NATIONAL HARBOR, Md. -- Physicians tussled here over whether the American Medical Association should continue its opposition to physician-assisted suicide (PAS) -- also known as "aid-in-dying."
At the AMA's House of Delegates' Interim Meeting on Sunday, dozens of physicians made impassioned speeches, clashing over whether to ultimately endorse an AMA policy report that, while it reflected more nuanced views, ultimately left the association's intact, declaring PAS "fundamentally incompatible with the physician's role as healer."
James "Jim" Sabin, MD, chair of the AMA's Council on Ethical & Judicial Affairs (CEJA) presented the council's study on " and "The Need to Distinguish 'Physician Assisted Suicide' and 'Aid-in-Dying'" during a committee meeting Sunday morning.
"[P]hysicians who oppose [physician-assisted suicide] and physicians who support the laws that make it legal, both base their moral reasoning on the of our code [of medical ethics] and in particular the values of care, compassion, respect, and dignity," Sabin said, explaining that the report, including its recommendations and conclusions, had been revised following comments to the committee at the last AMA meeting, which saw a mismatch among supporters of PAS between the report's substance and its conclusions. PAS supporters also stressed their concern that because of the AMA's opposition to PAS they might "automatically be subject to ethics discipline or even expulsion," even in states where the practice has been legalized, he said.
In response to the feedback CEJA received, the council revised its report and integrated "crucial material" into its recommendations, Sabin said.
"We believe that the code as it exists is excellent moral guidance to our profession," said Sabin, of ,which states the AMA's opposition to PAS/aid-in-dying and a second the "Physician's Exercise of Conscience," which addresses the concerns of those practicing in states where PAS is legal.
He applauded AMA members for maintaining respectful dialogue on the matter, and warned that the topic is one "that if not handled well, could split the association."
Katalin Roth, MD, a geriatrician who practices in Washington D.C., urged the committee not to adopt the report and pressed for "referral," which would require the committee to once again rethink and revise its stance.
Speaking on her own behalf, Roth noted that she is one of the first physicians in D.C. to write a prescription for a terminally ill patient. (D.C's became law in February 2017 and became applicable that summer.)
Roth shared the story of a patient named Mary, who had ovarian cancer for 4 years, and felt abandoned by the medical system" when her own doctor would not support her decision to end her life.
Roth cared for her symptoms and provided her with "excellent palliative care" for 4 months until her disease became unbearable.
"The day Mary ingested the medication, she was no longer able to walk, her hands and feet were blue, and no medication could ease her pain," Roth said.
"It was my profound honor to help Mary have the end-of-life care she wanted," Roth continued, but the AMA's position causes her "significant moral distress."
"I urge the AMA to respect irreducible differences without condemning or assailing one set of beliefs or marginalizing many, many ethical and caring physicians," Roth concluded.
John Cullen, MD, a family physician from Valdez, Alaska, and president of the American Academy of Family Physicians (AAFP), speaking on its behalf, urged the committee not to adopt the current report.
Cullen admitted to feeling "conflicted" about the issue. He acknowledged that in years past, he himself had argued that as long as patients' pain is controlled, they won't feel the need to end their lives. Yet, the reality is that PAS/aid-in-dying is legal in seven states and Washington D.C., he said, adding that he suspects more states will "join those ranks."
And the AAFP has physician colleagues in those states whose patients now have a legal right to request their help their help in ending their lives, "if they are adult, and terminal and competent to make decisions."
In October, the AAFP took a stance "neither for or against" medical aid-in-dying, known as "engaged neutrality."
While the AAFP will not, as an organization, lobby to support making assisted suicide/medical aid-in-dying legal, the Academy will support laws that protect physicians from criminal prosecution for assisting terminally ill patients in ending their lives in states where such practices are legal.
On the AAFP's behalf, Cullen asked that the report be referred so that the AMA can clarify how physicians can respect their patients' legal rights and wishes -- "not abandoning them when the care is impossible."
In referring to the report, Cullen asked CEJA to consider the question: "If medical aid in dying is incompatible with physicians' role as healer, how do we remain engaged and ensure that the necessary safeguards are in place?"
Kevin Donovan, MD, director of the Pellegrino Center for Clinical Bioethics, and a professor at Georgetown University, speaking on behalf of himself and his center, said he supported the Council's report and argued against changing the code of medical ethics.
Donovan urged the AMA not to declare itself "indifferent to suicide."
"If you don't equate neutrality with indifference, you may be right ... [but] silence gives assent. So, to not speak against this is indirectly an endorsement," Donovan argued.
The AMA would never take a neutral stance on other "equivalent concerns," such as female genital mutilation or prisoner torture, so considering a neutral stance in this situation seems irrational, he said.
"Any retreat from our Hippocratic tradition on which the AMA position rests is unwise and unnecessary," he said.
Vernon Zurick, MD, a radiologist from Boulder, Colorado, speaking on his own behalf, said he supported the CEJA report and was wary of the "very slippery slope" that he believes would follow any endorsement of even a neutral policy around PAS.
In Colorado, where PAS/aid-in-dying was adopted in 2016, advocates began pressuring hospitals, "many of whom had ethical issues," to carry out the practice, Zurick said.
"Neutrality is permissability," Zurick continued. He also expressed concern that health systems worried about reining in costs could influence the practice of PAS and could hurt the patient-physician relationship. He cited "abuses" by the late Jack Kevorkian, MD, who spent 8 years in prison after being convicted of second-degree murder for assisting in the deaths of roughly 130 people suffering from chronic and usually terminal illnesses who sought his help in ending their lives, according to the .
"The AMA has wisely stated that we should not help in the execution of prisoners. I think there needs to be a very careful look at whether or not people are being coerced into an early death for reasons [that are not justified] ... I think we have other ways to deal with this issue," Zurick said and urged adoption of the report.
Disclosures
None of the sources quoted reported any conflicts of interest.