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PHYSICIAN-ASSISTED SUICIDE AND VOLUNTARY ACTIVE EUTHANASIA
AGS Ethics Committee
*Last Updated 2007*
Background
The American Geriatrics Society has previously issued a statement on Physician-Assisted Suicide (PAS) and Voluntary Active Euthanasia (VAE). The public debate on this subject reflects the concerns of many individuals about what will happen in the last phase of their lives. The Society has affirmed that patients have the authority to choose among available plans of care, but their autonomy is limited when there are substantial detrimental effects on the lives of others or their choices conflict with legal or professional standards. (See AGS position statement, "Medical Treatment Decisions Concerning Elderly Persons"). Advocates of extending legal and professional standards to include VAE and PAS believe it is the patient's right to choose deliberately to end his or her life, under circumstances of intolerable suffering, when that individual reasonably and voluntarily prefers death to the life that confronts him or her.
DEFINITION OF TERMS
Physician-assisted suicide: When a physician provides either equipment or medication, or informs the patient of the most efficacious use of already available means, for the purpose of assisting the patient to end his or her own life.
Voluntary active euthanasia: When, at the request of the patient, a physician administers a medication or treatment, the intent of which is to end the patient's life.
Withholding or withdrawing treatment: When a medical intervention is either not given or the ongoing use of the intervention is discontinued, allowing natural progression of the underlying disease state.
POSITION
1. For patients whose quality of life and expected lifespan has become so limited as to make earlier death preferable to prolongation of life, the professional standard of care should be that of aggressive palliation of suffering and enhancement of opportunities for a meaningful life, not that of intentional termination of life. It is morally acceptable for a physician to administer a medication or forgo a treatment calculated to improve the patient's and the family's experience, knowing that this plan of care may have the unintended effect of hastening the patient's death. Good care may include the withholding or withdrawing of any medical intervention as well as the specific palliation of symptoms, even if this shortens a person's life.
2. The patient's request for death should trigger the physician's thorough exploration and understanding of the patient's suffering, the reason the request is being made at that particular time, and a vigorous and sustained effort to relieve the distress.
3. Patients for whom these issues are relevant should be informed of two important facts:
a) profound pain can be relieved with analgesia or sedation, if necessary, and b) patients may choose to forgo any life-prolonging intervention including artificial nutrition and hydration.
Because these issues are often misunderstood, physicians have the responsibility to inform their patients of these alternatives.
3. Laws prohibiting VAE and PAS should not be changed. In giving a patient the means to palliate his or her symptoms, a physician may unavoidably provide the means for suicide (e.g., by prescribing necessary but potentially lethal medications). The law should differentiate between this situation and the intentional participation in the planning and execution of a suicide.
4. If PAS or VAE are legal in any jurisdiction, the AGS contends that the strongest protection for patients to make a choice free of coercion should be in place, and that it should be illegal for professional caregivers to receive financial compensation for assisting in suicide or euthanasia.
RATIONALE FOR CONTINUED PROHIBITION
1. Historically, the fundamental goal of the doctor/patient relationship has been to comfort and to cure. To change the physician's role to one in which comfort includes the intentional termination of life is to alter this alliance and could undermine the trust between physician and patient.
2. Allowing VAE and PAS opens the door to abuse of the frail, disabled, and economically disadvantaged of society, by encouraging them to accept death prematurely rather than to burden society and family.
3. It is the general consensus of the AGS that most individuals who consider PAS or VAE do so out of fear of the dying process. The vast majority of patients can be comfortable (which might require sedation) and potentially could find meaning in the last phase of life and choose to forgo a life-sustaining treatment and accelerate dying. All of these options for care, are already legal. Most would choose to live if they had full confidence that the care system would serve them well. A thorough search for the underlying reason for the request for death may uncover several areas amenable to potential interventions (e.g., undertreated physical symptoms, psychosocial or spiritual crisis, clinical depression, etc.).
4. Legalization of physician-assisted suicide might thwart society's resolve to expand services and resources aimed at caring for the seriously ill, eventually dying patient.
RECOGNITION OF THE CONSEQUENCES OF CONTINUED PROHIBITION
1. By prohibiting physicians from participating in VAE or PAS, society is limiting the patient's autonomy to choose his or her mode of death. For a patient who has intractable suffering and a limited life span, who has turned down general sedation, and who wishes to avail him- or herself of the choice to plan or execute his or her own demise, this position statement calls upon physicians to withhold our professional assistance. This seems to be a reasonable balancing of our commitment to securing adequate care for the many patients who would be put at risk of shortened lives if VAE and PAS were made available.
2. A small number of patients will choose this alternative despite our professional non-participation and they may be troubled by losing their doctor's involvement. Nevertheless, to respect the moral commitments of all concerned, physicians must be able to disengage from involvement in this aspect of the patient's plan. The physician should ensure that the patient continues to have access to needed medical care.
Developed by the AGS Ethics Committee and approved by the AGS Board of Directors in November 1994. Reviewed and updated in May 1998, November 2002, and May 2007. This statement will next be reviewed in 2010. The American Geriatrics Society, The Empire State Building, 350 Fifth Avenue, Suite 801, New York, NY 10118, 212-308-1414, Fax: 212-832-8646, info.amger@americangeriatrics.org.
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