By Dave Andrusko
On May 22, the Psychiatric Times published a very thoughtful article written by Dr. Ronald Pies, Editor in Chief emeritus of the publication. The headline says it all: Will the AMA Heed its own Ethics Council Regarding Assisted Suicide?
Who is his audience? A quick Google search tells us that the Psychiatric Times “is a medical trade publication written for an audience involved in the profession of psychiatry” and “is distributed to about 50,000 psychiatrists monthly.”
Some background. Pro-lifers were understandably ecstatic earlier this month when the AMA’s Council on Ethical and Judicial Affairs (CEJA) recommended that the AMA retain its position in opposition to assisted suicide. But as Dr. Pies keenly points out, such headlines as “The AMA Continues to Oppose Physician-Assisted Suicide” and “AMA Rebuffs Advocates of Physician-Assisted Suicide” simply went too far.
The CEJA’s recommendation is important but by no means definitive. The real vote comes when the AMA House of Delegates votes on its recommendation, which went against those who wanted the AMA to “go neutral.”
On the other hand it was the thrust of Dr. Pies’ argument that the CEJA’s report was nothing short of brilliant and that the AMA staying neutral would be consistent with the position of the American Psychiatric Association. The implication is clear that if the AMA were to go wobbly, so, too, might the APA.
Pies begins with the CEJA’S insistence on clarity.
The authors of the CEJA report wisely noted the critical role of language in this controversy, stating: “Not surprisingly, the terms stakeholders use to refer [to] the practice of physicians prescribing lethal medication to be self-administered by patients in many ways reflect the different ethical perspectives that inform ongoing societal debate.”
Those who favor the practice just described generally prefer the terms “death with dignity” or “medical aid in dying.” Those who oppose physician provision of lethal medications generally favor the term “physician-assisted suicide.”
The CEJA report reached two main conclusions, but not without much deliberation, Pies explains:
1. The AMA Code of Ethics should not be amended, effectively sustaining the AMA’s position that physician-assisted suicide is fundamentally incompatible with the physician’s role as healer.
2. With respect to prescribing lethal medication, the term “physician assisted suicide” describes the practice with the greatest precision.
For our purposes, the meat of Dr. Pies narrative is to demonstrate that retaining its opposition is in line with the American Psychiatric Association (APA) which
“in concert with the American Medical Association’s position on Medical Euthanasia, holds that a psychiatrist should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death.”
Why the need for this statement in 2017? Pies’s explanation is invaluable:
The American Psychiatric Association’s code of ethics is based on that of the AMA; accordingly, official APA policy is opposed to PAS of any kind. However, in light of the emerging practice in Belgium and the Netherlands of euthanizing non-terminally ill patients—including psychiatric patients—the APA felt it important to craft a position explicitly addressing this population. And so, in December 2016, the APA Board of Trustees passed the following position statement, which originated in the APA Assembly and was unanimously supported by the APA Ethics Committee: “The APA, in concert with the American Medical Association’s position on Medical Euthanasia, holds that a psychiatrist should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death.”6
The statement by the APA Trustees speaks forcefully to the “slippery slope” of medically authorized killing in countries like Belgium and the Netherlands, where psychiatric patients are now routinely (and legally) euthanized.
If I may offer one more long quotation, I think you will appreciate how important his assessment is:
The thorny issue of “end-of-life care” is likely to remain controversial in the US, with physicians themselves holding a wide variety of views.10 Critical in this debate is the finding that most persons requesting PAS are not actively experiencing extreme suffering or inadequate pain control. Data from the Washington and Oregon PAS programs show that most patients request PAS because they fear loss of dignity and control over their own lives.11 These are matters that lend themselves to psychiatric intervention and counseling—not the dispensing of lethal medication. As the CEJA report wisely observes:
Patient requests for assisted suicide invite physicians to have the kind of difficult conversations that are too often avoided. They open opportunities to explore the patient’s goals and concerns, to learn what about the situation the individual finds intolerable and to respond creatively to the patient’s needs other than providing the means to end life—by such means as better managing symptoms, arranging for psychosocial or spiritual support, treating depression, and helping the patient to understand more clearly how the future is likely to unfold.
The values of Hippocratic medicine admonish the physician as follows: “I [the physician] will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect.”12 It is my hope that the AMA House of Delegates will uphold the wisdom of its own Ethics Council, and reaffirm that assisted suicide does not belong in the House of Medicine.