The thorny issue of “end-of-life care” is likely to remain controversial in the US, with physicians themselves holding a wide variety of views.
Dr. Pies is Editor in Chief Emeritus of Psychiatric Times, and a Professor in the psychiatry departments of SUNY Upstate Medical University, Syracuse, NY and Tufts University School of Medicine, Boston.
Editor's Note: A selection of reader responses and rejoinders by the author can be found here.
It seemed like a major statement on physician-assisted suicide (PAS) by the American Medical Association, and several media websites trumpeted the story in just such terms; for example, “The AMA Continues to Oppose Physician-Assisted Suicide” and “AMA Rebuffs Advocates of Physician-Assisted Suicide.”1,2
However, more cautious observers quickly pointed out that the Council on Ethical and Judicial Affairs (CEJA) Report 5-A-18 merely put forward the
of the Council3 and that “…the AMA House of Delegates has not yet taken action on this report [which]…does not represent adopted policy of the AMA at this time” (E.J. Crigger, PhD, American Medical Association, personal communication, May 8, 2018). Indeed, until the delegates actually vote, which at the time this went to press was scheduled for June, it is far from clear how this will be addressed. That said, it will be hard, in my view, for the delegates to repudiate the very clear conclusions of the CEJA report. First, though, a bit of background.
The CEJA report had its genesis in two requests for clarification or revision of the AMA’s 1994 “Code of Medical Ethics Opinion 5.7.” That opinion stated quite clearly that
Physician-assisted suicide occurs when a physician facilitates a patient’s death by providing the necessary means and/or information to enable the patient to perform the life-ending act (eg, the physician provides sleeping pills and information about the lethal dose, while aware that the patient may commit suicide) . . . Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.4
In essence, the two requests (officially known as Resolutions 15-A-16 and 14-A-17) asked the CEJA to consider, respectively, whether the AMA should take a “neutral stance” on physician “aid in dying;” and whether the phrase physician assisted suicide ought to be replaced by the phrase aid in dying in official AMA references to this practice. (I am condensing and paraphrasing for the sake of simplicity; the more technical language of the resolutions may be found in the actual
The authors of the CEJA report wisely noted the critical role of language in this controversy, stating: “Not surprisingly, the terms stakeholders use to refer [to] the practice of physicians prescribing lethal medication to be self-administered by patients in many ways reflect the different ethical perspectives that inform ongoing societal debate.”
Those who favor the practice just described generally prefer the terms death with dignity or medical aid in dying. Those who oppose physician provision of lethal medications generally favor the term physician-assisted suicide.
AFTER MUCH DELIBERATION, the CEJA report reached two main conclusions:
1. The AMA Code of Ethics should not be amended, effectively sustaining the AMA’s position that physician-assisted suicide is fundamentally incompatible with the physician’s role as healer.
2. With respect to prescribing lethal medication, the term physician assisted suicide describes the practice with the greatest precision.
On the second point, the Council noted that “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.”
Notably, the Council’s analysis and recommendations, if accepted by the AMA House of Delegates, would put the AMA squarely in the camp of the American College of Physicians, whose 2017 position on PAS (and on euphemistic alternative terms, like death with dignity) is crystal clear:
Physician-assisted suicide is neither a therapy nor a solution to difficult questions raised at the end of life. On the basis of substantive ethics, clinical practice, policy, and other concerns, the ACP does not support legalization of physician-assisted suicide . . . [Moreover], dictionaries define suicide as intentionally ending one’s own life. Despite cultural and historical connotations, the term is neither disparaging nor a judgment. Terms for physician-assisted suicide, such as aid in dying, medical aid in dying, physician-assisted death, and hastened death, lump categories of action together, obscuring the ethics of what is at stake and making meaningful debate difficult; therefore, clarity of language is important.5
What about the APA?
The American Psychiatric Association’s code of ethics is based on that of the AMA; accordingly, official APA policy is opposed to PAS of any kind. However, in light of the emerging practice in Belgium and the Netherlands of euthanizing non-terminally ill patients-including psychiatric patients-the APA felt it important to craft a position explicitly addressing this population. And so, in December 2016, the APA Board of Trustees passed the following position statement, which originated in the APA Assembly and was unanimously supported by the APA Ethics Committee: “The APA, in concert with the American Medical Association’s position on Medical Euthanasia, holds that a psychiatrist should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death.”6
The statement by the APA Trustees speaks forcefully to the slippery slope of medically authorized killing in countries like Belgium and the Netherlands, where psychiatric patients are now routinely (and legally) euthanized. As my colleague, Mark S. Komrad, MD, wrote:
People with non-terminal illnesses have been legally euthanized at their own request in several countries for nearly 15 years. This has included certain eligible patients who have only psychiatric disorders.
In 2002, Belgium, the Netherlands, and Luxembourg removed any distinctions between “terminal” and “non-terminal” conditions, and between physical suffering and mental suffering, for legally permitted PAS/euthanasia…
Between 2008 and 2014, more than 200 psychiatric patients were euthanized by their own request in the Netherlands (1% of all euthanasia in that country): 52% had a diagnosis of personality disorder, 56% refused one or more offered treatments, and 20% had never even had an inpatient stay (one indication of previous treatment intensity). When asked the primary reason for seeking PAS/Euthanasia, 66% cited “social isolation and loneliness.” Despite the legal requirement for agreement between outside consultants, for 24% of psychiatric patients euthanized, at least one outside consultant disagreed.7
These and many other shortcomings in the European regulation of PAS are vividly illustrated in a new documentary by Canadian filmmaker, Kevin Dunn, Fatal Flaws.8,9
The thorny issue of end-of-life care is likely to remain controversial in the US, with physicians themselves holding a wide variety of views.10 Critical in this debate is the finding that most persons requesting PAS are not actively experiencing extreme suffering or inadequate pain control. Data from the Washington and Oregon PAS programs show that most patients request PAS because they fear loss of dignity and control over their own lives.11 These are matters that lend themselves to psychiatric intervention and counseling-not the dispensing of lethal medication. As the CEJA report wisely observes:
Patient requests for assisted suicide invite physicians to have the kind of difficult conversations that are too often avoided. They open opportunities to explore the patient’s goals and concerns, to learn what about the situation the individual finds intolerable and to respond creatively to the patient’s needs other than providing the means to end life-by such means as better managing symptoms, arranging for psychosocial or spiritual support, treating depression, and helping the patient to understand more clearly how the future is likely to unfold.
The values of Hippocratic medicine admonish the physician as follows: “I [the physician] will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect.”12 It is my hope that the AMA House of Delegates will uphold the wisdom of its own Ethics Council and reaffirm that assisted suicide does not belong in the House of Medicine.
By a 56-44 vote, the AMA House of Delegates decided to reject the CEJA report as it is now written, and to send it back to the Council for
re-evaluation. However, as of now, the official AMA position remains opposed to physician-assisted suicide.
Acknowledgment-I wish to thank Dr. Mark Komrad for his helpful comments on an earlier draft of this article.
Comments are closed. -The Editor
Letter to the Editor
A California judge has closed a PAS law, in essence claiming that it was not a healthcare issue. That was a fundamental error in which life was seen as separate from death. It opens broader questions about the role of physicians in death as well as life.
I often agree with Dr. Pies and regard him as a wise and compassionate person. I must disagree with his position on physician assisted death. First, he has relinquished personal judgement to the ancient words of Hippocrates. Is it the same problem when people want to read the bible or the constitution as if they are the final words on life today? Second, I think that people with documented terminal illness should be granted assisted end-of-life on demand. I say that knowing that among such patients, the chief complaints are not pain, but isolation and loss of meaning in their lives. Assisted death for nonterminal persons is a much more complex issue for which I have no encompassing answer, but am not prepared to say no in a blanket fashion. We must acknowledge that we cannot in every case produce a meaningful existence for people. We must acknowledge that psychotherapy or medication or multidisciplinary intervention, although they should often be applied, are not always adequate for the task. Physicians should not be punished for sometimes attending carefully to quality and not quantity of life. Due care must be exercised, as it is in all of medicine, to guard against abuses.
-Michael Gross, MD
Dr. Pies responds:
I appreciate Dr. Gross’s letter on this controversial topic, and I respect his extensive experience as a psychiatrist. I also recognize that physicians of conscience will differ-often passionately-regarding what Dr. Gross calls “physician assisted death”, and what the American Medical Association and American College of Physicians call “physician assisted suicide” (PAS). As I indicated in my essay, I believe PAS is the most honest and accurate description of the practice in question.
Dr. Gross is quite right in cautioning against mere appeals to authority-whether Hippocrates, the Bible, or the U.S. Constitution-in defending an ethical claim or principle. But when we embrace Hippocratic principles, we are not relinquishing our personal judgment; rather, we are choosing to base our personal judgment on the underlying ethos that motivated Hippocrates and his students: respect for the sanctity of human life; adherence to the principle of “doing no harm”; and affirmation of the principle that physicians are fundamentally healers, not (assistant) killers. These core principles aren’t right because Hippocrates embraced them. Hippocrates and his followers embraced them because they are right.
Indeed, as my colleague, Dr. Cynthia M. Geppert commented in a piece we co-authored, “Hippocratic medicine has constituted the irreducible core of medical ethics in the West for nearly 3 millennia.” Until the rise of “consumer movement” about 60 years ago, few if any physicians publically defended the practice of helping patients kill themselves-for when we strip away the nebulous euphemism of “assisted death”, this is what the practice in question really is.
To be clear: Hippocratic medicine does not mean “Life, life at any cost!” As medical ethicist Leon Kass, MD, has noted:
“The ancient Hippocratic physicians’ refusal to assist in suicide was not part of an aggressive, so-called “vitalist” approach to dying patients, or an unwillingness to accept mortality. On the contrary, understanding well the limits of the medical art, they refused to intervene aggressively when the patient was deemed incurable, and they regarded it as inappropriate to prolong the natural process of dying when death was unavoidable.”
The critical distinction, then, is between a physician’s aiding the suicide of a patient, on the one hand; and discontinuing futile medical interventions for terminally ill patients (“removing impediments to death”) on the other. The U.S. Supreme Court recognized this crucial distinction in two key cases-Washington v Glucksberg and Vacco v Quill. In the Vacco case, the Court wrote,
"We think the distinction between assisting suicide and withdrawing life sustaining treatment, a distinction widely recognized and endorsed in the medical profession and in our legal traditions, is both important and logical."
Indeed, there are well-established reasons, grounded in common law, why most states prohibit aiding or abetting a suicide. It is far from clear why, of all people, physicians alone should be exempted from this prohibition. That a handful of states have chosen to do so does not make it right.
I agree with Dr. Gross that psychiatrists must attend carefully to “quality of life” issues, and to what constitutes a meaningful life for our patients. But these generalizations do not justify our assisting in the patient’s suicide. We can explore with terminally ill patients how, even in their final days, they can still find meaning in their lives. And if, after such exploration, a mentally competent, terminally ill patient decides that he or she no longer wishes to live, we can respect the patient’s decision to discontinue futile, “heroic” measures, such as feeding tubes or respirators-which merely prolong the dying process. But this is a far cry from providing a lethal dose of a barbiturate to the patient.
Finally, Dr. Gross acknowledges that, “Due care must be exercised, as it is in all of medicine, to guard against abuses” in end-of-life care. Sadly, much evidence suggests that “due care” is often not exercised in places where PAS or euthanasia is legal. As Dr. Mark Komrad noted, in the Netherlands, “Despite the legal requirement for agreement between outside consultants, for 24% of psychiatric patients euthanized, at least one outside consultant disagreed.” Even in the U.S., there are many instances of abuse in PAS-permissive states. For example,
“Wendy Melcher died in August 2005 after two Oregon nurses, Rebecca Cain and Diana Corson, gave her overdoses of morphine and phenobarbital. They claimed Melcher had requested an assisted suicide, but they administered the drugs without her doctor’s knowledge, in clear violation of Oregon’s law. No criminal charges have been filed against the two nurses.”
Ultimately, there is no scientific study or experiment that can settle the ethical questions involved in the PAS debate. It comes down to how we choose to define the role and purview of the physician-and to what values physicians choose to embrace. I believe Dr. Leon Kass puts the matter most succinctly: “We must care for the dying, not make them dead.”
Ronald W. Pies, MD
For further reading:
5. Komrad MS. APA position on medical euthanasia. Psychiatr Times. 2017;34(2):20-25.
This article was originally posted on 5/22/2018 and has since been updated.
1. Soundcloud. The AMA Continues to Oppose Physician-Assisted Suicide. 2018. https://soundcloud.com/readytostand/the-ama-continues-to-oppose-physician-assisted-suicide. Accessed May 17, 2018.
2. Herout C. AMA Rebuffs Advocates of Physician-Assisted Suicide. 2018. https://www.crisismagazine.com/2018/ama-rebuffs-advocates-physician-assisted-suicide. Accessed May 17, 2018.
3. Agliano DS. Report of the Council on Ethical and Judicial Affairs. CEJA Rep. 5-A-18.
4. American Medical Association. Physician Assisted Suicide: Code of Medical Ethics Opinion 5.7. https://www.ama-assn.org/delivering-care/physician-assisted-suicide. Accessed May 17, 2018.
5. Sulmasy LS, Mueller PS, for the Ethics, Professionalism and Human Rights Committee of the American College of Physicians. Ethics and the legalization of physician-assisted suicide. Ann Intern Med. 2017. http://annals.org/aim/fullarticle/2654458/ethics-legalization-physician-assisted-suicide-american-college-physicians-position-paper. Accessed May 17, 2018.
6. Moran M. New APA policy prohibits participation in euthanasia of non-terminally ill. Psychiatr News. 2017. https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2017.1a4. Accessed May 17, 2018.
7. Komrad MS. APA position on medical euthanasia. Psychiatr Times. 2017;34(2):20-25.
8. Dunn K. Fatal Flaws. Dunn Media Productions. 2018. https://fatalflawsfilm.com. Accessed May 17, 2018.
9. Laurence L. New Documentary Exposes Big Lie Behind Euthanasia Movement. 2018. https://www.lifesitenews.com/news/new-documentary-exposes-big-lie-behind-euthanasia-movement. Accessed May 17, 2017.
10. Pies R. The Conversation. How Does Assisting With Suicide Affect Physicians? 2018. http://theconversation.com/how-does-assisting-with-suicide-affect-physicians-87570. Accessed May 17, 2018.
11. Loggers ET, Starks H, Shannon-Dudley M, et al. Implementing a death with dignity program at a comprehensive cancer center. New Eng J Med. 2013;368:1417-1424.
12. Pies R. Deferring to the mastery of death: Hippocrates, Judge Gorsuch, and the autonomy fallacy. Psychiatr Times. 2017;34(4):16C-16F.