The American Medical Association’s misguided position on euthanasia

From their website:

Screen Shot 2014-12-03 at 1.45.46 PM

This is simply wrong, and something that could have been written by the Catholic church (except there’s no talk of “souls” or “empathy with Jesus’s suffering”). For a patient who is terminal, and suffering horribly, the role of the physician as “healer” is no longer attainable. And of course many physicians, as I’ve been told by doctors, actually perform euthanasia by giving overdoses of pain medication to terminal patients, perfectly aware that it will cause their deaths. Why is this not euthanasia? After all, AMA policy also says this:

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Isn’t “withdrawing life-sustaining medical treatment” really equivalent to “helping people die”? It surely is. Here we have a medical version of the trolley problem, where people feel it’s okay to take a passive role that will kill someone (to save more people) but not an active one. You can turn off the feeding tube, but not give an overdose of morphine (which doctors already do anyway) or barbiturates. But the borders are less clear for assisted suicide than for the runaway trolley .

Finally, the canard that euthanasia is “difficult or impossible to control,” poses “serious societal risks,” and “could be readily extended to incompetent or vulnerable patients and other vulnerable populations” can and has been taken care of in those places where assisted dying is legal, as in Switzerland, Holland, and the few states in the U.S. that allow it.

It’s time for the AMA to catch up to the rest of society. When a doctor can no longer heal, and the patients want his or her torment to end, there is nothing wrong with a doctor helping. In fact, with their medical knowledge, doctors are the best people to do so.

Of course I do agree with the AMA’s stand to not assist with legal executions in the judicial system, because I’m opposed to capital punishment. But there’s a world of difference between assisted suicide and involuntary execution of criminals.

 

79 Comments

  1. KENNETH SANDERS
    Posted December 3, 2014 at 1:15 pm | Permalink

    Life without quality isn’t life worth living…..not for my companion animal patients….not for me.

    • Nicholas
      Posted December 3, 2014 at 1:47 pm | Permalink

      I feel it is a basic human right to die with dignity at a time of one’s choosing, REGARDLESS of circumstances, situation or medical condition. To this end I believe that Dignitas style clinics should be made available for all those who need them in as many locations as necessary.

      At present this right is denied to so many thousands of suffering individuals purely to satisfy the whims of a religious and natalist driven orthodoxy. If we do not have rights over our own bodies, then we do not have any rights at all. In my view it is unforgivable keeping someone alive against their will and who no longer wants to be here. Society condemns so many to die alone in agony, to die from very violent deaths or continue living in pain from botched suicide attempts. It is a simple enough request to have drugs like Nembutal (Pentobarbital) readily made available, to aid a peaceful and dignified exit from this world. And not to have Big Brother dictating to us what is in our best interests. We are all adults and capable of making life (and death) choices for ourselves.

      So I now suggest there is an immediate change in the law to allow not only assisted suicide for those who desire it, but also drugs like Nembutal to be made available on prescription for the purposes of ending life. Suicide is not illegal and should be made much easier to carry out, without incurring discrimination, blame, stigma or criminality of any kind.

      It is indeed the human rights issue of the 21st Century.

      • Posted December 3, 2014 at 1:58 pm | Permalink

        +1 – It’s a mystery how the resistance to euthanasia comports with our tolerance for executions and the slow-motion suicides of tobacco and alcohol. Not that society doesn’t make some effort to discourage self-destructive habits, it’s just hard not to notice that “personal choice” and “liberty” and “healing” are so inconsistently applied in terms of forced intervention in people’s lives.

        • Posted December 3, 2014 at 3:30 pm | Permalink

          My friend Alexandra gets incensed with he AMA about this issue. She is a charge nurse for the ICU at a local hospital. All of the terminal oncology patients in the hospital are on her floor. Her husband is a veterinarian. I suppose just like any vet, part of his practice is “putting down” terminal animals. She can’t understand why his patients often get to pass in relative comfort, surrounded by people who love them while her patients are, as she puts it, “forced to carry-on to the bitter end”, even if that means months of suffering.
          It’s really upsetting to watch a loved one wither away like that and, unfortunately, that sometimes means that relatives are reluctant to visit, if there are any relatives at all. To hear Alexandra tell it, it isn’t just prolonged physical pain, but often prolonged fear and loneliness that patients are made to endure in that condition. I hope the AMA comes to their senses as soon as possible.

      • Pali
        Posted December 3, 2014 at 7:27 pm | Permalink

        “I feel it is a basic human right to die with dignity at a time of one’s choosing, REGARDLESS of circumstances, situation or medical condition.”

        This, this, THIS. If I am 80 and in constant pain or if I’m 20 and in perfect health, the choice regarding when I’m done with life is MINE to make, not someone else’s. The latter may be one I would advise against, sure, but the call in the end should be up to the person living that life.

        I’ve always wanted to smack the people who argue that suicide is selfish – because while it is, it is immeasurably more selfish to demand that someone else stay alive when they don’t want to because you like having them in your life. Doing so when you have young children or have accepted similar responsibilities is of course a different matter, but overall the idea that one is obliged at all to live a life they do not wish to is one I find abhorrent.

        • Nicholas
          Posted December 3, 2014 at 9:20 pm | Permalink

          Hi Pali,

          “I’ve always wanted to smack the people who argue that suicide is selfish”

          Me too.

          One of the leading suicide researchers, Dr. Edwin Shneidman, has said that individuals who commit suicide typically have been…. “the victim of a vandalized childhood, in which the preadolescent child has been psychologically mugged or sacked, and has had psychological needs, important to THAT child, trampled on and frustrated by malicious, preoccupied or obtuse adults”

          Anyway, I always have the same 3 questions:

          1) Does anyone owe anyone else his or her life?

          2) Does anyone have a duty to suffer for anyone else’s benefit (or to forestall anyone else’s prospective suffering)?

          3) Does the mere fact (i.e. imposition) of being born render each one of us a slave — to family, to community, to the species?

          It seems to me that, in the absence of answering any of the above in the affirmative, there’s nothing more selfish, and therefore more hypocritical, than stigmatizing suicide as “a selfish act.”

          Even if it is, so what? Unless the ‘collateral damage’ of killing oneself is premeditated & also irreparable (which it very rarely is), so what? ‘The world’, after all, could stand to be relieved — freely by self-selection — of as many desperately miserable people as possible; gratitude rather than scorn (or taboo-fear) being the more appropriate, more civilized response.

          Perhaps killing oneself is simply an act of self-defense against ‘involuntary self-torment’. If so, reparable collateral damage is a reasonable trade-off (risk), no?

          • Michael Waterhouse
            Posted December 3, 2014 at 9:44 pm | Permalink

            That’s a very interesting comment. I will look further into Dr. Edwin Shneidman.

            I would agree in general except with caution regarding people being in full possession of their faculties, and, younger people who may get caught up in fantasising about what people will think about them after they are dead. (Was it Tom Sawyer or Huck Finn who got to observe their own funeral?)
            But overall, yes, the stigma is absurd.
            Again, the wording of that phrase by Dr. Edwin Shneidman has me very intrigued.

          • Pali
            Posted December 4, 2014 at 1:43 pm | Permalink

            I’ve used varieties of those questions myself in discussions of the subject.

        • Keith Cook or more
          Posted December 27, 2014 at 4:33 am | Permalink

          Suicide tends to leave the grieving, perplexed and guilt ridden that’s probably why it is termed with being a selfish act. Quite often as I have seen myself it is ‘out of the blue’ and left their family bewildered as to why.
          It is also a bad role model, if he can do it, then I can too, it seems a simple way to deal with your problems and can look like self indulgence, it’s all about me, a selfish act.

          Euthanasia on the other hand is planned and probably thought out and discussed in detail, as it should be with all parties involved. I would say this is the ultimate in care of someone terminally ill.

    • Posted December 3, 2014 at 1:49 pm | Permalink

      I’ve had to put down several cherished pets, and obviously know many friends and family members who have had to do the same. I have never heard anyone express regret for having done the deed, but have felt and heard of deep regret for having hesitated to do it especially when last-ditch surgeries have only prolonged the animals’ suffering. We mourn loved ones when they die, but the first consolation we have is that their suffering has ended. How ironic that those who believe the dead awaken in eternal peace and joy are often the most resistant to letting go – maybe they are just jealous.

  2. Posted December 3, 2014 at 1:16 pm | Permalink

    How annoying. You said everything. There’s nothing I can add.

    • GBJames
      Posted December 3, 2014 at 1:19 pm | Permalink

      I’ll add this…

      sub

  3. Jeff Rankin
    Posted December 3, 2014 at 1:16 pm | Permalink

    I’m curious where palliative care organizations stand on this. I suspect they’re ahead of the AMA on it.

    • Garnetstar
      Posted December 4, 2014 at 9:31 am | Permalink

      My friend is the head of the Palliative Care unit of a large hospital, and she says that, if people knew what that is like, they’d all get Do Not Resuscitate tattooed on their foreheads.

      It’s not that the medical staff doesn’t do everything possible. It’s that there really is nothing that can be done to relieve the suffering of some patients. The AMA says “adequate pain control”, but there isn’t any such thing, unless you give morphine in doses that you know may well cause the patient’s death. It not that they mean to cause it, but that the patient has chosen to receive doses that may prove to be an overdose.

      My friend is also on the “Pain Board” (well named), a committee of doctors who try to manage chronic pain in outpatients. It’s not easy or even successful. She had to push hard for her own grandfather to get enough morphine to keep him comfortable: the board was saying that he might become an addict. She answered that he was in his eighties with termnial cancer, so what if he became hooked? If she hadn’t been his advocate, he would have spent the last months of his life in agony.

      So she’s all for physician-assisted suicide, and wishes it was legal in her state.

      And, what arrogance bu the AMA! As if I would let some doctor or some government decide when I will die! I will make that decision myself, thank you very much.

  4. John Conoboy
    Posted December 3, 2014 at 1:24 pm | Permalink

    Yet some doctors have, and will continue, to give large doses of morphine (for example) to patients to control their pain. They know that the morphine will kill the patient before the disease. Everyone knows this goes on. No one should have to die in pain.

  5. Posted December 3, 2014 at 1:24 pm | Permalink

    Hospices and nursing homes most definitely do administer pain killers with the knowledge that the patient will die as a result.

    The only useful question is how certain it is that the patient will not recover. This should be covered by DNR documents.

  6. Darth Dog
    Posted December 3, 2014 at 1:24 pm | Permalink

    “Euthanasia could also readily be extended to incompetent or vulnerable patients and other vulnerable populations.”

    The problem with the slippery slope argument is that if you apply it here, the next thing you know people will be applying it to all sorts of things.

    • Dean
      Posted December 3, 2014 at 1:36 pm | Permalink

      Very meta!

      • Posted December 3, 2014 at 1:53 pm | Permalink

        Same-sex marriage will lead to pedophilia and bestiality.

        • Posted December 3, 2014 at 2:08 pm | Permalink

          Say the people whose ilk are most often guilty of those perversions.

      • Darth Dog
        Posted December 3, 2014 at 2:50 pm | Permalink

        Yes. To quote xkcd, “I’m so meta, even this acronym”.

  7. ROBIN CORNWELL
    Posted December 3, 2014 at 1:25 pm | Permalink

    The ability to choose euthanasia can reduce suicide and benefit not only the individual but his or her family as well. Medicine should be a benefit and not a method of extending life without quality. It is interesting that the religious are much more likely to expend every effort to extend life, even for a few weeks, compared to the non-religious. Attitudes about death and dying in the US are inconsistent with what is said among the devout and the preachings of clergy.

  8. drakodoc
    Posted December 3, 2014 at 1:32 pm | Permalink

    I agree with your sentiments. As a physician myself, I know many colleagues who also share a desire to assist patients at the end of life (EOL) transition with dignity, including determining the timing of their own demise. However,in most states active participation in such acts is both a crime and a violation of state medical societies rules. As you point out, however, there are ways to ease suffering, well known to hospice caregivers, that can get very close to euthanisia without crossing the line. Since providers do have a fair, if not perfect, EOL option I do not get a sense that the topic of assisted suicide is a hot button issue among my colleagues. Especially since most state legislatures are solidly red. Can you imagine the outrage if the medical community were to endorse legalizing euthansia as legislation? They would lose significant credibility with the right-wing nuts and jeopardize traction on political issues (tort reform, reimbursement, extending medicaid) that are more broadly supported by the active medical community. Maybe the AMA took this stance for the same reason (politics over principle)?

    • Taz
      Posted December 3, 2014 at 4:49 pm | Permalink

      I expect the AMA to lead when it comes to medical issues. Silly me.

  9. Posted December 3, 2014 at 1:32 pm | Permalink

    I don’t understand the AMA’s objection. I can at least understand the Christian objection. Why not allow each individual doctor to be guided by her own conscience (with appropriate policies and oversights to prevent error and abuse)? These are complicated questions with no easy answers, and every patient presents a unique set of circumstances. This simply isn’t the kind of issue that can be addressed with a one-size-fits-all policy imposed from the top.

  10. Randy Schenck
    Posted December 3, 2014 at 1:34 pm | Permalink

    What the AMA is doing there is giving us the Hypocritical Oath vs the Hippocratic Oath.

    They are having their cake and also eating it. We’ll work like heck to save your life but if you are going to insist on dying you are on your own.

  11. bobkillian
    Posted December 3, 2014 at 1:43 pm | Permalink

    Not mentioned yet is end-of-life coinciding with end-of-payments to doctors, hospices, hospitals, and other caregivers.

    Is is legitimate to inquire into the substantial transfer of wealth from the dying patient to those who piously prolong the suffering?

  12. Posted December 3, 2014 at 1:44 pm | Permalink

    The organization’s position being the case, how is DNR even a thing? Similarly, why is it okay to provide treatment with a vanishingly small likelihood of success?

    In the latter case, one might argue incremental improvements might be discovered, which makes me feel like the patient is a guinea pig, which is not an example of healing in the short term. If the patient is aware of the prognosis and consents, great, but why is that and DNR consent okay but end-of-life consent not okay?

    In the former case, I suppose that’s an example of drawing the line somewhere – but resuscitation of a dead person is still an attempt to heal, and no less hopeless than treating a person who is circling the drain, no? Is it cynical to question whether caution over potential malpractice and wrongful death suits is a bigger part of the equation than the commitment to so-called healing?

    The US will come to accept euthanasia eventually, hopefully the current position will be short-lived.

    • Garnetstar
      Posted December 4, 2014 at 9:36 am | Permalink

      Yes. My palliative-care physician friend has, for example, removed many feeding tubes on the request of the family. Why is that OK, and not assisting with the patient’s own choice to end their life?

  13. Posted December 3, 2014 at 1:53 pm | Permalink

    Many years ago I voted — both times it came up — in support of assisted suicide when I lived in Oregon. I still support the idea of facilitated suicide. But I am no longer a grad student and recent recipient of a bone marrow transplant. I’m now an internist / hospitalist and end of life care is something that I am actively involved in, in an almost daily basis. So, while not opposed to the concept of suicide, in the face of a slow lingering death, I become very uneasy when patients directly ask me to help them die. I’m not a huge fan of the AMA, but as someone who is involved in the process of dying, as an athiest (hail basement cat!), as a lymphoma patient in remission now for 18 years; I do not share your ire. Once you have pronounced a few people, once you have been the person who looks up at the clock and says “time of death….” re-read the AMA’s statement and see how you feel.

    • steve oberski
      Posted December 3, 2014 at 2:19 pm | Permalink

      That argument can be easily turned around, wait until you are dying and in intolerable pain and ask your doctor to help you die to which your doctor responds as you did – then “re-read the AMA’s statement and see how you feel”.

      It’s not about the doctor, it’s about the patient.

      • Diana MacPherson
        Posted December 3, 2014 at 4:08 pm | Permalink

        I thought the same thing. When I made the decision to euthanize my dog years ago because she had cancer and would die a few months later in horrible pain, I was very sad. But I realized that forcing her to live on in pain like that was for my benefit only because I would miss her. She, on the other hand, wouldn’t know it was her death day & would get lots of fusses & treats.

        When I went to the vet, the vet started to raise the option of euthanasia & I burst into tears telling her that I wanted her to have a good death. The poor vet started getting weepy too.

        I’d hate to be the one to have to kill people or kill animals but it’s for those people and animals that we do those things.

        • Diane G.
          Posted December 3, 2014 at 6:31 pm | Permalink

          Beautifully put.

        • Phil Giordana FCD
          Posted December 4, 2014 at 1:46 am | Permalink

          And now I’m crying too.

    • Kevin
      Posted December 3, 2014 at 2:20 pm | Permalink

      A spectator’s journey through euthanasia can be quite different form the participant’s, I imagine; probably more traumatizing for those who get to continue with the party to use Hitch’s phrase.

      • ladyatheist
        Posted December 3, 2014 at 3:50 pm | Permalink

        When Dan Ariely was a burn patient with (magnesium!) burns over 70% of his body, he argued with his nurses about the best way to change bandages (a very painful procedure). After 3 years, he was released and studied pain as a graduate student. He found that he was right: it was better for the patient to take a few breaks and to take more time. So he went back to the hospital and told the nurses. They answered “But it would be worse for us.”

        • John Scanlon, FCD
          Posted December 4, 2014 at 4:06 am | Permalink

          Humans, the acme of altruism. Not.

    • infiniteimprobabilit
      Posted December 4, 2014 at 5:17 am | Permalink

      With all due respect to the doctor there, I would say to anyone who takes that stance: it’s not about you, it should be about what the patient wants. If you can’t or won’t put the patient’s wishes first and help them to end their suffering then what use are you? Please find another field to employ your talents in and leave the patient to someone who can help them.

  14. Henry Fitzgerald
    Posted December 3, 2014 at 1:55 pm | Permalink

    When they say “incompatible with the physician’s role as healer” it feels like they’re trying to excuse themselves on a technicality.

    As they themselves acknowledge later on, physicians have other roles, too (providing advice, comfort, pain control, etc.) which you would think ought to kick in when healing is impossible. In fact, later on they admit that these roles should kick in when healing is impossible. So why not take these other roles seriously, too?

    They do in less serious cases where “respect for patient autonomy” often clashes with the physician’s role as healer. Suppose my doctor advises me to stop eating so much cheese, but I really like cheese and I don’t want to. Does she forcibly snatch cheese out of my hands? Strap me to a bed and monitor my diet?

    • Posted December 4, 2014 at 10:45 am | Permalink

      The way I see it is that they overlook one half of their role:

      “We both get the same two kinds of customers. The living and the dying.”

  15. Posted December 3, 2014 at 2:07 pm | Permalink

    I’m happy to live in Washington where euthanasia is legal. It’s absurd that most states consider it manslaughter or a felony and Massachusetts considers it 1st degree murder. I believe if put on the ballot, most states would pass euthanasia laws (at least the blue states would imo).

    • Mel
      Posted December 3, 2014 at 2:33 pm | Permalink

      I do not believe Washington state has legalized any form of euthanasia as defined in the above AMA statement. Is it not based on Oregon law where the patient actually administeres the drug? The doc only gives a prescription so that the patient can get the drugs.

      • Posted December 3, 2014 at 4:13 pm | Permalink

        Yes, you’re correct, point taken. The physician doesn’t administer the drug, just prescribes it. And the law was based on Oregon’s. I think Vermont’s law is also the same. I do believe the AMA is wrong in not allowing doctors to euthanize, but at least some states give their residents the freedom to opt out on their own.

        • Mel
          Posted December 4, 2014 at 9:19 pm | Permalink

          The AMA also has a position on physician assisted suicide: Opinion 2.211 http://goo.gl/fBELjv They’re against it too and the opinion reads much like 2.21.

          The assisted dying movement now, in both the US and UK, is exclusively focused on PAS as defined in 2.211. Using the term “euthanasia” for PAS muddies the debate considerably; IMO it should not be used by supporters of PAS.

          While I would support doctor administrated euthanasia if the patient wants it, this would require some new rules in each of several significantly different cases.

          You can follow the assisted dying movement on Twitter: @CompAndChoices @BCoombsLee @DeathwDignity @dignityindying (in UK). @BCoombsLee is head of Compassion and Choices and often tweets under her own account.

  16. Charles Sullivan
    Posted December 3, 2014 at 2:22 pm | Permalink

    There is an essay you might like written by philosopher James Rachels called Active and Passive Euthanasia.

    Although it’s decades old, it does a good job examining the problems with the AMA’s position on euthanasia. Here is a link to a PDF version online:

    http://rintintin.colorado.edu/~vancecd/phil1100/Rachels.pdf

    • JoanL
      Posted December 3, 2014 at 6:58 pm | Permalink

      “what is the cessation of treatment … if it is not ‘the intentional termination of the life of one human being by another?’ Of course it is exactly that, and if it were not, there would be no point to it.”

      Exactly.

      • Phil Giordana FCD
        Posted December 4, 2014 at 1:50 am | Permalink

        Maybe it’s just a technicality, but I don’t think “end of treatment” is the best way for euthanasia. Assisting the patient in ending their own life on their own terms, with all the medical tools available to make it as painless and comfortable as possible is the ticket, in my opinion.

        You can also call me Captain Obvious.

  17. Posted December 3, 2014 at 2:25 pm | Permalink

    I’m all for death with dignity. I have a question for the AMA and most physicians I’ve ever met.
    What’s the difference between withholding medical treatment for FINANCIAL reasons and your position on do no harm and all the other codswallop you use to defend anti euthanasia thinking??? All the “pro lifers” out there feel free to weigh in.

    • trou
      Posted December 3, 2014 at 2:51 pm | Permalink

      Exactly.
      Prof. Ceiling Cat told of his experience a few days ago when he got his toe smashed. Did they first do no harm? Did they make it a priority to heal?
      No, they needed to get him into the system so they could make sure they got their money.
      So it’s not a Hippocratic oath, but a hypocritical oath that they must take as healers.

      • JoanL
        Posted December 3, 2014 at 6:49 pm | Permalink

        The longer they can keep you alive, the more money they can charge.

  18. Mel
    Posted December 3, 2014 at 2:26 pm | Permalink

    Follow the assisted dying movement: @CompAndChoices @BCoombsLee @DeathwDignity @dignityindying (in UK)

    The current assisted dying movement is concerned ONLY with legalizing PATIENT ADMINISTERED toxic drugs prescribed by a doc. (legal in 5 states now)

    The above statement by the AMA says nothing about patient administered toxic drugs prescribed by a doctor, which, unfortunately is sometimes called euthanasia.

    • Posted December 4, 2014 at 9:30 pm | Permalink

      I found this today. The AMA has an opinion (Opinion 2.211 http://goo.gl/fBELjv ) about what they call “physician assisted suicide” which reads much like Opinion 2.21. The current assisted dying movement focuses only on this and not on euthanasia.

  19. Posted December 3, 2014 at 2:28 pm | Permalink

    I have to add, it would be easier to take this opinion seriously were it not that the American healthcare system reserves the right to deny care to people based on ability to pay and to force into bankruptcy patients with limited means. I have read estimates that 10,000 to 20,000 people will die before their time (over the next year? ten years? not sure) in states which rejected the Medicare subsidies under the Affordable Care Act, thanks to a six-year-and-counting campaign that paints the president’s program as the worst totalitarian assault on liberty since Kristallnacht. But we force people to live in incurable agony against their will because we just love liberty so much.

    • Phil Giordana FCD
      Posted December 4, 2014 at 1:56 am | Permalink

      Very well put. The blatant hypocrisy of the American healthcare system as it is today.

  20. Mel
    Posted December 3, 2014 at 3:08 pm | Permalink

    Fred Nelligan, victim of ALS. He used Oregon’s death with dignity law in mid November. Here’s his story:
    http://www.oregonlive.com/milwaukie/index.ssf/2014/11/fred_nelligans_journey_through.html

  21. ladyatheist
    Posted December 3, 2014 at 3:30 pm | Permalink

    And yet the AVMA has decided it’s humane:

    https://www.avma.org/kb/policies/documents/euthanasia.pdf

  22. Posted December 3, 2014 at 3:51 pm | Permalink

    Very disappointing coming from the AMA. I didn’t realize this formal opinion was on the books.

  23. Diana MacPherson
    Posted December 3, 2014 at 4:14 pm | Permalink

    Patients shouldn’t be abandoned once it is determined that cure is impossible.

    What a load of fear mongering crap! When have terminal patients ever been abandoned? There’s a whole field called palliative care, for crying out loud!!

    Speaking from a Canadian perspective, since euthanasia is not (yet!) permitted here, doctors instead ask for permission to withhold food. You still must give water. So, in other words, it’s okay to slowly starve a dying patient instead of peacefully ending their pain and suffering. To me, this is in direct opposition to the Hypocratic Oath – how is this doing no harm? How is denying euthanasia doing no harm?

    A friend whose father had suffered a stroke and was in a coma was given this option. He chose not to take it because it is so cruel. Instead, he allowed them to operate on his father, knowing he’d die and never wake up.

    • JoanL
      Posted December 3, 2014 at 7:02 pm | Permalink

      Strikes me as perverted.

    • infiniteimprobabilit
      Posted December 4, 2014 at 5:34 am | Permalink

      “Patients shouldn’t be abandoned once it is determined that cure is impossible.”

      No, they should only be abandoned when financial support for treatment is no longer available.

    • Sean
      Posted December 4, 2014 at 7:54 am | Permalink

      I came here to write a comment about palliative care, and how this opinion skirts insulting to the people who, for example, run hospices.

      People ‘pull the [figurative] plug’ on terminally ill people all the time by with holding meds, overdose pain meds, switching off ventilators etc…

      And nobody bats an eyelid, because [normally] it was the RIGHT THING TO DO.

  24. Pliny the in Between
    Posted December 3, 2014 at 4:51 pm | Permalink

    This is one of the many reasons I never joined the AMA.

  25. Zach Donaldson
    Posted December 3, 2014 at 6:30 pm | Permalink

    We’re talking about the same AMA which still holds that marijuana is a “dangerous substance” and should be prohibited by law, right?

    • Phil Giordana FCD
      Posted December 4, 2014 at 1:58 am | Permalink

      Pothead spotted!

      • Phil Giordana FCD
        Posted December 4, 2014 at 1:58 am | Permalink

        Sorry, I just really wanted to use that phrase.

  26. Mattapult
    Posted December 3, 2014 at 7:16 pm | Permalink

    If our medical knowledge were perfect, then physicians could be perfect healers. The reality is that they are not perfect healers, therefore trade-offs must be considered and employed with discretion.

    Chemotherapy is not healing. It is an attempt to kill the cancerous cells faster than the poison kills the patient. Hopefully, the end result is healing, but it’s a calculated risk, and it doesn’t always work. The AMA statement should address the limitations of our knowledge.

  27. Posted December 3, 2014 at 7:28 pm | Permalink

    Here we have a medical version of the trolley problem, where people feel it’s okay to take a passive role that will kill someone (to save more people) but not an active one. You can turn off the feeding tube, but not give an overdose of morphine (which doctors already do anyway) or barbiturates. But the borders are less clear for assisted suicide than for the runaway trolley .

    This is a superlative example of why I consider the Trolley Bullshit to be worse than useless.

    Ostensibly, the point of the exercise is to give us insight into how to approach situations like this. But, clearly, But, clearly, fantasizing about crushing fat men beneath trains can’t even begin to approach the sort of soul-wrenching deliberation it takes to decide whether it’s better to prolong the agony of a real person or grant the person dignity and bodily autonomy. And when you add a sudden onset of a likely-to-pass serious depression of an otherwise healthy person into the mix? What’s the best thing to do in that case?

    These issues need to be confronted head-on, not dance around.

    For example, a psychological study I’d like to see would be one in which participants are told up front that this is one in which they’ll self-administer pain and then be asked to extrapolate how long they’d be willing to live with such pain before wanting suicide as an option. Then hand them the apparatus, complete with the intensity dial and on-off switch for them to control. Invite them to explore the threshold between “I could put up with this if I had to,” and, “If this is all I had to look forward to for the rest of my life, I’m outta here.” Make sure they know that they can opt out at any point, no pressure, no questions asked beyond, “Are you okay? Can we help?” but that you hope they’ll give it their best and you’re there to assist in any way they can think of.

    Such a study would reveal far more about this matter than an infinite number of Trolley Bullshits.

    (And, of course, it would need extremely careful oversight by the ethics board and others….)

    b&

  28. Posted December 3, 2014 at 8:36 pm | Permalink

    I quit the AMA years ago. It might have been a good organization once upon a time, but it’s proven itself so worthless, over the past couple decades, that it has faded, and keeps fading further, into relative obscurity, where it now belongs. Something isn’t right, there, though I don’t know enough for an outright claim of corruption.

  29. Posted December 4, 2014 at 5:28 am | Permalink

    This is why I have never belonged to the AMA. First, euthanasia is not “fundamentally incompatible with the physician’s role as healer.” It has never been clearer to me as a physician that it is the end of suffering that must take precedence at the end of life. To withhold interventions that end suffering–even if they hasten a death that is already inevitably hastening–is the true moral crime. If “the social commitment of the physician is to sustain life and relieve suffering” but those two imperatives become mutually incompatible, as they are and will continue to be more and more as medical technology advances, of course our obligation is to follow the wishes of the patient. (In what circumstances where a patient is of sound mind should it ever not be?) A patient of mine with end-stage ALS was recently admitted to the hospital. I had promised him when he was first diagnosed that I would do everything in my power to preserve his autonomy and prevent him from suffering, and I was able to keep that promise. And here is why the “slippery slope” argument is utter nonsense: intervening to speed a person’s death may be morally equivalent to allowing them to die on their own, but to the person intervening it FEELS completely different. While the latter is painful and sad, the former, for me at least, is gut-wrenching. But when the former is what a patient of sound mind facing a terrible terminal illness tells me he wants–convinces me he wants–then preservation of his autonomy and the relieving of his suffering becomes my primary responsibility. It is sometimes hard to tell when medical interventions are no longer prolonging life but instead are prolonging dying–but that period of uncertainty is typically short. And if not a trusted physician who has a long-standing relationship with the patient, who should it be that helps the suffering terminally ill end their suffering?

    • infiniteimprobabilit
      Posted December 4, 2014 at 5:43 am | Permalink

      Thank you.

    • Posted December 4, 2014 at 11:47 am | Permalink

      For anyone here who’s interested, I put up a personal story on my blog about the difficulty of figuring out exactly how to decide about end-of-life care for patients who are mentally incapacitated. http://bit.ly/1wzf6z4

      • Posted December 4, 2014 at 12:01 pm | Permalink

        I just read Alex’s post, and it’s ineffably sad and deeply moving. I recommend it highly.

  30. Sojourner
    Posted December 4, 2014 at 10:16 am | Permalink

    My wife taught biomedical ethics at 2 different institutions where we live. She taught would be nurses and doctors. While the doctors, as a whole, agreed with her lessons that suffering and/or terminally ill patients should be able to die with dignity she found a high amount of resistance to that among the nurses.
    My older daughter & I aren’t so sure that my wife’s suffering wasn’t brought to a quicker end by the administration of ever more frequent pain killers. If that was the case then we are ok with that. Cancer invaded my wife’s ribcage which brought on agonizing pain for her. When she was taken to the palliative care ward the supervising doctor asked me what I wanted for her in medical care and I responded that I wanted her kept comfortable and pain free as much as possible. There was no point in any “heroic” life saving procedures especially since that would likely open the tumour(s) and cause her to bleed out. The doctor was glad to hear what I wanted for my wife.
    My wife had always said that if she could no longer use her mind then she would want to be left, or assisted, to die because her quality of life was all about being able to use her mind.
    As was said above, when doctors can no longer heal, as with the terminally ill, then they should be able to choose to alleviate a patients suffering with allowing or helping a patient to die in a manner agreeable to the patient.

  31. Posted December 4, 2014 at 10:28 am | Permalink

    The AMA position is not really defensible methinks.
    ‘Quality of life’ and preventing suffering are just as important as preserving life in the ‘mission’ of a physician.

    Luckily many physicians use a painkilling combination of opiates and sedatives to kill terminal patients, even in countries where euthanasia is a nono. I have been complicit in these actions in the (long ago0 past (I hope to be offered the same compassion when I will be in such a situation). In the end death is inevitable anyway, a fact that is often neglected.
    Of course it would be better if euthanasia were legal, supported by medical associations and open, submitted to rules and protocols of best practice, in fact, that would prevent rather than cause the ‘slippery slope’. It is there that AMA is completely out of touch with reality.

    I think that the medical assistance in carrying out death sentences (which in principle I do not support) is indeed a completely different issue.

    ‘Sub’, in other words.

  32. lancelotgobbo
    Posted December 4, 2014 at 12:06 pm | Permalink

    Warning: stupendously long reply coming!
    I do hospital care as well as an office practice, and it commonly involves palliative care. I’ve known my patients in this rural and under-doctored area for up to thirty years and I’m not going to forsake them at the end. Assisted suicide is not legal here, but there is a good chance that it will be considered in parliament when we get rid of Harper. In general, the emphasis in end of life care in Canada is much more humane than that which I read about in the US – quality of life prevails over quantity. We simply don’t do heroics on dying people, and it may be that’s because there is no financial incentive to do them (and perhaps even a disincentive as their extra costs are paid for in our taxes). Proper palliative care can diminish the need to think about assisted suicide, but of course it doesn’t eliminate it.
    Let’s think first of who might qualify:
    1. There will be people who hate their lives, but who aren’t terminally ill. Should they qualify?
    2. How about the depressed, especially those who have been resistant to treatment. They may be rational and simply feel it isn’t worthwhile.
    3. Physically disabled people, perhaps in great pain or having shitty quality of life, but with their life=expectancy undiminished?
    4. I assume none of us would object to the terminally ill being included.
    So those things need to be hashed out. It doesn’t have to be all at once; we could easily agree to write a law for the terminally ill and later add other categories if there is general agreement among the public and the politicians that it is right to do so. In jurisdictions where these things have been enacted, it is generally left to a physician to prescribe a lethal dose of medication, and it is up to the patient to self-administer it. There is no expectation that a physician must do this on demand; they have the option to decline and allow some other doc to do it as a matter of conscience.
    In the comments here, there is a good deal of ‘it’s about the patient, not about you’ directed at docs who raise even mild objections to being given this role, to the extent in one case of a thoughtful doc being told he needs to change career. Well, I’ve some sympathy with him/her, despite my long history of supporting assisted suicide, and my liberal exploitation of the ‘dual-effect’ of narcotics in the terminally ill. The first reason is that as a professional, I owe my patients something that is central to my job – my best opinion. I don’t do my job if I give people what they want, I only do it if I give them what my professional judgement says is right. I have to justify it to myself, which I assess by imagining all my colleagues looking over my shoulder and second-guessing me. If I think they would agree, I can go ahead. There is no such thing as just writing a prescription that somebody requests without some judgement being applied; anything else is an abnegation of duty. It’s not always popular, but it is the difference between seeking a professional opinion and hiring a tradesman. It’s nothing to do with arrogance, but is a basic expectation of fulfilling the duty of care and any licensing body would come down hard on a doctor who didn’t take it seriously. Consequently, I have to approach a lethal prescription the same way. This is a matter that should be up to the patient, but by involving a doctor you invoke his judgement. I don’t really want to be the judge of that – it is simply not my decision, as well as being exhausting. There’s something else too, and that is that I carry another burden afterwards in that I would feel some responsibility for that death. We all have a metaphorical bag of bones that we drag around after ourselves, filled with our mistakes that we wish we could do over. None of us need to make it heavier than it is. Now it’s likely that 90% of requests wouldn’t trigger any difficult ethical decision, but even then I still get the burden of responsibility.
    The second reason is a logistical one. I’m in a rural area. There isn’t another doctor always available to step in when the first doesn’t want to do it. It would also be the strong expectation (and a reasonable one) that a patient who has trusted me for thirty years would want me to be in on this very important matter. There would be pressure to conform, whatever my conscience said, or whether or not I agreed in that particular case (again, I know it’s not my decision, but you can’t get me involved without me having an opinion.) I’m already the only doctor in the area willing to dirty his hands with abortions. The others can keep their lillywhite consciences clean by telling their patients to see me for this purpose, though how they justify that to themselves as being morally superior I’m not sure. What does it do to my reputation and self-respect if I’m not only ‘the abortion doctor’, but the one who is willing to ‘finish off’ patients?

    So all in all, I am in favour of assisted suicide being available, and I’m probably more willing than most to include ‘rational suicides’ outside the traditional terminally ill applicants. I’m not sure we need to include a doctor in the process, beyond certifying that a patient has no hope of cure in the latter cases, and that the patient understands the nature and implications of his decision in the former. I’m sure I’m being influenced in this by a couple of factors. One was the decision made by me, my brother and my mother to withdraw fluids from my father after a devastating stroke (paralysed, no speech, nor understanding of speech, no ability to swallow, but eyes open and able to smile. All in a man who had lived the life of the mind. ‘Shut-in’ syndrome with presumably nothing but wordless feeling to occupy his consciousness.) It’s common practice to treat big strokes palliatively when there seems no hope of any quality of life, and I don’t know how many times I have led a family through the decision making process. I never knew I would still be questioning myself as to whether I had done the right thing 15 years later. The other thing is that it seems likely I now know how I shall die myself (leukemia), and that it will probably be between five and ten years from now. Naturally I have been thinking on it a lot, but I’m still confused as to how I should proceed mentally. Yes, I would want the right to die, but I suspect decent palliative care will make the process comfortable enough that I don’t exercise that right. Complicated.

    • Diana MacPherson
      Posted December 4, 2014 at 1:31 pm | Permalink

      I know there are challenges before the Supreme Court and we should hear the results soon so change is hopefully coming to Canada.

    • Diane G.
      Posted December 9, 2014 at 11:00 pm | Permalink

      I’m very sorry about your illness, lancelotgobbo.

      And–I wish I had a doctor like you.

  33. Mel
    Posted December 4, 2014 at 7:39 pm | Permalink

    The AMA’s position on physician assisted suicide is in another opinion: Opinion 2.211. Note that it reads much the same as Opinion 2.21. Opinion 2.211 is the one relavant to the assisted dying movement in progress now in the US and UK. Neither are asking for any form of euthanasia as defined by the AMA in Opinion 2.21. Use of the term “euthanasia” for PAS only muddies the discussion because it’s also used for a procedure not being advocated.


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