September 16, 2015
ACP President Wayne Riley, MD, MPH, MBA, MACP
President, American College of Physicians (ACP)
On September 16, the American College of Physicians sent the following letter to California Governor Jerry Brown asking him to veto the End of Life Option Act (ABX2-15), which would legalize physician-assisted suicide.
Dear Governor Brown,
The American College of Physicians (ACP), the largest medical specialty organization and the second-largest physician group in the United States, writes to urge you to veto "The End of Life Option Act." This is a physician-assisted suicide bill. ACP does not support the legalization of physician-assisted suicide (PAS) and does not support PAS as an appropriate action (see the ACP Ethics Manual and position paper). Terms such as "end of life option" and "aid-in-dying" used in the bill are confusing and obscure what is at stake when physicians are asked to facilitate suicide. We are deeply sympathetic to the concerns and fears patients and their families have at the end of life. However, PAS is not the answer and in fact, ACP sees it as abandonment of the dying patient. It is not the role of the physician to give individuals control over the cause and timing of death-the medicalization of suicide.
The physician must always act in the best interests of the patient as healer, comforter and trusted advisor. PAS undermines trust in patient-physician relationships and trust in the profession of medicine. Proponents of PAS claim it is an act of compassion in keeping with the physician's role as comforter. However, this argument incorrectly assumes that physicians can only provide comfort for certain patients through facilitating suicide. In fact, physicians can and do provide comfort to dying patients. It is a lack of awareness of these services and a perceived concern that patients will not have access to this care that helps drive interest in PAS as an option. We need to ensure that all patients have access to palliative care and hospice services at the end of life rather than promote suicide.
Surveys show that many individuals do not know what palliative care is but when told its definition, they overwhelmingly respond that they would want it for themselves or their family members if they were severely ill (Kelley Amy S., Morrison R. Sean. Palliative Care for the Seriously Ill. New England Journal of Medicine (2015) 373: 747-755). Palliative and hospice care have yet to receive the attention PAS has received in this country.
The highest priorities for care of dying patients should be excellent palliative care, including alleviation of pain and other symptoms, and strong support for the patient's right to refuse treatment, including life-sustaining treatment. Patients often fear pain at the end of life, but physicians have an ethical obligation to treat pain with competence and compassion. Aggressive management of pain at the end of life is ethically acceptable, even when the risk of hastening death is foreseeable, if the intent is to relieve pain: the ACP Ethics Manual states that "…the physician may appropriately increase medication to relieve pain, even if this action inadvertently shortens life." The option of aggressive pain control has been consistently supported by US courts, including the US Supreme Court, and PAS has been distinguished from the right to refuse treatment by the courts as well (see especially Washington v. Glucksberg, 117 S.Ct. 2258 (1997) and Vacco v. Quill, 117 S.Ct. 2293 (1997)).
Procedurally, we were also very troubled by the last-minute inclusion of the PAS bill in the special legislative session on health care financing, bypassing usual procedures. We also note the paradox of access to PAS where there is no general right to health care. In Oregon, the irony of difficulties getting coverage for palliative services and pain drugs under the state's Medicaid program-- but no problem receiving PAS paid for as a covered service-- has been noted (Toffler William L. A doctor-assisted disaster for medicine. Wall Street Journal. August 18, 2015:A1). PAS is especially troubling in an environment of cost control in health care and continuing disparities in care.
We hope you will join ACP in advocating that society should encourage those who seek suicide with a physician's help to instead be provided with full access to the care and compassion that can alleviate their suffering. No Californian, or any other American, should have to fear an undignified or pain-filled life or death.
Providing greater access to palliative and hospice care needs our full attention. In this way, physicians can fulfill their mission and give dying patients and their families the care, compassion, and comfort they need and deserve.
We hope that you will veto this bill.
About the American College of Physicians
The American College of Physicians is the largest medical specialty organization and the second-largest physician group in the United States. ACP members include 143,000 internal medicine physicians (internists), related subspecialists, and medical students. Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. Follow ACP on Twitter and Facebook.