Chapter 11:Deliberate Termination of Life and Physician Assisted Suicide: Aid in Dying

Section 4. Readings

Author: Lonnie R. Bristow

Title: Physician-Assisted Suicide

Publication Information: Statement by Lonnie R. Bristow, President of the American Medical Association, before the U.S. House of Representatives Committee on the Judiciary, Subcommittee on the Constitution, Congressional Record,

April 29, 1996

Summary by Nancy Weitzman (QCC, 2004)

The American Medical Association rejects physician-assisted suicide as unethical and incompatible with a physician’s commitment “to healing and to life”. Recent proposals to legalize physician-assisted suicides are viewed by the AMA as a sign that the needs of the patient are not being met by our health-care system and that our society has not adequately addressed end-of-life issues. The AMA believes that physician-assisted suicide is unethical and fundamentally inconsistent with the pledge physicians make to devote themselves to healing and life. Laws that sanction physician-assisted suicide undermine the foundation of the patient-physician relationship that is grounded in the patient’s trust that the physician is working wholeheartedly for the patient’s health and welfare. Yet, physicians have an ethical responsibility to relieve pain and to respect their patient’s wishes regarding care, and it is when these duties converge at the bedside of a seriously or terminally ill person that physicians are torn. The AMA believes that these additional ethical duties require physicians to respond aggressively to the needs of the patients at the end of life with adequate pain control, emotional support, comfort care, respect for patient autonomy, and good communications. Patient education is the other essential component of an effective outreach to minimize the circumstances which might lead to a patient’s request for physician-assisted suicide. These patient concerns are: inadequate social support, the perceived burden to family and friends, clinical depression, hopelessness, loss of self-esteem, and the fear of living with chronic, unrelieved pain.

The physician’s primary obligation is to advocate for the individual patient. At the end of life, this means the physician must strive to understand the various existential psychological and physiological factors that p[ay out over the course of terminal illness and must help the patient cope with each one of them. Patients who are understandably apprehensive or afraid of their own mortality need support and comforting, not a prescription to help them avoid the issues of death. Patients who believe sudden and “controlled” death would protect them from the perceived indignities of prolonged deterioration and terminal illness must receive social support as well as the support of the profession to work through these issues.

Proponents of assisted suicide cite a fear of prolonged suffering and unmanageable pain as support for their position. For many patients, advancements in palliative care can adequately control pain through oral medications, nerve blocks or radiotherapy. However, there are patients whose intractable pain cannot be relieved by treating the area, organ or system perceived as the source of the pain. For patients whose pain cannot be controlled by other means, it is ethically permissible for physicians to administer sufficient levels of controlled substances to ease pain, even if the patient’s risk of addition or death is increased. This practice of pain management poses risks for physicians, however, because there is the potential of legal action against him in administering controlled substances (opiates) in large amounts to patients with intractable pain. In some cases, administration of adequate pain medication will have the secondary effect of suppressing the respiration of the patient and actually hasten his death. This is referred to as the “double effect”. The AMA supports legislation for state medical societies to clear the path for the use of opiates for patients with intractable pain in the end stages of their terminal disease.

The distinction between this action (double effect) and assisted suicide is crucial. The physician has an obligation to provide care and comfort for the patient. Should there be no other alternatives but to increase the risk of death in order to provide that comfort, the physician is ethically permitted to exercise that option. In this circumstance, the physician’s clinical decision is guided by the intent to provide pain relief, rather than an intent to cause death. This distinguishes the ethical use of palliative care medications from the unethical application of medical skills to cause death.

The argument of withholding or withdrawing treatment and assisted suicide largely ignores the distinction between act and omission. Some say the results are the same and therefore the acts carry equal moral status. However, in the circumstances of terminal care, this issue does not address many of the principles that underlie the right of patients to refuse the continuation of medial care and the duty of physicians to exercise their best clinical judgment.

There is a failure to recognize the crucial difference between a patient’s right to refuse unwanted medical treatment and the proposed right to receive medical intervention which would cause death. Withholding or withdrawing treatment allows death to proceed naturally with the underlying disease the cause of death. Assisted suicide, however, requires action to cause death, independent from the disease process.

It is difficult to imagine adequate safeguards which could effectively guarantee that patients’ decisions to request assisted suicide were unambivalent, informed and free of coercion. A policy allowing assisted suicide could also result in the victimization of poor and disenfranchised populations who may have greater financial burdens and social burdens which could be relieved by hastening death. Recent studies documenting reasons for patient requests for physician-assisted suicide were rarely suffering intractable pain. Rather, they cited fears of losing control, being a burden, being dependent on others for personal care, and loss of dignity often associated with end-stage disease.

The movement for legally sanctioning physician-assisted suicide is a sign of society’s failure to address the complex issues raised at the end of life. It is not a victory for personal rights. We are equipped with the tools to effectively manage end-of-life pain and to offer terminally ill patients dignity and to add value to their remaining time. The AMA offers its capability to coordinate multidisciplinary discourse on end-of-life issues, for it is essential to coordinate medical educators, patients, advocacy organizations, allied health professionals and the counseling and pastoral professions to reach a comprehensive solution to these challenging issues. Our response should be a better informed medical profession and public, working together to preserve fundamental human values at the end of life.

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