential last-minute options, such as sedation.

"They are dying, they're trying to stay whole and intact as they're dying, and I just see this as part of the dying process," Dr Quill said. "We have monkeyed around with the dying process tremendously, extending in so many different ways often until people are falling apart. If the wheels were to fall off, we really have a responsibility to work with them."

He also emphasized the importance of open, forthright discussions with patients because the practice occurs secretly in states where physician-assisted dying is illegal.

"If it's done way underground, it feels dangerous to talk about," he told Medscape Medical News. "It's much better for bereavement and best practices to have an open system and make sure the practice is restricted to people who really need it."

Because physician-assisted dying is already legal in several states, the ACP has a responsibility to at least provide some guidance in best practices, Dr Quill said. "Just saying you shouldn't do it is not a strategy for studying it."

A study from Oregon, also published in Annals of Internal Medicine today, examines the use of physician-assisted dying in that state. Dr Ende said he has great respect for his Oregonian colleagues and that it appears "many, if not most, of physicians who are participating in this are doing it properly." However, although generally not a fan of slippery slope arguments, Dr Ende, like Dr Kussmaul, harbors some concerns about how changing attitudes toward physician-assisted dying can lead to broadened scope of the practice, as is seen in the Netherlands and Belgium.

In reviewing the data from Oregon, Dr Ende expressed concern about the increase in physician-assisted deaths, although they remain 0.2% of the state's deaths, and the "rarity of psychiatric referrals." Only 3 of 105 people who died under the Death With Dignity Act in Oregon in 2014 received psychiatric evaluation referrals. "I think, to some extent, it's a cautionary tale."

Dr Quill, however, pointed out the impracticality of referring all or most patients requesting a Death With Dignity Act prescription for a psychiatric evaluation.

"There are not enough psychiatrists who are used to seeing people who are this sick to have each person to see a psychiatrist," he told Medscape Medical News. "When you're doing public policy across a population, you have to be practical about what's really available, and an independent doctor seeing a patient and confirming they meet the criteria is sufficient as a general safeguard. When we're talking about removing life support, we don't have everybody see a psychiatrist about it."

Where all physicians appeared to agree, however, was the need to make palliative care and hospice fully accessible and affordable for all patients.

"Just to reiterate, the important message is that we can be doing a much better job in taking care of our patients at the end of life," Dr Ende told Medscape Medical News.

The ACP operating budget provided the sole funding for the position statement's development.

Ann Intern Med. Published online September 18, 2017. Abstract, Kussmaul editorial, Quill editorial

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