Two Case Western Reserve University School of Medicine bioethicists are calling on organized medicine to end its refusal to provide clinical guidance regarding the care of patients actively seeking assistance in dying.
Writing in the November 15, 2016 issue of the Annals of Internal Medicine (now available online), John Frye, MA, a PhD candidate in the Department of Bioethics, and Stuart Youngner, MD, professor of bioethics and professor of psychiatry, say that professional organizations such as the American College of Physicians, American Medical Association, and American Osteopath Association are doing a disservice to their physician members by formally opposing physician-assisted suicide. The organizations currently refuse to offer training and similar support to physicians caring for very sick patients who have asked for help in committing suicide.
This past June, California joined Oregon, Washington, Montana, and Vermont in legalizing physician-assisted-suicide, making the practice available to one in five Americans.
Other professional organizations such as the California Medical Association and the American Academy of Hospice and Palliative Medicine have ended their formal opposition, in its place adopting a stance of “studied neutrality,” which the authors call a “hands-off position chosen to recognize the diversity of views and foster discussion.” Instead of this approach and formal opposition, Frye and Youngner argue that professional organizations should choose engaged neutrality, “in which [the organizations] take responsibility for helping to minimize or avoid [physician-assisted suicides] potential harms, [thereby moving] beyond their current endorsement of palliative care.” Engaged neutrality, they write, allows for a diversity of views including the right of doctors to refuse to participate in physician-assisted suicide.
Frye and Youngner note that professional organizations have based their opposition to physician-assisted suicide on such concerns as possible reductions in the quality of end-of-life care; potential encouragement or coercion by family members and others of individuals to seek death, especially among the poor, uneducated, uninsured, and disabled; and a “slippery slope” to non-voluntary euthanasia.
But, the authors say, these possibilities constitute the very reason that “constructive engagement by organized medicine is essential.” Formal opposition and studied neutrality, they write, provide “little assistance to health care professionals who must decide how best to respond to their patients’ requests and to reduce harm from abuse. This puts the entire burden on individual physicians to struggle in isolation … in responding to such patient requests.”
The authors write that their concerns are not simply theoretical. They note that primary physicians facing requests to help patients commit suicide in Oregon reported “feeling frustrated by not being able or willing to communicate with others in their practices and profession, given the polarizing nature of the issue.” This is problematic because under state laws allowing physician-assisted suicide, primary physicians must identify a consulting physician to confirm the prognosis and decision-making capacity of the patient. Organized medicine is missing important opportunities, Frye and Youngner say. First is the chance to educate primary care physicians in how to choose a second-opinion consultant. Second is the opportunity to train physicians to better support these patients and their families as well as recognize factors such as treatable depression, which may be contributing to the desire to commit suicide.
Moreover, studied neutrality can have negative consequences for patients. A study concluded that most Oregon hospice policies were consistent with studied neutrality. This included prohibiting participation in any way, even forbidding staff members from being present when a patient ingests the lethal medication. Such restrictions, say Frye and Youngner, can block health professionals from providing needed care and personal support: “If one removed the lens of ideological opposition, such ‘neutral’ restriction could be viewed as a form of patient abandonment.”
The authors write that if organized medicine, at minimum, adopted engaged neutrality, the potential problems that it and others have identified could be rigorously studied, with an aim toward improving existing policies. This approach has been adopted by professional medical organizations in countries where physician-assisted suicide is legal, such as the Netherlands. There the Royal Dutch Medical Society trains the consulting physicians, supports in-depth review of each case, and publishes clinical guidelines for professionals that include narrative examples of questionable cases and how to respond to them. The Canadian Medical Association has been developing clinical guidelines and organizational support for physicians for several years.
In this country the American Society of Health-Systems Pharmacists, American Women’s Medical Association, American Medical Student Association, and the American Public Health Association support physician-assisted suicide. The American Psychological Association takes a position of engaged neutrality but encourages research and develops responses to the real challenges of legal assisted dying.
In conclusion, write the authors, “When confronted with a patient’s request for assisted dying, physicians who consider moving forward should not feel unprepared or isolated. They should be supported by their profession in supporting their patients.”
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Founded in 1843, Case Western Reserve University School of Medicine is the largest medical research institution in Ohio and is among the nation's top medical schools for research funding from the National Institutes of Health. The School of Medicine is recognized throughout the international medical community for outstanding achievements in teaching. The School's innovative and pioneering Western Reserve2 curriculum interweaves four themes--research and scholarship, clinical mastery, leadership, and civic professionalism--to prepare students for the practice of evidence-based medicine in the rapidly changing health care environment of the 21st century. Nine Nobel Laureates have been affiliated with the School of Medicine.
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