Intervention Ethical Consensus Regarding Permissibility
We clearly support the steps outlined in the ACP position statement with regard to “responding to pa- tient requests for assisted suicide” (1). However, if re- quests persist and the unacceptable suffering contin- ues, we believe all legally available last-resort options
This article was published at Annals.org on 19 September 2017.
Table 1. Last-Resort Options
Intervention Ethical Consensus Regarding Permissibility
Legal Status
Aggressive symptom management Widely accepted in North America and western Europe
Legally permitted
Stopping or not starting life-sustaining therapy Widely accepted in North America and western Europe
Legally permitted
Palliative sedation (potentially to unconsciousness) Consensus if death unintended; controversial otherwise
Probably permissible but never tested
Voluntarily stopping eating and drinking Some controversy, often depending on religious views
Probably permissible but never tested
Physician-assisted suicide Opinion about permissibility differs widely Legally permitted in 6 states and the District of Columbia; legality uncertain in most other states; legal in Canada
Voluntary active euthanasia Opinion about permissibility differs widely Illegal and likely to be prosecuted in the United States; legal in Canada
Annals of Internal Medicine EDITORIAL
© 2017 American College of Physicians 597
should be explored (Table 1). Clinicians should deter- mine in advance which options they can and cannot personally support (4). They should extend themselves, if possible, to respond to their patients’ needs and re- quests without violating their fundamental personal val- ues, regardless of the status of the law. If a patient de- sires a legally permitted option that the physician cannot support and common ground cannot be found, the patient should be given the opportunity to change physicians in a timely way so that access is allowed.
Given the rapidly changing legal environment with regard to physician-assisted suicide and voluntary ac- tive euthanasia, we are concerned that concluding a guideline by stating “physicians should not do this” is a problematic public health response. Even if one per- sonally disagrees with the behavior, studying it might tell us much about the state of end-of-life care and how it can be improved. The Remmelink studies from the Netherlands (5) and Oregon Health Department data (7) provide examples of collecting meaningful informa- tion in an attempt to understand and improve practice. The scale and diversity of a state like California and a country like Canada warrant similar studies. Table 2 gives examples of areas that should be examined as these large-scale implementation efforts are under way.
In addition, we worry that the ACP’s rigid opposi- tion will prevent physicians who will practice physician- assisted suicide from sharing ideas about better poli- cies and procedures. Given the diversity of opinions and the legality of the procedure for so many people, this response seems like a missed opportunity to edu- cate clinicians and learn about best practices.
We should continue to debate the ethical and moral implications of permitting or prohibiting poten-
tially life-ending medical practices. We need to support an environment that both redoubles our efforts to pro- vide palliative and hospice care to all seriously ill pa- tients and enhances our imperative to listen and re- spond to those who still feel they may need an escape from the last stages of this process. We currently have an opportunity to learn about this process on a larger scale with a more diverse population than ever before. Let’s make sure our processes and safeguards are as robust and responsive as possible, and 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.
Timothy E. Quill, MD University of Rochester Medical Center Rochester, New York
Robert M. Arnold, MD University of Pittsburgh Pittsburgh, Pennsylvania
Stuart J. Youngner, MD Case Western Reserve University Cleveland, Ohio
Disclosures: Disclosures can be viewed at www.acponline.org /authors/icmje/ConflictOfInterestForms.do?msNum=M17-2160.
Requests for Single Reprints: Timothy E. Quill, MD, University of Rochester Medical Center, 601 Elmwood Avenue, Box 687, Rochester, NY 14642; e-mail, [email protected] .edu.
Current author addresses are available at Annals.org.
Ann Intern Med. 2017;167:597-598. doi:10.7326/M17-2160
References 1. Snyder Sulmasy L, Mueller PS; Ethics, Professionalism and Human Rights Committee of the American College of Physicians. Ethics and the legalization of physician-assisted suicide: an American College of Physicians position paper. Ann Intern Med. 2017;167:576-8. doi:10 .7326/M17-0938 2. Quill TE. Doctor, I want to die. Will you help me? JAMA. 1993;270: 870-3. [PMID: 8340988] 3. Pearlman RA, Hsu C, Starks H, Back AL, Gordon JR, Bharucha AJ, et al. Motivations for physician-assisted suicide. J Gen Intern Med. 2005;20:234-9. [PMID: 15836526] 4. Quill TE, Lo B, Brock DW. Palliative options of last resort: a com- parison of voluntarily stopping eating and drinking, terminal seda- tion, physician-assisted suicide, and voluntary active euthanasia. JAMA. 1997;278:2099-104. [PMID: 9403426] 5. Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Atti- tudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA. 2016;316:79-90. [PMID: 27380345] doi:10.1001/jama.2016.8499 6. Meier DE, Emmons CA, Wallenstein S, Quill T, Morrison RS, Cassel CK. A national survey of physician-assisted suicide and euthanasia in the United States. N Engl J Med. 1998;338:1193-201. [PMID: 9554861] 7. Oregon Health Authority. Death with Dignity Act Annual Reports. 2017. Accessed at www.oregon.gov/oha/PH/PROVIDERPARTNER RESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT /Pages/ar-index.aspx on 18 August 2017.
Table 2. Representative Study Questions to Understand the Effect of Legalization of Physician-Assisted Suicide
Cases Numbers Diagnoses Second opinions Presence of palliative care and/or hospice
Requests Main reason Acceptance rates Refusal rates Hypothetical future vs. now
Second opinions Who provides Palliative care certification Acceptance vs. refusal rates
Practical aspects Change in primary treating physician Number of visits from initial request Documentation Actual methods
Long-term effect Family members Participating clinicians Participating consultants Hospice workers
EDITORIAL Physician-Assisted Suicide: A Path Forward in a Changing Legal Environment
598 Annals of Internal Medicine • Vol. 167 No. 8 • 17 October 2017 Annals.org
Current Author Addresses: Dr. Quill: University of Rochester Medical Center, 601 Elmwood Avenue, Box 687, Rochester, NY 14642. Dr. Arnold: 1232 North Highland Avenue, Pittsburgh, PA 15206. Dr. Youngner: Department of Bioethics, Case Western Re- serve University, 10900 Euclid Avenue, Cleveland, OH 44106.
Annals.org Annals of Internal Medicine • Vol. 167 No. 8 • 17 October 2017