Divergent views on the ACP position statement on physician-assisted suicide

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The American College of Physicians maintains the belief that ethical issues preclude physician participation in patient suicide.
The American College of Physicians maintains the belief that ethical issues preclude physician participation in patient suicide.

In November 2016, Colorado became the sixth state to legalize physician-assisted suicide, which is also permitted in the District of Columbia. Recent findings show that 47% to 69% of Americans support the practice.1 However, the American College of Physicians (ACP) has long opposed its legalization, first stating their views on the topic in a 2001 position paper. They reaffirmed their opposition in an updated paper published in the Annals of Internal Medicine.2 

Although the ACP "recognizes the range of views on, the depth of feeling about, and the complexity of this issue," as well as the sense of comfort that having control over one's death may offer some patients, the organization maintains the belief that ethical issues preclude physician participation in patient suicide. The position paper notes that although respect for patient autonomy is an ethical principle that informs physicians' duties to patients, it must be considered in the context of the other principles of beneficence, nonmaleficence, and promotion of fairness and social justice.3

"Only by this balancing of ethical principles can physicians fulfill their duties, including those in more everyday encounters, such as when a physician advises against tests requested by a patient that are not medically indicated, declines to write an illegal prescription, or breaches confidentiality to protect public health," according to the position paper. "Physicians are members of a profession with ethical responsibilities; they are moral agents, not merely providers of services."

Instead, the ACP proposes that efforts should focus on improving end-of-life care, as through palliative and hospice care. Results of a public opinion survey show that although 90% of US adults are unaware of what palliative care is, more than 90% indicated they would desire such care for themselves or loved ones if they were seriously ill.4 There are many challenges to be addressed in these areas, including issues pertaining to access, communication, coordination of care, and reimbursement for these services.

Other key points in the article include the difference between physician-assisted suicide and a patient's refusal of life-sustaining treatment, and recommendations for physicians on how to thoughtfully address patients' request for assistance in ending their lives. The paper outlines 12 steps to be followed in these cases; for example, open discussion with the patient regarding their concerns and goals of care, assessment and treatment of pain and other distressing symptoms, and arrangement of hospice care at the patient's home if that is their wish.

The practice of physician-assisted suicide "is problematic given the nature of the patient-physician relationship, affects trust in that relationship as well as in the profession, and fundamentally alters the medical profession's role in society," the authors concluded.

Articles accompanying the ACP position paper offer varying opinions on the topic, including 1 expressing agreement with the ACP's stance and another that suggests the statement missed the mark.5,6 In addition, representatives from the Oregon Health Authority published data relevant to the 20-year practice in that state as valuable information to inform the ongoing discussion.7

Medical Bag asked the authors of these papers to provide key takeaways for clinicians.

William G. Kussmaul, III, MD, cardiologist and associate professor of medicine at Drexel University College of Medicine, Philadelphia, Pennsylvania

Physicians have a duty to accompany their patients through illness. Cure is not always possible; comfort and care can and should be achieved. Suffering is a bad thing, and relieving suffering as far as possible through appropriate treatment, empathy, and medication, if required, is every physician's duty.

Ending suffering through suicide has somehow become thinkable, and in some places it has become legal for physicians to provide the means to commit suicide. What has happened to "First, do no harm"? This principle, beneficence, threatens to be eclipsed by the principle of autonomy. Hence, some argue that if a patient requests suicide, presumably because of overwhelming suffering, the physician has a duty to give the patient what they request.

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