By JULIE MINDA
Organizations that advocate for the legalization of physician-assisted suicide have been increasing their efforts in almost every state where the practice it is not yet permitted.
Sulmasy
As part of their strategy, such organizations have been gaining influence on state medical associations and urging them to change their stance on assisted suicide, from opposition to neutrality, according to Dr. Daniel Sulmasy.
In a CHA webinar late last month, Sulmasy, an internist, professor of biomedical ethics at Georgetown University and acting director of Georgetown's Kennedy Institute of Ethics, said physician organizations should be actively opposing the practice. They should not be declaring themselves "neutral" as the American Academy of Family Physicians did by resolution in October 2018 — or, worse yet, outright supporting it as the New York State Academy of Family Physicians has done.
Nationwide push
According to the website of the Death with Dignity organization, eight states and Washington, D.C., now permit medically assisted suicide: California, Colorado, Hawaii, Maine, New Jersey, Oregon, Vermont and Washington.
In most of these states, medical associations had taken a neutral stance on assisted suicide be–fore the state had legalized the practice, according to an article Sulmasy co-authored that was published in the May 2018 edition of the Journal of General Internal Medicine.
In states where physician-assisted suicide is prohibited, Sulmasy said, organizations including Compassion & Choices are working to sway physicians to take a neutral position on medically assisted suicide. Sulmasy said physicians who favor neutrality can work their way onto medical association ethics committees or into other leadership roles and then use their influence to push for the organization to withdraw its opposition to medically assisted suicide.
Sulmasy said opponents should fight these efforts, including through personal involvement in state medical societies, by joining and participating actively and even seeking leadership positions.
"We need to recognize what's at stake," he said. "The timidity of the opposition to assisted suicide has gotten in the way of maintaining resistance in medical associations."
Sulmasy said for now many state medical associations seem to be "holding the line politically," but once they stop formally opposing assisted suicide, momentum seems to build in favor of assisted suicide. He added that advocates for assisted suicide "know this well."
Sulmasy said medical associations do not want to sow discord among members. Since some physicians support physician-assisted suicide, associations may see striking a neutral stance on the issue as a reasonable compromise. Sulmasy takes umbrage at this docility. Physician neutrality on medically assisted suicide "is an abdication of our professional responsibility," he said.
Countering opposing arguments
During the webinar, Sulmasy rebutted common arguments made in defense of physician-assisted suicide.
In response to the contention that medically assisted suicide should be available to patients who want it, Sulmasy said that patient autonomy is not the only principle in play. Suicide is never a private act that harms only one person. A loved one who witnesses a patient die after the self-administration of a lethal prescription could suffer from that experience. And there can be a contagion effect if medically assisted suicide weakens mores against suicide in the broader culture.
To those who contend it is humane and compassionate to allow terminally ill patients to avoid prolonged suffering, Sulmasy would say that palliative care and hospice care specialists can effectively manage physical pain and anxiety in a terminally ill patient. He called on physicians to work to improve knowledge of and access to palliative and hospice care that address physical, mental and spiritual needs.
Sulmasy said that people who seek aid in dying may do so because they fear they will not be able to have personal agency and dignity as their medical condition deteriorates at the end of life, and they do not want to become a burden on others. The ethical and compassionate response for physicians who vow to do no harm is not to provide a lethal prescription but rather to direct patients to palliative and hospice services that focus on alleviating this mental and physical suffering, Sulmasy said.
Sulmasy said some physicians who are personally opposed to assisted suicide do not feel they should impose their beliefs on others. But all law and ethics requires judgment and restrictions on behavior, Sulmasy said, and physicians should be willing to argue for what they believe is right for society and for patients, if it will protect patients' lives.
While some may argue that prohibiting medically assisted suicide is tantamount to abandoning the sufferer, Sulmasy said the opposite is true. When physicians say that they will write a lethal prescription to end the suffering of a terminally ill patient, they are abandoning their patient, said Sulmasy. When physicians treat or palliate a patient's symptoms, they are saying, "I want to walk that last mile with you, and accompany you."
Sulmasy said those who contend there is no real difference between assisting with suicide and allowing someone to die are wrong. Intent matters, and physicians should never intend to kill their patients, he said.
To those who would argue that opposition to physician-assisted suicide is based on religious doctrine and that church and state should not mingle, Sulmasy counters that the primary arguments against legalizing assisted suicide are not religious in nature. He pointed out that many atheistic and nonreligious individuals oppose the practice too.
Bad medicine
Sulmasy said physicians should support a ban on medically assisted suicide because it is an affront to the physician-patient relationship, ripe for abuse and a slippery slope to other morally questionable practices, including assisted suicide for people who may not be mentally competent to authorize it at the time it is done and assisted suicide for people with severe disability who are not at the end of life.
Sulmasy told the webinar audience that physicians are responsible for healing, not harming, their patients. When healing is no longer possible, he said it is nevertheless ethically incumbent on a physician not to ignore, endorse or practice harmful practices like physician-assisted suicide.
The CHA-hosted "A Discussion of Why Organized Medicine Must Maintain Its Opposition to Assisted Suicide Webinar" took place Oct. 24. It is available to CHA members at chausa.org/learning.