Report of the Council on Ethical and Judicial Affairs of the American Medical Association.

• Position: Transcript

Subject: Physician-assisted Suicide (Resolution 3, A-93) Presented by: John Glasson, M.D., Chair

Referred to: Reference Committee on Amendments to Constitution and Bylaws (Louis R. Zako, M.D., Chair) Introduction(*)

Physician-assisted suicide presents one of the greatest contemporary challenges to the medical profession's ethical responsibilities. Proposed as a means toward more humane care of the dying, assisted suicide threatens the very core of the medical profession's ethical integrity.

While the Council on Ethical and Judicial Affairs has long-standing policy opposing euthanasia, it did not expressly address the issue of assisted suicide until its June 1991 report, "Decisions Near the End of Life." In that report, the Council concluded that physician-assisted suicide is contrary to the professional role of physicians and that therefore physicians "must not ... participate in assisted suicide." Previously, the Council had issued reports rejecting the use of euthanasia. In June 1977, the Council stated that "mercy killing or euthanasia--is contrary to public policy, medical tradition, and the most fundamental measures of human value and worth." Similarly, in June 1988, the Council reaffirmed "its strong opposition to |mercy killing.'"

Broad public debate of assisted suicide was sparked in June 1990, when Dr. Jack Kevorkian assisted in the suicide of Janet Adkins. The debate was advanced in March 1991 when Dr. Timothy Quill disclosed his assistance in the suicide of Diane Trumbull. Other public events quickly followed. Physician-assisted suicide, together with euthanasia, was placed on the public ballot in Washington state, in November 1991, and in California, in November 1992. Both times, voters turned down proposals to legalize physician-assisted dying. In September 1993, by a vote of 5-4, Canada's Supreme Court denied a woman's request to end her life by assisted suicide. In 1994, voters in Oregon will decide whether to legalize assisted suicide in their state.

Resolution 3, introduced at the 1993 Annual Meeting by the Medical Student Section and referred to the Board of Trustees by the House of Delegates, requested an ethical study of assisted suicide. In this report, the Council revisits the issue of physician-assisted suicide.

Definitions

Assisted suicide occurs when a physician provides a patient with the medical means and/or the medical knowledge to commit suicide. For example, the physician could provide sleeping pills and information about the lethal dose, while aware that the patient is contemplating suicide. In physician-assisted suicide, the patient performs the life-ending act, whereas in euthanasia the physician administers the death-causing drug or other agent.

Assisted suicide and euthanasia should not be confused with the provision of a palliative treatment that may hasten the patient's death ("double effect"). The intent of the palliative treatment is to relieve pain and suffering, not to end the patient's life, but the patient's death is a possible side effect of the treatment. It is ethically acceptable for a physician to gradually increase the appropriate medication for a patient, realizing that the medication may depress respiration and cause death.

Assisted suicide also must be distinguished from withholding or withdrawing life-sustaining treatment, in which the patient's death occurs because the patient or the patient's proxy, in consultation with the treating physician, decides that the disadvantages of treatment outweigh its advantages and therefore that treatment is refused.

Ethical Considerations

Inappropriate Extension of the Right to Refuse Treatment

In granting patients the...