ACOI Ethics Committee
ACOI Board of Directors
Adopted: June 16, 2001
In response to the nationwide dialogue regarding Physician-Assisted Suicide (PAS) and the potential impact of this issue as it relates to professional and ethical tenets underlying the practice of osteopathic medicine, the ACOI has prepared this position statement on PAS. The ACOI recognizes the need for improved care for dying patients. Much needs to be achieved in the areas of training, education, research and public policy to effect the changes necessary to provide good care at the end of life. The ACOI also views the lack of quality end-of-life care as the principle factor leading to the call for legislation of PAS.
Physician-assisted suicide occurs when a physician provides the means, usually medication, for a patient to end his or her life. In the United States, PAS is currently legal only in the State of Oregon with the passage of the Death with Dignity Act of 1997. While similar legislation has been defeated in other states, debate on this issue continues to be intense. Proponents of PAS argue that terminally-ill patients who have decision-making capacity and have intolerable symptoms should be allowed this option to end their suffering. They view PAS as a patient's right to self-determination which is justifiable on the basis of the ethical principle of autonomy. Opponents of PAS view it as a violation of professional ethics, with a likelihood of widespread abuse. They view patient self-determination, or autonomy, as having limits when the interests of the community are at risk through the likelihood of abuse.
The ACOI opposes the practice and legalization of PAS. This position is based on the following factors:
- For those nearing the end-of-life, the focus of care should be aggressive palliative care, treating symptoms, and assuring that the patient's remaining days are as comfortable and meaningful as possible. This approach should not include the intentional termination of life as called for by PAS. Care for the dying patient may include withdrawing or withholding medical interventions and providing aggressive pain management even though these actions may hasten the dying process.
- A physician, when confronted with a patient who requests PAS, should explore the reasons and circumstances for the request and focus on the sources underlying the request. Patients often fear that their suffering will be prolonged and their pain not treated. Physicians need to inform patients that effective pain management is available and that life-prolonging interventions may be withdrawn or withheld, including artificial nutrition and hydration.
- Physician-assisted suicide is a violation of professional ethics and, more specifically, the Osteopathic Oath. Required of all graduates of osteopathic medical colleges, the Oath states, "I will administer no drugs for deadly purposes even though they may be asked of me."
- PAS will lead to abuse. Dying patients may feel a duty to request it because of financial and caregiver burdens. This may be particularly pertinent now due to the pressures of cost containment and managed care. Data from the Netherlands, where there is acceptance of PAS, has demonstrated abuse in the form of euthanasia administered to patients who did not request it.
- While legal only in the State of Oregon, state laws vary, are often vague and many states are without PAS legislation. State and federal laws should prohibit PAS. Should the law permit greater access to PAS in the future, the legislation must be crafted to protect as much as possible against any form of patient coercion. Legislation that may compel unwilling physicians to comply with PAS requests must be avoided.
The focus of end-of-life care should be on providing good care for dying patients. This can be achieved by identifying effective clinical approaches to care at the end of life. Much is needed to refine, enhance and retool our health care system to provide effective care for dying patients. There is evidence that acceptance of PAS may negate the commitment and determination of society to provide the needed resources to achieve this goal.
The law in Oregon should be changed to prohibit PAS in that state and federal legislation should be enacted to make PAS illegal. Effective lobbying strategies by opponents of PAS are needed to effect legislation. New public policy is needed to assure that all dying patients have access to effective, multi-disciplinary end-of-life care.
There is great need for education of physicians on effective pain management and symptom management at the end of life and an understanding of the various options for care of dying patients, including withdrawing and withholding of medical interventions and artificial nutrition and hydration. There needs to be a greater commitment to address end of-life care in undergraduate and graduate medical education as well as continuing medical education programs. There is a similar need for enhancement of education for patients and the community at large.
Acceptance of PAS places the very nature of the Doctor-Patient relationship at risk. This relationship has been built on the physician's role of curing and comforting. The underling trust and dynamics of the relationship are changed when the potential for terminating life is introduced.
The likelihood for abuse places the elderly, the disabled and economically disadvantaged at potential risk. Traditionally, the medical community at large and osteopathic physicians in particular have provided care for those at the margins of society. Yet, data from the Netherlands has demonstrated that this vulnerable population is at risk for abuse with the acceptance of PAS.
Clearly, PAS will continue to be a subject for debate for many years to come. Physicians, other health care providers, policy makers and society at large need to discuss this issue carefully after thorough study of its ramifications for the community at large. The ACOI believes that the focus of this dialogue should center on the need to provide good care for dying patients and not on physician-assisted-suicide.