ACP Renews Stance Against Physician-Assisted Suicide

Physicians should focus on providing more compassionate, comprehensive end-of-life care, ACP president says.

This week, the American College of Physicians (ACP) reaffirmed its opposition to the legalization of physician-assisted suicide and placed renewed emphasis on the professional responsibility to improve the care of dying patients.

Citing ethical arguments and clinical, policy, legal, and other concerns for its positions, the ACP's paper is published in the Annals of Internal Medicine, along with two editorials and a related review article.

Jack Ende, MD, president of the ACP, spoke with HealthLeaders about the paper’s implications for physicians and leaders. The transcript below has been lightly edited.

HealthLeaders: Why did the ACP decide to reiterate its position on this issue now?

Jack Ende, MD: The “now” question can be answered in a couple of ways. One is that we’ve had a policy paper out since 2001, and the issue continues to get addressed as our ACP ethics manual is continuously updated.

Since 2001, there has been a fair amount of legal activity: Seven states, Washington D.C., and Canada have legalized physician-assisted suicide, and it’s up for discussion in several other states and districts.

Related: Physician-assisted Suicide and the ICU

The other reason is the perception that the care we’re providing for terminally ill patients is not as good as it could be, and perhaps physician-assisted suicide is sort of a compromise.

For these reasons, the ethics committee decided that it was worth review.

Related: Few Docs Discuss Advance Care Planning

HLM: Does the underlying issue have more to do with improving palliative and end-of-life care?

Ende: There is a link. We have studies showing that most patients don’t know what palliative care is; yet when they hear about it, it’s the type of care they would want for themselves and their loved ones.

Yet when you’re practicing medicine, there are many places that still do not support hospice and palliative care. These are services that are not as available as they should be or covered by insurance plans as widely as they should be.

We have a long way to go in really getting hospice and palliative care built in as an expected and necessary part of the medical system.

Related: 5 Ways to Improve Palliative Care

HLM: What kind of feedback are you anticipating in response to this paper?

Ende: We’re likely to hear, “What about patient autonomy? Isn’t our guiding principle that patients should get what they ask for?” And our response is that patient autonomy is extremely important, but there are limits to autonomy, and it is not our sole principle.

We are more focused on munificence—doing what is best for the patient—and non-malfeasance or never doing harm.

The second question is, “Well, what do you do?” And I think the paper does a good job outlining 12 conversation points that physicians may want to address with patients and their families when they’re asked about physician-assisted suicide.

They include providing reassurance that the physician will be there for the patient’s entire journey, understanding what the patient’s goals are, and trying to meet those goals in ways that patients will appreciate.

And once that’s done, I think the request for physician-assisted suicide will be less pressing.

HLM: What’s most important thing for healthcare executives to understand about this issue?

Ende: There are three critical points:

• First, be aware that the Supreme Court has said that nobody has a right to commit suicide. States can legalize physician-assisted suicide, but it’s not seen as a right.
• Second, assisting somebody in suicide is not part of the caring process. It’s not part of why doctors take oaths, and it’s not part of what we should be doing. So there is a concern about medicalizing death.
• Third, there is the concern that regarding physician-assisted suicide as a well-accepted may take us away from what we should be doing, which is providing compassionate, comprehensive care, which includes hospice care and palliative care and assisting patients through a much more comfortable, natural dying process—one that retains the physician-patient relationship and also retains the physician’s ethical standing.