Position Statements

Comprehensive End-of-Life Care and
Physician-Assisted Suicide

Approved by the Board of Directors
June 25, 1997

The American Academy of Hospice and Palliative Medicine ("Academy") believes that hospice and palliative care must play a central role in end-of-life care. The mission of the Academy is to promote the development and universal availability of comprehensive palliative care. This care should be extended to those with limited life expectancy due to advanced age, developmental or congenital anomalies, injuries, or disease.

The central goal of hospice and palliative care is the relief of pain and suffering. In order to achieve this, a physical and social environment must be established conducive to comfort. This environment must include the patient’s personal and cultural values in the face of expected death.

The ideal model of hospice care is one in which fully informed patients, having considered all feasible treatment options, determine that the potential burdens associated with curative interventions are outweighed by the anticipated benefits of care focused on symptom relief and quality of life. Patients may opt for treatment in the setting of their choice (usually at home) surrounded by supportive family members and friends. Assisting in this process is an interdisciplinary team of health care professionals, clergy, and volunteers dedicated to providing the means for patient and family to remain free from intolerable suffering, whether physical, emotional, psychosocial, or spiritual. Patients and families are thus helped not only to live comfortably during end-stage illness, but also helped to cope with and adequately prepare for inevitable death. Indeed, such care may facilitate significant growth and healing during the dying process.

The ability of hospice and palliative care to alleviate suffering is vastly under-estimated and under-utilized by the public and health care professionals. Access to these services by a large portion of our population has been limited by cultural, financial, regulatory, and philosophical barriers. Their absence as an informed choice has regrettably compelled some patients to seek death prematurely. We therefore promote major efforts towards improving such access to hospice and palliative care by the ongoing education of health care providers, training programs, third party payors, and society. This must include education in the principles, practice, and benefits of palliative medicine.1 Scientific research with the goal of improvement of symptom relief and care of patients with end-stage illness remains essential.

Principles Guiding Care at the End of Life

Ethical care of patients at the end of life centers around the principles of autonomy, beneficence, and non-maleficence (see glossary)2,3. There is a great difference of opinion as to how to balance these frequently conflicting principles. Professional integrity must prevail as these principles are weighed and applied to specific clinical situations3,4. All members of the Academy strongly support respect for patient autonomy. There are limits to autonomy, though, as it conflicts with beneficence toward the patient and society as well as the health care provider. Respect for autonomy includes the right to have interventions withdrawn or withheld upon request of the patient or designated surrogate, thus relieving the patient of interventions he feels too burdensome compared to expected benefits. The withholding or withdrawal of life-sustaining intervention is not considered euthanasia in current ethical and legal contexts.

Palliative care entails intensive assessment and multidisciplinary interventions to alleviate suffering. Liberal use of opioids and other medications may be essential to the adequate and ethical management of a patient’s condition. At times, medication doses may be required that put a patient at risk for hastened death as an unintended effect. While such possibilities demand caution in treatment, one would still have acted ethically should death occur as a result of the treatment needed to relieve undesired symptoms. Although the primary goal of palliative care is to provide symptom relief without sedation, it may at times be appropriate to provide sedation to achieve adequate relief from distressing symptoms, at the patient’s request.

Physician Assisted Suicide and Euthanasia

Patients enduring severe suffering may at times ask for assistance in ending their lives. Suffering may arise from many sources including fear of pain or other distressing symptoms, isolation, or loss of dignity near the end of life. Our obligation as an organization is to reduce this suffering by increasing the awareness and availability of palliative care. Universal availability of comprehensive palliative care would greatly reduce the perceived need for physician-assisted suicide ("PAS") or euthanasia.

Physicians have an obligation to scrutinize carefully the source of requests for assistance in suicide in hopes of discovering ways to alleviate the patient’s suffering. Attention must focus on sources of physical, emotional, psychosocial, and spiritual distress. Sources of fear need to be addressed including patients’ perceptions of being an undue burden on family and caregivers. Patients should be evaluated and treated for depression when present. Above all a caring, understanding attitude must prevail to encourage dialogue and to effect the best chance of relieving distress. However, even given the best that palliative care can offer, not all severe suffering can be alleviated.

Deep disagreement prevails as to the morality of euthanasia and PAS as well as to patients’ rights in this regard. Sincere, compassionate, morally conscientious individuals stand on either side of the debate on these issues. Many questions regarding euthanasia and PAS warrant serious consideration but are difficult or even impossible to answer at this time. Different assumptions and responses exist regarding the nature, likelihood, and significance of dangers that might occur were euthanasia and PAS openly practiced in our society and help to account for the diversity of opinion. Controversial areas include those regarding the likelihood of the "slippery slope" leading to involuntary euthanasia; patient/physician trust issues; how legalization of euthanasia/PAS might undermine or enhance the quality and availability of palliative care in terms of pain and symptom management as well as improvement of approaches to care that focus on the human and personal aspects of dying and life completion; and how society might be impacted by a more open and supervised practice of euthanasia/PAS in contrast to the current covert, unmonitored and illegal practice.

Should euthanasia and/or PAS become legalized, the Academy believes such legislation must take into account many essential issues including:

1. these acts could only be entertained in the context of an adequate trial of comprehensive palliative care;
2. no one should ever be pressured to act against his own conscience if asked to assist someone in dying;
3. safeguards must minimize the potential for abuse, focusing in particular on protection of more vulnerable groups such as the elderly, poor, physically and mentally handicapped, and frail; and against undue family or external influences upon patient preferences;
4. financial pressures by third party payors to terminate life would need to be forbidden; and
5. involuntary PAS or euthanasia would never be acceptable.

Were euthanasia and PAS being practiced in a regulated fashion, the hospice and palliative care approach should be that of non-interference in the receipt of these services, and non-abandonment of the person seeking assistance in suicide or of the family during the dying process and the period of bereavement. In the practice of palliative care, the appropriate response to the request for physician-assisted suicide is to increase care with the intent to relieve suffering, not to deliberately cause death.

Conclusion

As end of life approaches, patients deserve to be treated in ways that provide as peaceful, humane, and dignified a death as possible. The primary goal of end-of-life care must be alleviation of suffering while upholding respect for patients’ and families’ values. The optimal relief of suffering near death is best achieved through the skilled and compassionate care offered by hospice and palliative care programs where the focus of care is relief of physical, psychological, social, and spiritual distress. It is through such an integrated approach to end-of-life care that fears and suffering are eased, personal growth and preparation for death can occur, and desire for a hastened death can be minimized.

Euthanasia and/or physician-assisted suicide may well become legalized in our society. Were such legalization to occur, the Academy would promote many precautions to their use as well as intense efforts to alleviate suffering and obviate any perceived need for PAS or euthanasia. In the practice of palliative care, the appropriate response to the request for physician-assisted suicide is to increase care with the intent to relieve suffering, not to deliberately cause death. Within hospice and palliative care programs in this context, the Academy would promote an approach of non-interference and, above all, non-abandonment of the patient and family.

It is toward the continuing improvement of the art and science of hospice and palliative care through practice and research, as well as their ever expanding availability through promotion and education, that the American Academy of Hospice and Palliative Medicine focuses its primary commitment.

Glossary

Autonomy: The principle that allows individuals to have freedom and authority over decisions regarding their lives and treatment in accord with their own particular values, consciences, and religious convictions. This includes not only the freedom to be given all relevant information, but also the freedom to choose among all ethical, legal and medically available choices. It is thus one’s right to pursue the "good" as one defines it for himself, free of unjustified interference.

Beneficence: Beneficence is defined by the goals of our actions--to achieve "good" for patients and society. Action in the best interests of a person is a manifestation of beneficence. The principle of non-maleficence, on the other hand, promotes the avoidance of harm. Our attempts to achieve good, in accordance with the principle of beneficence, however, are complicated by the great diversity that exists in how individuals, even within a given ethnic, socioeconomic, or educational community, rank order goods and harms.

Death with Dignity: Experience of the dying process in a fashion in which the patient is treated respectfully, consistent with his value system.

Euthanasia: Applied to contemporary contexts, the term euthanasia is generally used to designate the active provision, upon voluntary request, of a medication or other means, the primary intent of which is to end life rather than simply to alleviate symptoms.

Palliative Care: The total care of patients with progressive and advanced disease for whom the prognosis for survival is limited and the focus of care is on relief of suffering and promotion of the best quality of life for patient and family. Relief of pain and other physical symptoms, as well as attention to psychological, social, and spiritual problems are essential. Palliative care is best provided by an interdisciplinary team.

Physician-Assisted Death (PAD): This term is sometimes used interchangeably with physician-assisted suicide, but technically goes one step further. Here a physician actually helps to administer oral or injectable medication with the primary purpose of fulfilling a patient’s informed wishes to end life rather than endure further suffering. In this respect, PAD is actually voluntary active euthanasia with a physician participating in the administration of some pharmacologic agent.

Physician-Assisted Suicide (PAS): A patient’s choice of suicide is aided by a physician providing the pharmacological means and/or instruction of how to accomplish suicide without direct physician participation in the actual administration of such means.

Professional Integrity: Acting with professional integrity in medicine is conduct consistent with a framework in which ethically appropriate means are used to achieve the goals of medicine. Words and actions must be consistent with a core set of professional values and moral principles that are essential to the practice of medicine.

Withdrawal of Life-Sustaining Medical Interventions: The intentional discontinuation of an intervention already underway, even if death due to the underlying process is a probable consequence of this action.

Withholding of Life-Sustaining Medical Interventions: The intentional decision to not start a particular medical intervention, allowing the patient to die from a known underlying process.

References

Byock IR, Forman WB, Appleton M, "Academy of Hospice Physicians’ Position Statement on Access to Hospice and Palliative Care." J. of Pain and Symptom Management, 11 (2): 69-70, 1996.

Engelhardt HT, Jr., The Principles of Bioethics. Oxford: Oxford University Press, 1986.

Beauchamp TL, Childress JF. Principles of Biomedical Ethics. Fourth ed. New York: Oxford University Press, 1994.

Miller FG, Brody H, "Professional Integrity and Physician-Assisted Death," Hastings Center Report,25, no. 3 8-17, 1995.

"Physician-assisted Suicide: Toward a Comprehensive Understanding." Report of the Task Force on Physician-Assisted Suicide of the Society for Health and Human Values. Academic Medicine, 70(7): 86-93, 1995

Further Reading

Brody BA, ed., Suicide and Euthanasia. Historical and Contemporary Themes. Dordrecht: Kluwer Academic Publisher, 1989.

Buehler DA. "CQ Sources/Bibliography: Special Section: Physician-Assisted Suicide: The Escalating Debate." Cambridge Quarterly of Healthcare Ethics, 5(1): 138-143, 1996.

Cassel CK, Mayer RJ, Clark H, Schecter GP, Edwards AL, Blank LL, Caring for the Dying. Identification and Promotion of Physician Competency. Philadelphia: American Board of Internal Medicine, 1996.

Cavanaugh TA, "The Ethics of Death-Hastening or Death-Causing Palliative Analgesic Administration to the Terminally Ill." J. of Pain and Symptom Management, 12(4): 248-254, 1996.

Doyle D, Hanks G, MacDonald N, eds., Oxford Textbook of Palliative Medicine. Oxford: Oxford University Press, 1993.

Fins JJ, Bacchetta MD, "The Physician-Assisted Suicide Debate: an Annotated Bibliography of Representative Articles." The Journal of Clinical Ethics, 5(4): 325-340, 1994.

Jonsen AR, "A Guide of the Perplexed--Assisted Suicide." Western Journal of Medicine, 165(4): 250-251, 1996.

McCarrick PM. "Scope Note 18: Active Euthanasia and Assisted Suicide." Kennedy Institute of Ethics Journal, 2(1): 79-100,1992.

Miller FG, "The Good Death, Virtue, and Physician-Assisted Death: An Examination of the Hospice Way of Death." Cambridge Quarterly of Healthcare Ethics, 4: 92-97, 1995.

Sheehan DC, Forman WB, Hospice and Palliative Care. Boston: Jones and Bartlett, 1996.

Stanley, JM, ed., "The Appleton International Conference: developing guidelines for decisions to forgo life-prolonging medical treatment." Journal of Medical Ethics, 18, supplement: 3-22, 1992.

Storey P, Knight CF, Ethical and Legal Decision Making when Caring for the Terminally Ill. Gainesville: American Academy of Hospice and Palliative Medicine, 1996.

Thomasma DC. "An Analysis of Arguments For and Against Euthanasia and Assisted Suicide: Part One." Cambridge Quarterly of Healthcare Ethics, 5(1): 62-76, 1996.