California Medical Association Policy On Physician-Assisted Suicide
CMA policy on the issue of physician-assisted suicide has been prompted in part by two unsuccessful initiative measures in California, both of which the CMA Board of Trustees voted to oppose: the "Humane and Dignified Death Act," which failed to qualify for the 1988 ballot; and the "Death With Dignity Act" initiative (Proposition 161), which was rejected by voters in November 1992. Although both initiatives would have permitted the practice of active euthanasia (i.e., the administration of lethal injections or other affirmative acts to kill terminally ill patients) in addition to physician-assisted suicide, a white paper approved by the Board of Trustees in 1988 ("Voluntary Active Euthanasia: The 'Humane and Dignified Death Act")* found no ethical distinction between the two practices:
There rarely has been such a direct attack on the ethical foundations of the healing professions, all of which share prohibitions against taking of life. In examining this issue, clear terminology must first be established: "physician-assisted suicide" or "aid-in-dying" is identical to voluntary active euthanasia, i.e., the deliberate shortening of life by administering lethal medications. It is not suicide per Se, as it relies upon professional authority to sanction and participate in the act.Together with the 1988 white paper, four House of Delegates resolutions form the core of CMA policy on physician-assisted suicide and active euthanasia. Resolution 812-87 stated CMA's opposition to "the enactment of any law which would require a physician to provide the medicines, techniques, or advice necessary for a patient to pursue a course of suicide, of which would require a physician who is unwilling to participate in suicide to refer a patient to another physician so willing." Resolution 801-88 formalized CMA's opposition to "the practice of voluntary active euthanasia" and "the enactment of any legislation or initiative that would legalize voluntary active euthanasia," and reaffirmed CMA's support of "humane and compassionate care for the terminally ill, including the provision of appropriate pain control and emotional counseling and support necessary to alleviate the physical and mental suffering of dying patients." Resolution 507a-95 reiterated this opposition, stating that the Association "continues to condemn voluntary active euthanasia as unethical and unacceptable." Finally, Resolution 516-97 affirmed that "while opposition to the legalization of physician-assisted suicide remains the position of the California Medical Association, CMA shall remain receptive to multiple views and perspectives expressed by various participants in the societal dialogue on this issue."
Among CMA's specific concerns about active euthanasia and physician-assisted suicide are the following, which were outlined in the 1988 white paper and further articulated during the Proposition 161 campaign:
- Legalizing physician "aid-in-dying" would introduce disturbing potentials for abuse. The "right" to a lethal injection could become an expectation of appropriate behavior, and then a duty, pressed forward by other demands on scarce resources and by the perceived burden imposed on others. Further down this "slippery slope," an expectation might arise for other "unfit" members of society (e.g., certain disabled individuals) to voluntarily end their expensive suffering as well.
- Suicide is rarely a rational decision; most often it is a psychologically abnormal event associated with depression or other disorders. This has been found to be as true among terminal patients as among others. Suicidal behavior suggests a condition deserving medical treatment, not lethal medication.
- Pain suffered by the vast majority of terminal patients can be controlled, and other needs, including emotional counseling and support, can be provided for through hospice care. Legalizing euthanasia could undermine efforts to further improve pain control and to promote hospice care, since an expectation could arise that terminal patients should simply dispatch themselves rather than consume valuable resources by "prolonging the inevitable."
- There is always an element of uncertainty in medical diagnosis and prognosis. Errors are bound to occur, as hospices and cancer research centers have learned through experience. The course of a terminal illness is not always predictable. Someone given six months to live may actually live several more years with a reasonable quality of life.
- Legalizing assisted suicide might glamorize the practice and establish its acceptability, thus inviting imitative suicides. Studies have shown that publicized suicides raise the overall suicide rate, especially among teens.
- Physicians are healers, not killers. Physician-assisted suicide and physician-administered lethal injections contravene the fundamental ethic of the medical profession: "do no harm." Proponents seek the moral authority of the medical profession to legitimize an attempt to overturn ancient prohibitions against taking the life of another. Placing physicians in the dual role of healer/killer would undermine trust in the physician-patient relationship, since patients may fear that physicians will steer them toward a lethal injection rather than pursuing what may be a more difficult course of treatment to relieve suffering.
The committee recognizes that there may be rare cases in which a dying individual's pain and suffering cannot be adequately controlled; while sensitive to these extraordinary situations, the committee feels strongly that the dangers of legalizing and regularizing the practice of physician-assisted suicide far outweigh the perceived advantages to this extremely small segment of terminally ill patients.Notwithstanding the Council's continuing opposition to the legalization of physician-assisted suicide as a matter of ethical principle, Resolution 5 16-97, which was authored by the Council, signaled a desire on the part of the Council to take a step back from the hard-line, "just-say-no" position of many active euthanasia and assisted suicide opponents. The Council concluded that there is limited value in the continuing pro/con debates about the issue; rather than pursuing an adversarial strategy, the Council instead seeks to encourage dialogue about the problems underlying the perceived need for physician-assisted suicide —and the challenges those problems present—among stakeholders who remain sensitive to differing philosophical views.
The Council also remains committed to improving the quality of care for terminally ill patients, which it deems a critical component of the medical profession's response to this issue. Following up on a Western Scientific Assembly conference the Council sponsored in 1994 ("Caring for the Terminally Ill: How to Care When You Can't Cure") and a document it authored the same year titled A Primer on End-of-Life Care, the Council is currently developing guidelines to assist physicians in responding compassionately to patient requests for "aid-in-dying." These efforts have been augmented by two issues of The Western Journal of Medicine devoted in part or in whole to the issues of assisted suicide and end-of-life care, and a series of symposia on pain management in chronic and terminal illness sponsored by the CMA Council on Scientific Affairs pursuant to Resolution 7O4-97.