EXECUTIVE SUMMARY

Medical aid in dying is now legal in six states, the District of Columbia, and Canada, with several of the laws recently passed. Some ethical considerations include the following:

• Not all patients have access to providers offering this option.

• There is the possibility of coercion for vulnerable patients.

• Physicians may withhold referrals or information because of their own beliefs.


Recently passed state laws allowing physician-assisted death are in conflict with a newly updated position statement from the American College of Physicians (ACP) objecting to the practice.

“These issues are unresolved. But laws continue to appear and to chip away at what was, and has until recently been, a rather general medical opposition to physician assistance in suicide,” says Thomas S. Huddle, MD, PhD, professor of medicine at UAB School of Medicine in Birmingham, AL.

Physician-assisted death is currently legal in the District of Columbia and six states: Oregon, Washington, Vermont, California, Montana, and Colorado.

“Widespread legal acceptance, if that occurs, is likely to precede general physician willingness to participate,” says Huddle.

Inequities in access to providers offering this option to patients is one ethical concern. “Currently, best access is for white, educated, insured, male, and terminal patients,” says Catherine Sonquist Forest, MD, MPH, medical director of Stanford (CA) Primary Care at Los Altos.

A related concern: Not all patients can afford medical assistance in dying. “The costs of the drugs have skyrocketed, making them out of reach for many dying people — especially since not all insurance is covering them,” says Joanne Lynn, MD, a Washington, DC-based geriatrician, and director of the Center for Elder Care and Advanced Illness at Ann Arbor, MI-based Altarum.

Gradual Acceptance

The overall trend is toward acceptance of medical assistance in dying, both by the general public and healthcare providers.

“It’s becoming gradually accepted, by more terminally ill patients and the physicians who care for them, as a legitimate end-of-life option,” says Ben A. Rich, JD, PhD, emeritus professor of medicine (bioethics) and school of medicine alumni association endowed chair of bioethics at University of California, Davis School of Medicine in Sacramento.

In Forest’s view, the barrier to participation typically is more hesitance than resistance. “This has been the case for most shifts in medical practice,” she says.

Forest gives the analogy of anesthesia administered to women in labor, altering the “normal” course of birth. “Medical culture will shift, as experience widens, to increase access and develop best practices for terminal patients that choose medical assistance in dying,” she predicts.

Some physicians who conscientiously object to medical assistance in dying may withhold information or referrals to patients who would choose it, based on the physician’s own belief system. “This falls in the same category as not referring for experimental treatment, or sterilization, or termination of a pregnancy,” says Forest.

Reaffirmed Opposition

In Canada, the expectation is that a physician who has a conscientious objection to medical assistance in dying will provide a referral for patients. “However, this is currently being contested in court by a group of faith-based physicians,” says Blair Henry, D.Bioethics, a senior ethicist and assistant professor at the University of Toronto. The physicians claim that such a referral represents a degree of cooperation and assistance in the process which they feel is unconscionable.

The overarching ethical question is what allowances faith-based institutions have when they also are mandated to treat the larger public. “Can they conscientiously object, as is now allowed with abortions?” asks Henry. “Or has the fabric of society changed such that all of this needs to be revisited?”

In a recently updated position paper, the ACP reaffirmed its opposition to the legalization of physician-assisted suicide and affirmed a professional responsibility to improve the care of dying patients.1

“Physician-assisted suicide alters the physician’s role as healer and comforter and the medical profession’s role in society. It affects trust in the patient-physician relationship and the profession,” says ACP president Jack Ende, MD, MACP, the Schaeffer professor of medicine at University of Pennsylvania’s Perelman School of Medicine in Philadelphia.

There have been many changes in the legal landscape since 2001, when the ACP first published a position paper opposing the legalization of physician-assisted suicide. “There is increased public interest in the topic, and continuing problems with access to palliative and hospice care,” notes Ende.

The updated paper considers clinical practice, ethics, law, and policy. Ende says that withdrawal of treatment, based on patients’ wishes, respects the patient’s bodily integrity and right to be free of unwanted treatment. In contrast, physician-assisted suicide is performed with the intent to end the patient’s life. “This distinction is ethically and legally important,” says Ende.

Medical ethics and the law support a patient’s right to refuse treatment, including life-sustaining treatment. The intent is to avoid or withdraw treatment judged by the patient as unduly burdensome and inconsistent with his or her health goals and preferences. “Death follows naturally after the refusal, due to underlying disease,” says Ende.

The position paper emphasizes the importance of good palliative and hospice care. Access to this is not uniformly available. “Progress has been made, but the principles and practices of hospice and palliative medicine have not been fully realized,” says Ende.

If a patient requests aid in dying or expresses fear about suffering, those concerns and reasons for the request should be thoroughly discussed, according to the position paper. “Requests for physician-assisted suicide are unlikely to persist when compassionate, supportive care is provided,” says Ende.

Aaron Kheriaty, MD, associate professor of psychiatry and director of the bioethics program at University of California, Irvine School of Medicine, says the lack of requirement for psychiatric evaluation is a big ethical concern.

“The desire to end one’s life, or the request for assisted suicide — or aid in dying, as proponents prefer — is almost always a cry for help. And it should be interpreted as such by the physician,” says Kheriaty.

Kheriaty says that the desire or request to die is a distress signal indicating that something in the patient’s situation is not adequately being attended to. This might be untreated depression, fear or anxiety about the medical condition or the future, untreated pain, or a family or relationship strain or conflict.

“Efforts aimed at suicide prevention for vulnerable individuals, particularly those diagnosed with a serious or terminal medical condition, may be weakened by the laws,” says Kheriaty.

Kheriaty adds that the idea that serious mental health issues could be overlooked in the application of the law is not merely theoretical. “Consider the case of Michael Freeland, an Oregonian who had a 43-year history of depression and prior suicide attempts. Yet, the physician who prescribed for him the deadly drug did not deem it necessary to refer for psychological counseling,” he says.

In Canada, medical assistance in dying was legalized in 2016. “Our legal framework is less restrictive than the California statute, in that neither a terminal diagnosis or set prognostic period are required to meet eligibility,” notes Henry. Neither law requires an assessment by a mental health specialist. “The premise used is the same as all encounters requiring informed consent — that it is the practitioner’s responsibility to make that determination of capacity,” says Henry. Two independent assessments by a physician and/or nurse practitioner are required.

“Only if the clinician feels that an underlying psychiatric condition might be impacting the patient’s decision-making capacity is a referral to psychiatry expected,” says Henry.

Rich supports well-crafted medical assistance-in-dying laws, but objects to the often-used term “physician-assisted suicide.” “Patients who utilize aid-in-dying laws are not suicidal in any legitimate psychiatric sense. They do not want to die, but their death from an underlying terminal illness is imminent,” says Rich.

The goal is to control the time and manner of the patient’s closely approaching death so as to preserve his or her dignity and prevent potentially refractory pain and distress, says Rich: “None of the aid-in-dying laws in the U.S. use the term ‘suicide.’”

Forest says it’s important to evaluate for coercion of patients whose lives may not be as valued by society. These include disabled individuals, or those with low socioeconomic status. “Protecting vulnerable groups for all medical decisions is crucial,” says Forest.

Lynn says the most serious ethical concern with physician-assisted dying is that it will become “ordinary — and just part of what patients are offered.”

Patients who need long-term care may feel that physician-aided dying is their only option, if there is no apparent alternative. “Will people feel that ‘choosing’ physician-aided dying is expected of them, as a way to cut short the burdens on family and public funds?” asks Lynn.

Looking Forward

Rich notes, “The politics of the aid-in-dying debate, which is permeated with ‘ethics talk,’ has changed markedly over the last five years or so.” Notably, prior to the passage of the California law, the California Medical Association changed its position from opposed to neutral.2

“Opponents argue that making aid-in-dying available to competent, terminally ill patients will place society on a slippery slope, eventually leading to providing aid-in-dying to incompetent, non-terminally ill patients,” says Rich.

Rich says that data from Oregon’s Death With Dignity Act, in place for two decades, refutes this, and also counters arguments that legalizing lethal prescriptions will threaten vulnerable populations and that those who seek assistance in dying have not received adequate palliative care.

“The vast majority of individuals who have obtained and utilized a lethal prescription are well-educated, adequately insured, enrolled in hospice, and have been deemed by two physicians to have decisional capacity uncompromised by depression or the undue influence of another person,” says Rich.

A broader ethical objection is that aid-in-dying violates a core principle of medical ethics: that physicians must not intentionally be the cause of a patient’s death. “The medical profession continues to be divided among those who strongly support aid-in-dying, those who strongly oppose it, and those somewhere in between on the continuum of opinion whose views are evolving,” says Rich.

REFERENCES

1. Sulmasy LS, Mueller PS. Ethics and the legalization of physician-assisted suicide: An American College of Physicians position paper. Ann Intern Med 2017; 167(8):576-578.

2. California Medical Association removes opposition to physician aid in dying bill. California Medical Association; 2015. Available at: http://bit.ly/2C23olj. Accessed Dec. 13, 2017.

SOURCES

• Jack Ende, MD, MACP, Schaeffer Professor of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Phone: (215) 662-8989. Email: jack.ende@uphs.upenn.edu.

• Catherine Sonquist Forest, MD, MPH, Medical Director, Clinical Associate Professor of Medicine-Family Medicine, Stanford (CA) Primary Care at Los Altos. Email: csforest@stanford.edu.

• Blair Henry, D. Bioethics, Department of Family and Community Medicine, University of Toronto, Ontario. Phone: (416) 480-6100 ext. 7178. Email: blair.henry@sunnybrook.ca.

• Thomas S. Huddle, MD, PhD, Professor of Medicine, Division of General Internal Medicine, UAB School of Medicine, Birmingham, AL. Email: thuddle@uab.edu.

• Aaron Kheriaty, MD, Associate Professor of Psychiatry/Director, Bioethics Program, University of California, Irvine School of Medicine. Phone: (714) 456-8774. Email: akheriat@uci.edu.

• Joanne Lynn, MD, Director, Center for Elder Care and Advanced Illness, Altarum, Washington, DC. Phone: (202) 776-5109. Email: joanne.lynn@altarum.org.

• Ben A. Rich, JD, PhD, Emeritus Professor of Medicine (Bioethics)/School of Medicine Alumni Association Endowed Chair of Bioethics, UC Davis School of Medicine, Sacramento. Phone: (916) 734-6010. Fax: (916) 734-1531. Email: barich@ucdavis.edu.