1. American College of Physicians Reaffirms Opposition to Legalization of Physician-Assisted Suicide
ACP also calls for improved hospice and palliative care
In “Ethics and the Legalization of Physician-Assisted Suicide,” an updated paper published today in Annals of Internal Medicine, the American College of Physicians (ACP) reaffirmed its opposition to the legalization of physician-assisted suicide and affirmed a professional responsibility to improve the care of dying patients. ACP cites ethical arguments and clinical, policy, legal, and other concerns for its positions.
“The American College of Physicians acknowledges the range of views on, the depth of feelings about, and the complexity of the issue of physician-assisted suicide,” said Jack Ende, MD, MACP, president, ACP. “But the focus at the end of life should be on efforts to prevent or ease suffering and on the often unaddressed needs of patients and families. As a society, we need to work to improve hospice and palliative care, including awareness and access.”
A recent study found 90 percent of US adults do not know what palliative care is, but when told its definition, more than 90 percent said they would want it for themselves or family members if severely ill.2
Despite recent changes in the legal and political landscape and arguments by proponents, ACP finds ethical and other arguments against physician-assisted suicide to be the most compelling, including that physician-assisted suicide alters the physician’s role as healer and comforter and the medical profession’s role in society, and it affects trust in the patient-physician relationship and the profession.
ACP published a position paper in 2001 opposing legalization of physician-assisted suicide. The issue has been reviewed and considered in multiple editions of the ACP Ethics Manual, now in its 6th edition. ”Ethics and the Legalization of Physician-Assisted Suicide” was developed in light of increasing calls for legalization, public interest in the topic, and continuing problems with access to palliative and hospice care, and considers clinical practice, ethics, law, and policy issues.
The updated paper discusses the role of palliative and hospice care, explores the nature of the patient-physician relationship and the critical distinction between refusal of life-sustaining treatment and physician-assisted suicide, and provides recommendations to physicians for responding to patient requests for physician-assisted suicide, recognizing that some individual cases will be medically and ethically challenging.
As noted in the paper, medical ethics and the law strongly 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 her health goals and preferences. Death follows naturally after the refusal due to underlying disease. Vigorous management of pain and symptoms such as nausea at the end of life is ethical and, indeed appropriate, even when the risk of shortening life is foreseeable, if the intent is to relieve those symptoms.
ACP recognizes that improvements need to be made to fully realize the principles and practice of hospice and palliative care, including improving access to, financing of, and training in palliative care; improving hospital, nursing home, and at-home capabilities in delivering care; and encouraging advance care planning and openness to discussions about dying.
ACP advises physicians to thoroughly discuss patient concerns and reasons for requests for physician-assisted suicide. The paper has a list of 12 steps that physicians should follow with all patients nearing the end of life. Requests for physician-assisted suicide are unlikely to persist when compassionate supportive care is provided, ACP says in the paper.
“Through effective communication, high quality care, compassionate support, and the right resources for hospice and palliative care, physicians can help patients control many aspects of how they live out life’s last chapter,” Dr. Ende said.
ACP has been long active in end-of-life care issues, with a prior series of consensus panel papers and “Communication about Serious Illness Care Goals: A Review and Synthesis of Best Practices;” content in the ACP Ethics Manual; advocacy on advance care planning, pain management, and other issues; and patient education materials.
About the American College of Physicians
The American College of Physicians is the largest medical specialty organization in the United States with members in more than 145 countries worldwide. ACP membership includes 152,000 internal medicine physicians (internists), related subspecialists, and medical students. Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness.
2. American Psychiatric Association position on euthanasia
In the current edition of the Psychiatric Times, Dr Mark Konrad outlines the position of the American Psychiatric Association (APA) concerning euthanasia and assisted suicide. Dr Konrad explains:
Early in December 2016, the American Psychiatric Association (APA) Board of Trustees passed an historic Position Statement that originated in the 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.
Some might be concerned that the position only prohibits euthanasia and assisted suicide for people who are not terminally ill. In fact, the APA statement has caused a stir in countries where euthanasia and/or assisted suicide have become legal. Dr Konrad states:
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/E. That was when patients with psychiatric disorders became eligible for this “right” in these countries. Independent consultants have to declare their condition “untreatable,” and the patient needs to declare it to be “insufferable.”
Dr Konrad then explains how people with non-terminal psychiatric conditions are approved for euthanasia in the Netherlands.
In the Netherlands, for example, for psychiatric-only cases, at least 1 consultant is required, but 3 are suggested. At least one should be a psychiatrist but does not have to be.
However, the patient can weigh in regarding the “untreatable” criterion as well. It is not based solely on what physicians have to offer, but on what the patient wishes to accept. For example, though potentially effective treatments may be offered, such as ECT, MAOIs, residential treatment, transcranial magnetic stimulation, and vagus nerve stimulation, “competent” patients may refuse these offers. That choice could make their case “untreatable.” So patients can rule on both the “untreatable” and “insufferable” axes; physicians can only opine on the former.
In the Netherlands, lethal injections are the most commonly used method to fulfill an approved patient’s death wish. This is often administered by the patient’s treating psychiatrist at home, in the office, or in specialized Levenseinde Klinieks (End of Life Clinics). 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/E, 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.
Some remarkable stories have been profiled in the Dutch media. For example, a woman was granted euthanasia for chronic PTSD due to childhood sexual abuse. The arguments based on personal autonomy to justify such access to PAS/E are being pushed even further in the Netherlands. Ministers of Health and Justice have proposed to their Parliament that criteria not be limited to medical conditions, but be extended to average citizens who feel they have lived “completed lives.”
Dr Konrad then comments on euthanasia for psychiatric conditions in Belgium:
From 2014 to 2015, 124 patients in Belgium were euthanized at their own request for psychiatric disorders. These patients had a wide range of psychiatric disorders: 4% had schizophrenia; 6%, bipolar; 4%, autism; 23%, dementia; 31%, depression; and 32%, personality disorders (half of which were borderline disorder). In one Belgian series that covered 2007 to 2011, diagnoses also included substance abuse, autistic spectrum disorder, OCD, ADHD, dissociative disorder, and “complicated grief.”
Prominent cases profiled in the Belgian media include a pair of deaf twins euthanized on request because they were going blind, a man with gender identity disorder who was unhappy with surgical results, and another man who sought euthanasia for ego-dystonic homosexuality.
Dr Konrad then comments on the new Canadian law that permits euthanasia for psychiatric conditions.
In the spring of 2016, at the instructions of their Supreme Court, the Canadian Parliament followed the course of these European countries. Physician-assisted suicide was legalized nationally, and terminal/non-terminal and physical/mental suffering distinctions were effaced. As in Europe, Canadian patients can refuse treatments that might forestall death —and still be eligible. However, thanks to the influence of the Prime Minister, Parliament stopped short of enacting its original intention to allow this for people with only psychiatric disorders.
Not surprisingly, several cases of psychiatric patients are working their way through the Canadian courts, demanding that there be no such discrimination for psychiatric patients. One case that received particular attention was a woman with chronic conversion disorder, who successfully fought in the courts to overrule the proscription on PAS/E for psychiatric disorders in her case. Several psychiatrists supported her pursuit of this action. So that legal precedent is now in place in Canada.
Dr Konrad then explains how the new California assisted suicide regulations open the door to assisted suicide for psychiatric conditions.
Even with current laws, there are emerging regulations that directly affect psychiatric patients in those states that allow assisted suicide. The California Department of Mental Health has adopted a regulation that requires state psychiatric hospitals to provide assisted suicide services to committed patients, if terminally ill. Under this regulation, a court hearing must be held to determine whether the patient is qualified for release to obtain physician-assisted death, even over clinically based objections of the treating psychiatrist. If a patient is deemed eligible, and no outside physicians can be located, the facility must provide fatal care itself, within the hospital. Unlike refusing treatment for mental disorders, committed inpatients’ competent refusal of treatment for medical disorders (eg, diabetes) cannot be overridden, even if refusal may result in death —thus rendering their condition “terminal.”
Dr Konrad then explains how the APA position may lead effect euthanasia and assisted suicide statutes world-wide.
The APA position implies that, even where legal for the non-terminally ill, it is neither the duty of a psychiatrist to fulfill that right, nor is it ethically appropriate to do so. Some (in the Belgian press) have argued that an American association does not have a place in the discussion of medical and psychiatric practices, which make most sense when seen in the context of different cultures. However, there is an understanding in the domain of medical ethics that there are some principles that transcend cultures.
The Ethics Committee of the World Psychiatric Association (WPA) has crafted a position similar to that of the APA, which will be submitted for a membership vote at the 2017 World Congress in Berlin. If endorsed, the WPA would be acknowledging that, on this particular issue, the ethical proscription against helping psychiatric patients to commit suicide may be so antithetical to the fundamental ethos of psychiatry that it should indeed be applied worldwide.
There was a significant reaction in the Belgian and Netherlands media after the publication of the APA position. Further to that, in Canada there is significant debate as to whether euthanasia should be permitted for psychiatric reasons alone.
Finally, the APA position protects psychiatrists who do not agree with killing their depressed or mentally ill patients. Thank you to the APA for creating a path that may lead to the end of killing people with psychiatric conditions.
Disclaimer: the views and opinions expressed in this article do not necessarily reflect those of Doctors for Life International