D. Joy Riley, M.D., M.A.
Executive Director
On 19 September 2017, the Ethics, Professionalism and Human Rights Committee of the American College of Physicians released their position paper on physician-assisted suicide (P-AS). A brief synopsis of it follows…
Re: Ethics and the Legalization of Physician-Assisted Suicide: An American College of Physicians Position Paper
The statement released last week builds on previous work:
- 1997 report by the Institute of Medicine (IOM), Approaching Death: Improving Care at the End of Life, which cited “inadequate end-of-life care” in the U.S.
- 2001 statement by the American College of Physicians, in which the ACP did not support the legalization of P-AS. Instead, the ACP-ASIM (American Society of Internal Medicine) remained “thoroughly committed to improving care for patients at the end of life.”
- 2014 IOM report, Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life, which found a “substantial body of evidence shows that broad improvements to end-of-life care are within reach,” but recommended “[c]hanges are needed throughout the health care system to incentivize provision of comprehensive palliative care.” Moreover, the report found that “Efforts are needed to normalize conversations about death and dying. Several social trends suggest that the time is right for a national dialogue…”
Several elements of the 2017 statement deserve mention:
On Physician Responsibilities: “Physicians are members of a profession with ethical responsibilities; they are moral agents, not merely providers of services (15).”
On Death Certificate Completion: “Death certificate requirements under physician-assisted suicide laws ask physicians to list the cause of death as the underlying illness, not the new pathology caused by ingestion of a lethal dose of medicine (24), which seems inconsistent with the physician’s duty of honesty.”
Alleviation or Elimination? “Just as medicine cannot eliminate death, medicine cannot relieve all human suffering; attempting to do so ultimately leads to bad medical care (25). Good medicine demands compassion for the dying, but compassion also needs reason (26). Both proponents and opponents wish to alleviate suffering of dying patients, and physicians have an ethical duty to provide competent palliative and hospice care (9). However, is physician-assisted suicide a type of control over suffering and the dying process that is within the goals and scope of medicine?”
Should Physicians Help Their Patients Commit Suicide? Perhaps the most telling aspect of the ACP’s deliberations is the following excerpt: “Despite changes in the legal and political landscape, the ethical arguments against legalization of physician-assisted suicide remain the most compelling. We are mindful that ethics is not merely a matter for a vote. Majority support of a practice does not make it ethical. Medical history provides several cautionary examples of laws and practices in the United States (such as racial segregation of hospital wards) that were widely endorsed but very problematic.”
Is a “Neutral” Position Really Neutral? The ACP answers with this: “Furthermore, the ACP does not believe neutrality on this controversial issue is appropriate. The medical profession should not be neutral regarding matters of medical ethics (9). The ACP is not neutral on practices that affect the patient–physician relationship and trust in the profession, such as laws that restrict or mandate discussions with, or certain recommendations for, patients. According to the American College of Physicians Ethics Manual, physicians have a duty to come forward, to ‘clearly articulate the ethical principles that guide their behavior in clinical care, research, and teaching, or as citizens or collectively as members of the profession. It is crucial that a responsible physician perspective be heard as societal decisions are made’ (9).”
The ACP Paper Addressed What Should Be Done, and Further Thoughts: “A few patients want to control the timing and manner of death; many more are fearful of what living the last phase of life with serious illness will be like. To the extent that the debate about legalizing physician-assisted suicide is a dilemma because of the failings of medicine to adequately provide comfort and good care to dying patients, medicine should do better. Legalized physician-assisted suicide medicalizes suicide (72). Physician-assisted suicide is not a private act but a social one, with effects on family, community, and society.”
Based on all of the above and more, the American College of Physicians “does not support legalization of physician-assisted suicide.” The Tennessee Center for Bioethics & Culture concurs, and is grateful for the thoughtful reasoning of the ACP in this most recent position paper.
To read the paper in full, visit here.
