ACP remains opposed to legalizing physician-assisted suicide

The American College of Physicians has reaffirmed its opposition to legalizing physician-assisted suicide and its commitment to improving hospice and palliative care, according to a recent position paper published in Annals of Internal Medicine.

“In 2001, the ACP published a position paper opposing legalization of physician-assisted suicide,” Lois Snyder Sulmasy, JD, and Paul S. Mueller, MD, MPH, from the Ethics, Professionalism and Human Rights Committee of the American College of Physicians (ACP), wrote. “Given recent changes in the legal landscape, public interest in the topic, and continuing barriers to palliative and hospice care, an updated position paper is presented here.”

Although hospice and palliative care can help ease suffering at end of life, it remains largely overlooked. Prior research has revealed that 90% of U.S. adults do not know the definition of palliative care. Faced with these challenges, some U.S. jurisdictions have legalized physician-assisted suicide, while gaining support from those who cite reasons like patient autonomy.

In this updated position paper, the ACP acknowledged the range of views on this topic, but believes that the ethical arguments against legalizing physician-assisted suicide are the most compelling. Suicide assisted by physicians can negatively affect the patient-physician relationship, trust in the relationship and in the medical profession, and the medical profession’s role in society, the ACP noted. The ACP also stated that legalization of physician-assisted suicide could put key physician duties at risk, such as providing care for patients based on clinical judgement, evidence and ethics.

Instead, society should focus on efforts to address suffering and the needs of patients and families at the end of life, the authors wrote. Improvements are still needed to support hospice and palliative care, including increasing access to, financing of and training in palliative care; improving delivery of care to hospitals, nursing homes and patients’ homes; and encouraging open discussions about dying and planning for end of life.

The ACP recognized that medical ethics and the law support a patient’s right to refuse treatment, and recommended that physicians carefully discuss patient concerns and reasons for requesting physician-assisted suicide. The paper also listed 12 steps that physicians should follow with patients nearing the end of life. With compassionate support and care from physicians, the ACP stated the requests for physician-assisted suicide are unlikely to persist.

“The [ACP] acknowledges the range of views on, the depth of feelings about and the complexity of the issue of physician-assisted suicide, but the focus at the end of life should be on efforts to prevent or ease suffering and on the often-unaddressed needs of patients and families,” Jack Ende, MD, MACP, ACP president, said in a press release. “As a society, we need to work to improve hospice and palliative care, including awareness and access.

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“Through effective communication, high quality care, compassionate support, and the right resources for hospice and palliative care, physicians can help patients control many aspects of how they live out life’s last chapter,” he continued.

In an accompanying editorial, William G. Kussmaul III, MD, of Drexel University College of Medicine, strongly agreed with the ACP’s stance on physician-assisted suicide, writing that physicians should “firmly decline to participate” where these practices are legal.

Contrastingly, in a second commentary, Timothy E. Quill, MD, of the University of Rochester School of Medicine, and colleagues wrote that the ACP’s “rigid opposition” to physician-assisted suicide limits the opportunity to discuss the topic, educate other clinicians and learn about best practices. Health care professionals should continue to debate the implications of legalizing or prohibiting life-ending medical practices, they wrote.

“Given the rapidly changing legal environment with regard to physician-assisted suicide and voluntary active euthanasia, we are concerned that concluding a guideline by stating ‘physicians should not do this’ is a problematic public health response,” Quill and colleagues wrote.

“We need to support an environment that both redoubles our efforts to provide palliative and hospice care to all seriously ill patients and enhances our imperative to listen and respond to those who still feel they may need an escape from the last stages of this process,” they wrote.

Quill and colleagues also stressed the importance of making sure processes and safeguards are as robust and responsive as possible. “Let's learn as much as we can so that these new laws help us serve our patients and families in the best way possible,” they wrote. – by Savannah Demko

References:

Kussmaul WG. Ann Intern Med. 2017;doi:10.7326/M17-2072.

Quill TE, et al. Ann Intern Med. 2017;doi:10.7326/M17-2160.

Sulmasy LS, et al. Ann Intern Med. 2017;doi:10.7326/M17-0938.

Disclosures: Mueller reports receiving honorarium from Boston Scientific and Medtronic, and serving on the patient safety advisory board of Boston Scientific. Quill reports receiving personal fees from speaking on end of life choices and books on end of life choices, and being a public advocate for a broader range of end of life choices. Sulmasy reports receiving an honorarium from Macmillan/Cengage Learning Publisher, being a member on the Society of General Internal Medicine Ethics Committee, and being employed by the ACP; her husband was a co-author of the 2001 ACP position paper on physician-assisted suicide. The other authors report no relevant financial disclosures.