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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
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.
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
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.