In a move which has global repercussions, the American Medical Association has voted reaffirm its opposition to physician-assisted suicide.
The AMA’s official position is that legalized assisted suicide is contrary to the physician’s role as healer, puts vulnerable patients at risk, and would be difficult or impossible to control.
We asked Dr Frederick White, a Louisiana cardiologist and an AMA delegate, to explain what happened.
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The AMA reaffirmed its opposition to physician-assisted suicide (PAS) last week. Can you fill us in on what happened?
Dr White: The votes taken at the AMA last week were the culmination of three years of debate on the issue of PAS. This debate began in 2016 when the AMA’s Louisiana delegation aske the AMA to reaffirm its opposition to PAS. The Oregon delegation objected and convinced the AMA to have its Council on Ethical and Judicial Affairs study the issue. After a year of intense study, the Council issued a report which recommended continued opposition to PAS. The AMA House of Delegates returned that report to CEJA twice before accepting CEJA’s recommendation this meeting.
The vote to accept the CEJA report was 360-190 (65%-35%). A vote was then held on reaffirming AMA policy that implements the provisions of the report, and that policy was reaffirmed by a vote of 392-162 (71%-29%).
The Canadian Medical Association, the American Academy of Family Physicians, the American Academy of Hospice and Palliative Medicine and several other medical associations have adopted a position of neutrality on PAS. How has the AMA managed to buck this trend?
The organizations you mention are actually out of the mainstream on this issue. The American College of Physicians, the American Osteopathic Association, the American Academy of Pediatrics, the American Psychiatric Association, the American Academy of Pain Medicine, the World Medical Association, the International Association for Hospice and Palliative Care, the British Medical Society, the German Medical Society, the National Council of the Order of Physicians (France), the Japan Medical Association, and many other organizations have policies against physician-assisted suicide.
Who was lobbying in favour of PAS at the annual meeting? The doctors from states where it is already legal?
Proposals to endorse PAS were formally sponsored by delegations from New Mexico, Vermont, Oregon, Colorado, California, and the Medical Student Section. Among those sponsors, physician-assisted suicide is legal in Vermont, Oregon, Colorado, and California.
Nationally, what is the significance of the AMA holding the line? Does it strengthen the case nationally against PAS?
Although the direct physician membership in the AMA is low, the AMA functions as the “federation” of American medicine, with representatives from state medical societies and every major specialty society throughout the profession. As such, the positions of the AMA are accorded high regard by policymakers and the public. For the AMA to continue to oppose PAS after intensive study and vigorous debate is highly significant from a public policy standpoint.
What's the problem with adopting a position of neutrality on assisted suicide? Wouldn't that accommodate the views of dissidents in the AMA?
The American College of Physicians (ACP) has stated that “it is crucial that a responsible physician perspective be heard as societal decisions are made.” In specific reference to PAS, the ACP has affirmed at “the medical profession should not be neutral regarding matters of medical ethics.”
Dr Daniel Sulmasy, the Acting Director of the Kennedy Institute of Bioethics, has written that “moving from opposition to neutrality is not ethically neutral, but a substantive shift from prohibited to optional.” In other words, lack of opposition is tacit approval.
Do you think that there is a “slippery slope” with physician-assisted suicide?
I have no doubt that the “slippery slope” applies in PAS. PAS can rapidly devolve into generally accepted euthanasia.
In the Netherlands in 2016, nearly 6,600 people were administered PAS or euthanasia, being about 5% of deaths. Almost 500 people died in “End of Life Clinics” and 212 people received PAS or euthanasia in the end-of-life clinics for dementia, psychiatric disease, or “accumulation of various old-age afflictions.”
In Canada, physician-assisted suicide and euthanasia were permitted by federal legislation in 2016. After three years, in 2018, euthanasia accounted for over 4,000 Canadian deaths. Euthanasia now accounts for 99% of all physician-directed intentional patient deaths in Canada.
What's the proper terminology? “Dying with dignity”, “physician-assisted suicide”, “medical aid in dying” — or what?
As the CEJA Report noted, “CEJA believes ethical deliberation and debate is best served by using plainly descriptive language.” CEJA felt that the term “physician assisted suicide” describes the practice with the greatest precision, clearly distinguishing it from euthanasia. CEJA also felt 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 that this degree of ambiguity is unacceptable for providing ethical guidance.
As the American College of Physicians has said, “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.”
Frederick White is a practicing physician and an AMA Delegate from Louisiana. He proposed the original 2016 resolution that launched the controversy by asking the AMA to reaffirm its opposition to physician-assisted suicide.