Report of the Board of Trustees of the American Medical Association.

• Position: Transcript

Subject: Euthanasia/Physician-Assisted Suicide: Lessons in the Dutch Experience Presented by: Lonnie R. Bristow, M.D., Chair Referred to: Reference Committee on Amendments to Constitution and Bylaws (Louis R. Zako, M.D., Chair) Executive Summary

This Board of Trustees Report urges physicians to be aware of continuing efforts by some in society to end suffering by speeding deaths through medical interventions. The experience in Holland with euthanasia and physician-assisted suicide is outlined in this report, as are the differing interpretations of the Dutch data by voices in Holland. The Dutch guidelines intended to protect patients have not been consistently respected. The sum of the experience suggests that implementation of their controls on euthanasia and physician-assisted suicide has not been effective.

Recognizing that there are differences between withholding or withdrawing life-sustaining treatment and euthanasia and physician-assisted suicide, the availability of mechanisms for end of life medical decisionmaking by patients, such as powers of attorney, etc., should be more widely promoted. The Board of Trustees recommends that the American Medical Association reject euthanasia and physician-assisted suicide as being incompatible with the nature and purposes of the healing arts.

The Report

The issue of physician-assisted suicide is not a recent one. The Oath of Hippocrates is said to have originated in approximately the fifth century B.C. and, even then, it incorporated a specific pledge against physician-assisted suicide when it said, "I will give no deadly medicine to anyone, even if asked." During the succeeding twenty-five centuries, both science and society have seen great changes. One result is a growing ambivalence in society, which simultaneously fears that high technology may maintain life long after life is meaningful, but that same powerful technology may be incapable of adequately controlling their pain. Another result is a society with a growing appetite for individual control of body and mind, to the point of an even stronger desire to designate their individual moments of death. Proponents of this latter "option" often point to the physician as a possible implementing instrument of choice, asserting that certain noncumbersome "safeguards" could be put in place to protect against the potential for abuse.

The Board of Trustees urges that physicians be aware of these continuing efforts by some in society to end suffering by speeding deaths through medical interventions. The Council of Ethical and Judicial Affairs has reported on the issues, more than once, most recently at this meeting. Regrettably, activism around this concept can be expected to persist. The medical profession must be prepared to be no less persistent in its rejection of all initiatives directed toward that end.

Because the Netherlands is the country one is most apt to identify when physicians and euthanasia are discussed together, a review of the experience in Holland appeared appropriate. The review was assisted by events; in 1990, Holland appointed a Commission of Inquiry into the Medical Practice Concerning Euthanasia, chaired by the attorney general of the Dutch Supreme Court, to evaluate the position of this issue. The essence of the information it developed and other materials on the Dutch experience are reviewed and summarized in this report.

It would be an error not to appreciate that this issue has already entered the arena of public debate and decision in the United States. One state, Washington, narrowly defeated an initiative recently that would have legalized "mercy killing." Similar initiatives currently are under consideration in a number of other states. Polls reveal that as many as 63% of the public favor legalizing some form of physician-assisted suicide and euthanasia, with even larger figures (81%) supporting legally allowing physicians to carry out the terms of a patient's advance directives and 76% favoring "legislation that would permit withdrawal of life-support systems (including food and water) from hopelessly ill or irreversibly comatose patients if they or their families request it."(1) When queried at a personal level, however, only 52% would consider some alternative to end their own lives if they had a painful terminal illness and no hope of recovery--revealing personal ambivalence over this issue.

In a Colorado survey, 60% of physicians stated that they have cared for patients for whom they believe active euthanasia would be justifiable, and 59% expressed a willingness to use lethal drugs in such cases if legal. In a study of 676 San Francisco...