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Long Skeptical, Doctors Debate Assisted Suicide



The Washington Post
Monday, June 11, 2018

During his three decades as a emergency-room doctor, Bob Uslander had never written a prescription for a lethal dose of medication. But then he shifted to geriatric and palliative care, and in 2016, a patient suffering from the neurodegenerative disease ALS wanted to use California’s new physician-assisted death law.

Uslander was apprehensive. Until then, he’d always viewed death as a failure.

“I didn’t really know what it would be like to be with somebody who had made the choice and was taking this medication,” he recalled recently. “I didn’t know if they would just gently fall asleep or if they would be gasping or struggling.”

His patient, a 67-year-old massage therapist with what is commonly known as Lou Gehrig’s disease, also was worried — for an entirely different reason. Her health was declining fast. Breathing and swallowing were becoming harder, and she could no longer walk. Uslander remembers her being terrified about what else would happen before it all ended.

So he wrote the prescription, and when she was ready to use it, he sat beside her and watched her die. “It was very peaceful,” he said. “Every experience I’ve had with aid-in-dying since then has been similar. There’s a sense of relief, there’s a sense of release.”

Although medically assisted death has gained ground in this country — with six states and the District of Columbia legalizing the practice — it remains a divisive issue among health-care providers. The American Medical Association, the nation’s most prominent doctors’ group, has maintained the same guidance for the past quarter-century: “Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.”

Yet this week in Chicago, the AMA House of Delegates will debate and vote on whether the association’s Code of Medical Ethics should be revised.

“The mere fact that they’re considering it again tells you that it’s a changing climate,” said Art Caplan, a professor of bioethics and head of the division of medical ethics at New York University School of Medicine. “The reality is, there are many more doctors in the AMA, but also outside the AMA, who have changed their minds about this.” And opinions, he predicted, will “continue to evolve.”

The AMA’s Council on Ethical and Judicial Affairs spent two years reviewing resolutions, not so much on whether to support the practice but on whether to take a neutral stance. The council is recommending that the Code of Medical Ethics “not be amended” and continue to refer to “physician-assisted suicide,” saying that language still “describes the practice with the greatest precision.” The delegates could accept the recommendation or send it back for further review.

It’s uncertain which way the vote will go, but in an open forum on the AMA’s website, doctors, delegates and others showed strong support for the status quo. That position is increasingly at odds with public opinion, with polls showing many Americans think doctors should be allowed to help terminally ill patients end their lives.

The AMA declined to comment before the meeting.

On one side, doctors argue that physician-assisted death should be a choice for patients who are already dying and want to end their suffering on their own terms. Those on the opposing side contend that such assistance violates one of the core principles of their profession — do no harm — and could become a slippery slope to euthanasia. There’s even disagreement about how to characterize the practice. Opponents say terms such as “aid in dying” are euphemisms that obscure the harsh reality, while proponents see “doctor-assisted suicide” as stigmatizing patients who choose it.

“This is not just a medical issue,” said cardiologist Thomas Sullivan, an AMA delegate from Massachusetts who agrees with the recommendation for no change. “This is a social issue. This is a moral issue. This is something that many, many people are faced with from time to time, when your own parents or your own children or your brother or sister or you are faced with a terminal illness.”

Neurologist Lynn Parry, a delegate from Colorado, said she will vote to reject the ethics council’s stance and ask it to spend more time “looking at what protections for physicians, and particularly for patients, would need to be in place” for the AMA to amend its guidance.

“How we look at the universe is really driven by our personal belief system and, in large part, by our philosophies and religious beliefs, and that’s as it should be,” she said.

Her state is among those that allow physician-assisted death. Oregon led the way with a 1994 ballot measure, followed by Washington in 2008 and then Vermont, California, Colorado, the District and Hawaii. A court case established the legality of assisted death in Montana. (California’s 2015 law was overturned by a judge last month, a decision that is being appealed.)

The practice drew intense national attention in fall 2014 after a terminally ill woman named Brittany Maynard moved from her home in California to Portland so she could utilize Oregon’s Death with Dignity Act. The 29-year-old had been diagnosed with a stage 4 brain tumor — glioblastoma, the same aggressive cancer that Sen. John McCain, R-Ariz., is battling — and was told it would kill her within six months. She instead set her own timeline, taking a fatal dose of barbiturates that November.

Half a year later, a Gallup poll found almost seven out of 10 Americans surveyed said doctors should be allowed to assist terminally ill patients in ending their lives — a notable increase from 2014.

David Grube, a retired family physician from Oregon and national medical director for Compassion & Choices, calls the current AMA policy “antiquated.”

“ ‘Do no harm’ leads to a lot of harm in medicine,” he said, with “people on breathing machines for months and all kinds of things.”

He considers the “enemy” to be terminal suffering, especially the cases where doctors can’t ease patients’ pain. Since his state passed its law, Grube said, “more people haven’t died, but fewer people have suffered.”

But the doctors are still debating it.

“I just do not believe that in the medical profession, which at its core is about protecting the quality and quantity of life, we should become the agent by which we hand them a prescription so they can choose the exact time and moment of their death,” said M. Zuhdi Jasser, an internist and primary care physician who serves as an AMA delegate from Arizona.

Jasser, who presented the resolution to maintain the term physician-assisted death, said he plans to vote for the association to hold firm.

“The big question that I think physicians are going to be dealing with over the next five, 10, 15 years as more of these states legalize it is: Are our ethical guidelines and core principles going to be determined by cultural shifts and by popular vote or populism,” he said, “or are they going to be things that we adhere to and hold on to regardless of the shifting winds of populists’ concerns?”