CEJA Report Was Flawed, Including Use of ‘Physician-Assisted Suicide’

In June the AMA House of Delegates voted to send back for revisions the flawed report from the AMA’s Council on Ethical and Judicial Affairs (CEJA) on “physician-assisted suicide” (PAS). The report recommended maintaining the current AMA position that PAS is unethical. The decision to reject the report was in the best interest of patients, families, and physicians.

The report’s shortcomings are multiple, including the use of “physician-assisted suicide” as the most acceptable term for this practice. There is a strong association between “suicide” and mental illness, whether conscious or unconscious. This represents significant implicit bias, implying that the former inevitably derives from the latter, which is untrue. In addition, a growing body of evidence clearly distinguishes the characteristics of persons who commit suicide resulting from mental illness from those of terminally ill persons who request aid in dying. These differences include the type and severity of psychological symptoms, degree of despair, reasons for wishing to end one’s life, communicativeness regarding their wishes and fears, degree of personal isolation, openness about the wish and intended method to end one’s life, and the impact on the person’s family or support system following the person’s death. A preferable substitute for PAS is patient-requested physician aid in dying (PRPAD), emphasizing that patients unambiguously initiate the process.

Regarding the concern about unintended consequences, there is ample accumulated experience in jurisdictions where PRPAD is legally permitted to establish that the “slippery slope” has not emerged. The safeguards in the legislation or regulations in these jurisdictions have proven to be adequate to prevent any significant inappropriate approval of requests for PRPAD for excluded reasons/criteria. Those who argue otherwise are not looking at the data with an objective understanding of what has happened.

In addition, the existence of PRPAD in those states has prompted a much broader discussion of end-of-life issues, more frequent conversations between physicians and patients about their end-of-life goals, appropriate pain management guidelines for terminally ill patients, more awareness of palliative care options, long-term care access and policies, as well as greater attention to quality of care provided to people in the “coda da vita.” This has been the case in Oregon over more than 20 years and is happening in the other jurisdictions in which PRPAD has been allowed.

The report failed to address whether, why, or how PRPAD should be allowed in states where such an option for end-of-life care is not permitted. CEJA putatively intended to promote a balanced and objective approach that honors and addresses “the needs of those who are suffering” and focuses on respecting “the intimacy and authenticity” of relationships among patients, families, and trusted physicians. To truly do this, the AMA should not persist in labeling PRPAD as unethical or support the selective prohibition of PRPAD in certain states while it is allowed in others.

PRPAD is legal for 20 percent of the residents of this nation. In jurisdictions where it is permitted, the ultimate decision to utilize PRPAD is left up to the patient, family, and treating physician. Universal access to certain reproductive health services is decided law and is available, albeit with varying degrees of local obstruction, in all states.  The report acknowledges that there are “irreducible differences in moral perspectives” and that dilemmas over reproductive health and end-of-life services revolve around “substantive, coherent, and reasonably stable values and principles.” Therefore, the same philosophical and ethical principles should apply to PRPAD as to abortion services; otherwise, we will continue to have disparity of access, where some individuals who request PRPAD and meet the eligibility criteria will be denied this end-of-life option.

Individuals, families, and treating physicians in all states deserve the same right to end-of-life autonomy and access to PRPAD. The AMA’s intention to honor or be inclusive of these “irreducible differences in moral perspectives” on end-of-life issues requires this action. ■