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"Engaged neutrality" on physician-assisted suicide better for patients than active resistance

10/25/2016

As physician-assisted suicide (PAS) gains wider acceptance across the United States, more states are adopting legalization to allow it. With the recent adoption by California of an Oregon-style “Death with Dignity” law, the discussion around physicians’ role in providing lethal medication has become a live issue for more health care professionals than ever before. Traditionally, doctors have opposed PAS. In the face of growing legalization of PAS, physicians are faced with difficult decisions. How do physicians uphold resistance to the practice of PAS, while still promoting the well-being of patients who legally choose it?

Writing for the Annals of Internal Medicine, John Frye, MA, and Stuart J. Youngner, MD, argue that active resistance to PAS by health care professionals can actually be damaging to patients. By standing aside from the process, doctors may engage in what amounts to “patient abandonment,” - leaving patients to their own devices in the last moments of life – rather than giving them the care and accompaniment they deserve. As an alternative to this grim scenario, the authors suggest a policy of “engaged neutrality,” in which medical professionals actively provide care and assistance to patients choosing PAS, even if they disagree with their decision to choose life-ending drugs.

Ultimately, they argue, the role of the medical community is to provide care to patients, even if patient choices do not line up with their own. Their resistance to doing so may be causing unintended damage to patient well-being. “The refusal of professional organizations—including the American College of Physicians, American Medical Association, and American Osteopathic Association—to provide clinical guidance on the care of patients actively seeking assistance in dying does a disservice to the practicing physicians who are their members.” Instead, physicians have an opportunity to minimize the potential harm of PAS by participating in its roll out, and watching carefully for problems that would affect patients.

Many professional organizations for physicians oppose PAS based on patient welfare issues. For example, the authors say, There are “concerns [such] as decreased quality of end-of-life care, families and society coercing persons to seek death, vulnerable populations (such as the poor, uneducated, uninsured, and disabled) being encouraged to choose death over life, access to lethal medication by persons who have inadequate decision-making capacity, and creation of a slippery slope to (nonvoluntary) euthanasia.” Yet the authors suggest that growing public acceptance and legalization of PAS is inevitable. In such a context, it is not a question of whether PAS will be allowed, but whether physicians will play a constructive and healing role in the midst of a health care system where PAS is a reality.

Frye and Youngner envision a role for physicians as vigilant, helpful presences, who ensure that PAS is carried out in compassionate, patient-centric ways. As PAS becomes normalized, they say, “Great care must be taken to ensure that helping patients die is never easier than providing them with the kind of care that would make them want to keep living. If these concerns are to be taken seriously, constructive engagement by organized medicine is essential.”

The current tendency among physicians towards “studied neutrality” is insufficient for the demands of patient care. This is because taking a neutral position on whether PAS should be legal does little, if anything, to provide guidance for medical professionals who do, in fact, have to care for patients for whom PAS is a legal option. This puts individual physicians in the unenviable position of having to figure out how to effectively practice medicine in a post-PAS world, without any meaningful guidance from the wider world of practitioners.

Moreover, the authors argue, the “studied neutrality” of some organizations can directly harm patients. This includes hospices that forbid direct participation in PAS. In Oregon, for example, some hospices required staff to avoid being present when lethal medication was being ingested. Frye and Youngner suggest that in any other context this could be viewed as patient abandonment.

Both the avoidance currently being embraced by many physicians organizations, as well as the active engagement suggested by the authors, allow for diverse views. One does not have to agree with PAS in order to actively engage in the health care of patients who choose it. Yet engagement is key for providing patient care that is compassionate and responsible. Ultimately, an organization’s political position on PAS will be determined by the views of its physician members, but its engagement should be directed solely by the manifest needs of patients. “When confronted with a patient’s request for assisted dying, physicians who consider moving forward should not feel unprepared or isolated. Their profession should support them in supporting their patients.” (Annals of Internal Medicine, 9/27, annals.org/article.aspx?articleId=2556137&guestAccessKey=049beed1-a55e-4d8c-a840-847627690659; NewsWise, 10/3, www.newswise.com/articles/case-western-reserve-bioethicists-call-on-organized-medicine-to-support-patients-desiring-assisted-death-and-their-physicians)