Physician-assisted suicide and euthanasia (PAS-E) has been a source of discussion for millennia, as evidenced by its explicit mention in the Hippocratic Oath from the fifth to third century B.C., where Hippocrates includes it among the list of things physicians must never participate in. In the aftermath of the horrors of the 20th century, where thousands of people were euthanized without their consent in World War II, there was an even stronger swing of the pendulum against any form of PAS-E.
However, the latter half of the 20th Century has seen a resurgence of this debate, with a number of countries, including Belgium, the Netherlands, Canada, and Luxemburg, having legalized euthanasia, with a push to normalize PAS-E worldwide. This month, the World Medical Association (WMA), the international organization representing physicians to ensure their independence and work towards the highest standard of ethical behavior and care, will hold its 212th Council Session, where it has called for written opinions re-examining the PAS-E statement in the WMA code of ethics.
Currently, the language in the code of ethics on PAS-E, adopted by the 53rd WMA General Assembly in 2002, states that “[PAS], like euthanasia, is unethical and must be condemned by the medical profession. Where the assistance of the physician is intentionally and deliberately directed at enabling an individual to end his or her own life, the physician acts unethically.” The statement even encourages national medical associations and physicians to refrain from participating in euthanasia, even if national laws allow it.
At the WMA medical ethics conference in October 2018, a proposal was submitted by the Canadian Medical Association (CMA) and Royal Dutch Medical Association (KNMG) to amend the WMA ethics code on PAS-E from condemning the practice to neutrality. This proposal was strongly opposed and was retracted.
Rather than make their controversial case before the conference, the Canadian and Dutch parties turned a minor scandal into a reason to leave the WMA altogether. The inaugural speech contained passages that had been plagiarized by a speechwriter; despite the WMA President's public apology, saying he was not aware of this, the CMA, without consulting with its wider membership, withdrew from the WMA, citing unethical conduct, and the KNMG also later withdrew, citing the same reasons.
The WMA called for written opinions re-examining the PAS-E statement in its code of ethics for the general session in April 2019. The German Medical Association has suggested a compromise to reword parts of the code such as “physician-assisted suicide” to “physician-assisted death” and “unethical and must be condemned” to “physicians should not engage.” Other national associations of the WMA had also overwhelmingly opposed this proposal.
With two major national associations having left the WMA, there will now be pressure on the WMA to come up with a compromise to woo them back.
However, the WMA should not respond to such bullying tactics. It sets a poor precedent for proposals from other countries, which would allow for similar responses in the future. It also introduces inequality in influence, with only two countries having disproportionate ability to influence WMA policy, whether considered ethical or not by the rest of the WMA.
The WMA should not consider the German proposal. Softened wording neuters the gravity of PAS-E by taking it out of the sphere of medical ethics, and such a change would also clearly signal having caved to the demands of the CMA and KNMG, encouraging these groups to press for further change. Furthermore, the WMA has a policy that physicians should not take part in unethical practices, even if they are legal. The German proposal would exclude PAS-E from that policy.
Most importantly, in a pluralistic society, the purpose of forums such as the WMA is to create a setting for debate and discourse. Whether one thinks that PAS-E is ethical or not, it is important for national medical associations to continue the process of engaging with colleagues, and convince or be convinced by them through debate rather than exiting the dialogue altogether.
John Y. Rhee, MD, MPH is an intern in the Department of Medicine at Mount Sinai Hospital in New York City and a resident in the Department of Neurology at Massachusetts General Hospital/Brigham and Women's Hospital at Harvard Medical School in Boston. This article has been republished from MedPageToday with the author’s permission.