Lois Snyder Sulmasy, JD; Paul S. Mueller, MD, MPH; for the Ethics, Professionalism and Human Rights Committee of the American College of Physicians *
Acknowledgment: The authors and the ACP Ethics, Professionalism and Human Rights Committee thank the many reviewers of the paper for helpful comments on drafts and Kathy Wynkoop for administrative assistance.
Financial Support: Exclusively from the ACP operating budget.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-0938.
Requests for Single Reprints: Lois Snyder Sulmasy, JD, American College of Physicians, Center for Ethics and Professionalism, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, firstname.lastname@example.org.
Current Author Addresses: Ms. Snyder Sulmasy: American College of Physicians, Center for Ethics and Professionalism, 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Mueller: Mayo Clinic, Gonda Building 17, 200 First Street Southwest, Rochester, MN 55905.
Author Contributions: Conception and design: P.S. Mueller.
Analysis and interpretation of the data: L. Snyder Sulmasy, P.S. Mueller.
Drafting of the article: L. Snyder Sulmasy, P.S. Mueller.
Critical revision for important intellectual content: P.S. Mueller.
Final approval of the article: L. Snyder Sulmasy, P.S. Mueller.
Administrative, technical, or logistic support: L. Snyder Sulmasy.
Collection and assembly of data: L. Snyder Sulmasy, P.S. Mueller.
Calls to legalize physician-assisted suicide have increased and public interest in the subject has grown in recent years despite ethical prohibitions. Many people have concerns about how they will die and the emphasis by medicine and society on intervention and cure has sometimes come at the expense of good end-of-life care. Some have advocated strongly, on the basis of autonomy, that physician-assisted suicide should be a legal option at the end of life. As a proponent of patient-centered care, the American College of Physicians (ACP) is attentive to all voices, including those who speak of the desire to control when and how life will end. However, the ACP believes that the ethical arguments against legalizing physician-assisted suicide remain the most compelling. On the basis of substantive ethics, clinical practice, policy, and other concerns articulated in this position paper, the ACP does not support legalization of physician-assisted suicide. It is problematic given the nature of the patient–physician relationship, affects trust in the relationship and in the profession, and fundamentally alters the medical profession's role in society. Furthermore, the principles at stake in this debate also underlie medicine's responsibilities regarding other issues and the physician's duties to provide care based on clinical judgment, evidence, and ethics. Society's focus at the end of life should be on efforts to address suffering and the needs of patients and families, including improving access to effective hospice and palliative care. The ACP remains committed to improving care for patients throughout and at the end of life.
Appendix Table. U.S. Jurisdictions Where Physician-Assisted Suicide Is Legal
…aimed to integrate palliative care and spiritual care into critical care practice. Eliciting and honoring wishes fostered a community of caring, promoting patient- and family-centeredness as a core component of palliative care. It encouraged the verbalization and realization of unmet spiritual needs, whether secular or faith-based. Our findings underscore the drive that we all have to search for meaning, memories, and closure in anticipation of death while helping to create preparedness, comfort, and connections during the dying process. (65)
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E. Wesley Ely, MD, MPH
Vanderbilt University, Pulmonary Critical Care
September 19, 2017
opposition with balance
As we have legalization of PAS in some states, we must be careful as physicians to uphold the principles of medicine (which are to cure sometimes, to relieve often, and to comfort always), while at the same time balancing these unchangeable truths with regional laws. This ACP position paper by Snyder Sulmasy et al. achieves this balance. It is encouraging and wholly appropriate that the ACP continues to oppose a doctor playing an active part in ending human life, as this would not be consistent with the mission of medicine stated above. At the same time, it would not be appropriate to penalize physicians who participate in PAS if the law in their region sanctions such action.
Adjunct Professor of Medicine, University of Pennsylvania
We should take a pass on PAS
I agree completely with the position paper of the ACP on physician assisted suicide (PAS). As a profession, we need to remain dedicated to our patients and their well being. A patient's well being is never promoted by eliminating the patient. While we should always take every appropriate step to minimize suffering in our patients, we should never agree to eliminate the patient to achieve this. We must always value the lives of our patients if we are to maintain their trust. If we become involved in PAS, we will compromise that trust. I am 100% behind the ACPs decision to take a pass on PAS.
RICHARD L. BARDIN, MD
ASSOC. PROF. OF MEDICNE, LOMA LINDA UNIVERSITY SCHOOL OF MEDICINE
September 21, 2017
ON PHYSICIAN ASSISTED SUICIDE
I am in agreement with the ACP position paper on physician assisted suicide and am very pleased that ACP has taken this position.
Mount Carmel St Ann's
I wholeheartedly agree and support the ACP statement which opposes physician-assisted suicide. I agree that the manner and timing of death is under God's control and is not my responsibility as a physician. Instead I strive to provide care and compassion to relieve suffering and provide dignity as a person dies and transitions through their last stage of life on this earth. Thank you again for this position which I believe is in medical community's best interest, as well as society as a whole.I stand with ACP's position.Thank you.Suzanne Snyder MD
Laura Johnson MD
Assistant Professor of Medicine, University of South Carolina School of Medicine - Greenville
Differentiating between legal and right
I very much appreciate this ACP position against physician-assisted suicide. It highlights that what is morally/ethically right is not defined by current laws (with at other times in our history have also legalized slavery or limited civil rights based on the color of one's skin). Legalization of physician-assisted suicide in some jurisdictions does not change our personal and professional duties to our patients and society. We treat with dignity and compassion and support our patients as much as possible; we commit to do no harm.
Paul Geary M.D., FACP
General internist: International Medicine & USA Hospitalist
Stay the course – say no to PAS: adhere to timeless values
Thank you to ACP and to the ACP team who have clearly and carefully readdressed here this challenging ethical question. The voices of current cultural norms are very strong at this time, pushing physicians to support PAS, elevating the right of radical individual autonomy above many other cruciall time proven principles. We must remain aware of past experiences and look long into the future to understand that this current push is just a cultural season. The pendulum will eventually swing back, and the position of the ACP against PAS will be clearly vindicated.
St. Vincent Hospital
September 20, 2017
As a member of the ACP, I would like to say that I support the stance that the ACP has taken as outlined in this position paper. At a time when other large medical organizations espouse questionable ethics in regards to PAS, I am proud to know where the ACP stands and to see that stance supported in such a thorough and compelling manner.
Banu E. Symington MD MACP
September 22, 2017
Assisted dying CAN be the compassionate choice
As a long-term member of the College and a practicing oncologist, I write to express my disappointment in the ACP position paper on the important topic of assisted dying. This disappointment starts with nomenclature-- the choice of the highly emotionally charged term physician assisted suicide, which plays on readers’ emotions, instead of physician assisted death (PAD). Patients are requesting assistance in ending a chronic medical condition and it would be better termed assisted dying or physician assisted death. This disappointment continues to the oversimplification involved in assuming that the desire for PAD is due to inadequate symptom control or inappropriate depression. This assumption is an injustice to patients and physicians both. First to the patients who are suffering from a variety of medical conditions who have carefully weighed and considered their options before requesting PAD. Second to the physicians who have valiantly but unsuccessfully tried to help alleviate their patient’s symptoms and suffering. There are undoubtedly patients with inadequate pain or nausea control who may prematurely turn to PAD. A mandatory preterminal consult would identify these patients and get them (appropriately) to a palliative care consult. However, modern medicine has not found a cure for ALS or a remedy for the progressive loss of neuromuscular control and dignity associated with it. There is no drug, no amount of psychotherapy, and no amount of time or compassion that can change the symptoms or suffering caused by this or many other degenerative neurologic conditions. To simply state that physicians should be present at these times is insensitive. The final disappointment is the fear mongering implicit in the statement that requests for PAD will be exploited or patients might be forced to choose this option. Data from Oregon, where PAD has been available for years, has not shown any evidence of such exploitation. Again, panels can be used to make sure that patients are not coerced by family or insurers to prematurely select death. And just as with abortion, physicians with religious or personal objections can opt out of participation. Let’s move into the current century and allow terminally ill patients to control the timing of their deaths if they so desire.
Rachel Lee, MD FACP FAAAAI
Head, Allergy Clinic and Asst Professor, NMCSD/USUHS
Fully support and agree with this position paper!
I fully support and agree with the position paper. This is well written and balances out the ethical and moral risks of physician assisted suicide.
September 25, 2017
A neutral position is best
There clearly is a difference of opinion within the medical profession on death with dignity legislation. The Oregon law has worked well with no slippery slope, no evidence of coercion and no deterioration of the patient-physician relationship. Surprisingly, the law has actually improved the patient-physician relationship by encouraging better communication about end of life issues. This issue is similar to the abortion issue--the right answer is to be pro-choice, to leave the decision between the patient and the physician.
Christie Reimer, MD FACP
Are we listening to our patients?
In the state of Colorado my patients, the voters, legalized physician-assisted death. I am disappointed to see the ACP take such a firm stance on an issue that impacts the heart of what the College has traditionally prioritized – the value of the physician-patient relationship. While the published recommendations for end of life care are helpful and appropriate, they do not address the real-life situation when the patient, family, care team, and physician thoughtfully come to an educated decision that physician-assisted death may be best. As we internists promote the importance of continuity of care and relationships with patients, it is easy to imagine that it would be quite harmful to then disrespect autonomy at the end of life. This does not seem to be concordant with the College’s well-known and respected patient-centric advocacy. My hope is that this position can be re-evaluated in the context of real-life patient care in 2017, and that a less judgmental and more supportive conclusion may be reached. Decisions regarding care for an individual patient are never black and white.
Alan B. Astrow, M.D.
Chief, Hematology/Medical Oncology, New York-Presbyterian Brooklyn Methodist Hospital, Professor of Clinical Medicine, Weill Cornell Medical College
September 24, 2017
I support the ACP's position paper.
This is a tough issue, but the ACP has carefully considered the arguments for and against p.a.s./p.a.d. and I support the ACP's opposition to legalization of the practice. Legalization of p.a.s./p.a.d. changes the physician-patient relationship in an undesirable way. I am very sympathetic to the argument that seriously ill patients may feel as if others see them as a burden. Legalization of p.a.s./p.a.d. might open vulnerable patients to the risk of subtle pressure from medical professionals and others to "get out of the way" and so increase the sense of loneliness and isolation that they may already experience. Physicians have an obligation to be present to those who are gravely ill, rather than create some new category of personhood that is stripped of the legal protections that we offer all others.
Russell L. Bedsole MD FACP
IMA, Wiregrass Clinics, Dothan, AL
I stand in complete agreement with the position paper as outlined. The ethical tenets of our profession hold forth a foundation beyond which we should not venture. In an era of political correctness and moral relativism, some form of Kantian principles must remain at the forefront of our collective and individual relationships with our patients. Participating in any for of suicide or euthanasia would radically transform what it means to be a physician, and such transformation would forever alter the solemn partnership which exists between doctor and patient.
Timothy L Gieseke MD
Associate Clinical Professor, UCSF
September 23, 2017
Caution re Aid in Dying
I live in California where we now have a law similar to Oregon's that gives our patients this option. In California, patients, families, and the medical community have a wide range of opinions on this emotionally charged subject. I appreciate the ACPs review of the ethical issues for providers to consider as they weigh a decision whether to support or refer requests for this option. I have been a hospice medical director and am committed to high quality palliative care for medically complex fragile persons living in the post-acute and long term care settings. Death is a common event in these settings. Even though it's challenging to adequately manage the various forms of pain and suffering associated with dying, I believe the struggle to assist patients and families through the dying process has value to them and our society that should rarely if ever be short circuited by selecting this legal option. As a provider, I am glad ACP addressed the abandonment argument that may pressure some providers to participate and violate their own ethical standards.
Professor of Oncology; Mayo Clinic, Rochester, MN
September 26, 2017
C. Everett Koop and PAS
As a practicing oncologist, I am in agreement with the stance that ACP has taken on this issue. I stand with the words of C. Everett Koop who once said."... we must be wary of those who are too willing to end the lives of the elderly and the ill. If we ever decide that a poor quality of life justifies ending that life, we have taken a step down a slippery slope that places all of us in danger."
Thoughtful consideration of a challenging issue
I am grateful the authors and ACP for this thoughtful discussion of all ethical aspects of physician aid in dying. The discussion does not minimize the intense suffering which some patients may have, despite high quality palliative and hospice care. The conclusion acknowledges that it is not the responsibility of the physician in our society to aid in ending the life of the patient whose suffering cannot be ended. Especially when that suffering is often not of a medical nature, but rather spiritual or existential.
Shawn O'Driscoll MD PhD FRCS(C)
Professor of Orthopedic Surgery, Mayo Clinic College of Medicine
September 27, 2017
I fully agree that physician-assisted suicide should not be legalized. Doing so puts us on a slippery slope. Conflicts of interest will arise. Patients and their families will doubt that we hold the best interest of the patient as the highest priority and ultimately lose their trust in the physician-patient relationship. I watched my father suffer extreme pain, total debilitation and ultimately death as a result of a series of complications from surgery. He expressed such a desire to have the suffering end that he welcomed death. At no time did he wish to actually end his own life nor have anyone help him do so. He experienced great peace amidst his suffering, and blessed so many in the process. I will never forget those blessings, nor of course will I forget his suffering. I have seen it from the side of the profession and the patient's family.
Dr. Ruth Bates
Mayo Clinic, Rochester
September 30, 2017
Just want to thank you for the thoughtfulness evidenced in this position statement. As physicians, we bring healing and hope to all situations.
Matthew A Bartlett
October 2, 2017
I am in complete agreement with the ACP position paper on physician assisted suicide and am very pleased that ACP has taken this position.
Allen H. Roberts II, M.D., M.Div., FCCP, FACP
Georgetown University Medical Center
October 11, 2017
I applaud the ACP’s reaffirmation of opposition to physician-assisted suicide (PAS). In an era where ethical discourse and dialogue has been reduced to assertions of “autonomy” that are inattentive to the weight of both community and moral order, the ACP’s reaffirmation should serve as a watershed moment, a trip-wire and stumbling block to the unbridled advance of a practice that has been regarded as anathema by civilized society and by majority scholarly opinion of all major religions for two millennia. Assisted suicide today will inevitably lead to active euthanasia tomorrow. The embrace of PAS by society and the medical profession signals that both entities have lost their way. Perhaps the moral courage displayed by the ACP will serve to re-direct the trajectory of both. I pray so.
Joanne Lynn, MD, MACP
Center for Elder Care and Advanced Illness, Altarum Institute
October 27, 2017
Have We Forgotten Long-Term Care?
How is it that all these articles and even the comments do not actually confront the issues that arise with long-term disability as the course to death -- a course that is now more common than a "terminal illness" with a relatively predictable demise. This is now the most common cause of bankruptcy. Caring for an elderly person costs a woman an average of a quarter million dollars toward her own retirement. If we accede to autonomy in a world in which many elderly people cannot get food, housing, and personal care - who are we fooling? Yes, I know that this has not yet been a major issue in Oregon, but it will be, eventually, wherever a cheap exit is readily available and persisting in living means losing the family business or crippling the opportunities for the grandchildren, or simply going without food. Our policymakers run from any serious discussion of long-term supports, and now my professional society does the same. We need to be strongly advocating, not just for palliative care, but for Meals on Wheels, and adapted and affordable housing, and support for family caregivers. Have we forgotten the struggles our elders face when needing long term supports and services?
Omega C. Logan Silva, MD, MACP
Professor Emeritus, George Washington University
November 16, 2017
The American College of Physicians (ACP) position paper opposing medical aid in dying concludes: “Societies focus at the end of life should be on efforts to address suffering and the needs of patients and families, including improving access to effective hospice and palliative care.”
Ironically, studies show that laws authorizing medical aid in dying do exactly that: improve access to hospice and palliative care, by spurring conversations between doctors and terminally ill patients about all end-of-life care options, regardless of whether they utilize medical aid in dying. In fact, medical aid-in-dying laws require patients who want this palliative care option to be advised of all other palliative care options, including hospice. Oregon’s medical aid-in-dying law has helped spur the state to lead the nation in hospice enrollment, according to the report published in the New England Journal of Medicine.(1)
In addition, a medical research and suicide prevention organization, the American Association of Suicidology, (2) whose membership includes mental health and public health professionals, recently concluded medical aid in dying: “…is distinct from the behavior that has been traditionally and ordinarily described as ‘suicide.’ … we believe that the term ‘physician-assisted suicide’ constitutes a critical reason why these distinct death categories are so often conflated, and should be deleted from use.” (3)
Citing the Hippocratic Oath to defend the ACP’s opposition to medical aid in dying is absurd because no U.S. Medical School currently employs this 2,500-year-old oath that would prohibit modern day surgery: "I will not use the knife…”
A Journal of Medical Ethics report about the Oregon Death with Dignity Act concluded:
“Rates of assisted dying in Oregon...showed no evidence of heightened risk for the elderly, women, the uninsured...people with low educational status, the poor, the physically disabled or chronically ill, minors, people with psychiatric illnesses including depression, or racial or ethnic minorities, compared with background populations.” (4)
The ACP position paper says it “does not believe neutrality on this controversial issue is appropriate.”
Finally, the Annals of Internal Medicine recently published an article arguing otherwise, “A Call for a Patient-Centered Response to Legalize Assisted Dying.” (5) The two ethicist authors concluded:
“A state medical association’s response to legalization might have to account for both a divided membership and the opposition of its parent association, but the imperative to provide for the real needs of patients and the community justifies taking a position beyond rigid opposition or hands-off neutrality.
1 Susan W. Tolle, M.D., and Joan M. Teno, M.D. Lessons from Oregon in Embracing Complexity in End-of-Life Care. N Engl J Med 2017; 376:1078-1078.
2 Colleen Creighton Statement of the American Association of Suicidology: Suicide is not the same as "Physician Aid in Dying". Approved October 30, 2017 http://www.suicidology.org.
3 Margaret Battin, PhD. Suicide is not the same as "Physician Aid in Dying November 2, 2017 https://www.einpresswire.com/article/413196468/suicide-is-not-the-same-as-physician-aid-in-dying
4 Margaret P Battin1, Agnes van der Heide2, Linda Ganzini3, Gerrit van der Wal4, Bregje D Onwuteaka-Philipsen4.
Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impact on patients in “vulnerable” groups. Journal of Medical Ethics, Volume 33, Issue 10. http://jme.bmj.com/content/33/10/591
5 John Frye, MA; Stuart J. Youngner, MD. A Call for a Patient-Centered Response to Legalized Assisted Dying. Annals of Internal Medicine. 15 November 2016. http://annals.org/aim/article-abstract/2556137
Lois Snyder Sulmasy, JD, Paul S. Mueller, MD, MPH
American College of Physicians, Mayo Clinic
January 12, 2018
We appreciate the comments posted online and the letters selected by the editors for response on the College’s position paper on physician-assisted suicide (1). It is clear we all desire the best care for dying patients.
Dr. Reimer asks, “Are we listening to our patients?” The College shares this concern and would respond, “Yes.” We agree physician-assisted suicide is a complex issue. ACP has considered the complexity through extensive debate and in the context of the patient-centered, ethically reasoned and evidence-based approach that is the foundation of College position statements. Although respect for patient autonomy is a fundamental ethical principle, it is not the only one—it must be considered and balanced with doing no harm and acting in the patient’s best interests. Physicians do this balancing when advising, educating, sharing medical expertise and working in partnership with patients, otherwise there is no way for physicians to explain and decline to provide futile care (such as nonindicated cardiopulmonary resuscitation or end-of-life treatment for a brain-dead patient requested by a family) or requested tests/prescriptions that are not medically indicated. We need, and patients depend on physicians, to be consistent in rationale and approach, building the trust essential to the patient-physician relationship and to medicine as a profession. In addition, patient voices are diverse and the vast majority of dying patients do not participate in physician-assisted suicide. Patients and their loved ones want good palliative and hospice care and the support that accompanies that care. The College wants them to receive it consistently.
Carrying out Dr. Symington’s recommendations, unfortunately, would not move us into the current century as she suggests. Rather, this would return us to pre-Hippocratic times. It also does not recognize the remarkable progress that has been made in end-of-life care. So much can be done today to address patient suffering that is within the scope of medicine and other disciplines. Regarding language, the paper outlines the need for clarity in the debate, using the term physician-assisted suicide. It notes the dictionary definition of suicide as the act of intentionally ending one’s own life. This is not judgmental. Terms such as “physician-assisted death” are vague and lead to a blurring of lines as illustrated by Dr. Symington's letter-- patients with ALS who meet the requirements for terminal illness would almost always be physically unable to self-administer the drugs and, therefore, would be ineligible for physician-assisted suicide under US laws. They would instead "need" euthanasia. Euthanasia is, for now, illegal everywhere in the US.
We appreciate Dr. Ely’s comments on the need to state and uphold the goals and principles of medicine and agree with Drs. Roberts and Gieseke on the need to remember our roots and remain with and not abandon dying patients. To be compassionate is to “suffer with” another person. ACP’s position paper calls for a redoubling of our efforts to accompany the patient in the last phase of life and meet the challenges of providing high quality, whole person, supportive, compassionate care.
Lois Snyder Sulmasy, JD
American College of Physicians
Paul S. Mueller, MD, MPH
1. Snyder Sulmasy L, Mueller PS, Ethics, Professionalism and Human Rights Committee of the American College of Physicians. Ethics and the legalization of physician-assisted suicide: an American College of Physicians position paper. Ann Intern Med. 2017;167:576-8. [PMID: 28975242] doi: 10.7326/M17-0938
Snyder Sulmasy L, Mueller PS, for the Ethics, Professionalism and Human Rights Committee of the American College of Physicians. Ethics and the Legalization of Physician-Assisted Suicide: An American College of Physicians Position Paper. Ann Intern Med. ;167:576–578. doi: 10.7326/M17-0938
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Published: Ann Intern Med. 2017;167(8):576-578.
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