CYTOSource Current Issues for Cytopathology
As laws legalizing physician-assisted suicide gain ground in Canada and elsewhere, physicians readjust their stance to retain a say This is Part 1 of a 2-part series on the medical profession’s recalibrated response to physician-assisted death. n November 2014, cancer patient Brittany Maynard ended her life after an incurable brain tumor left the 29-yearold woman with severe headaches, seizures, and increasing debilitation. Ms. Maynard had moved from California to Oregon to access the state’s Death with Dignity Act, which permits physicianassisted suicide among terminally ill patients. While Ms. Maynard’s decision reignited a simmering debate in the United States over the right to die, parallel battles were playing out in Canada, Great Britain, Australia, and other countries. Public support for legalizing assisted
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Cancer Cytopathology Cancer Cytopathology
death in most developed nations has long outpaced support from the medical community. However, over the past few years, more physicians have begun supplementing questions concerning whether the practice should ever occur with pragmatic queries about how it might be done in a way that protects both patients and physicians.
The Debate in Canada The shift has been most apparent in Canada, where the Supreme Court of Canada voted unanimously in February 2015 to reverse its 1993 ban on physician-assisted suicide, reasoning that the “right to life” also allows a patient to end it. The court stayed its decision for a year, however, giving the country’s parliament time to regulate the practice.
June June2015 2015
Opinions in the United States and Great Britain In Great Britain, a recent poll of more than 5000 adults found that an overwhelming 82% supported a proposed Assisted Dying Bill that would allow assistance in dying for a terminally ill and mentally competent person with an expected survival of 6 or fewer months. Reflecting a far lower level of support among medical professionals, the British Medical Association and the Royal College of Physicians both announced their opposition to the bill, patterned after Oregon’s 1997 Death with Dignity Act. However, The BMJ
327 2
Debating the Right to Die
a Shift in Tone Among Physicians
As the case wended its way through the courts in 2014, the Canadian Medical Association (CMA) publicly retreated from its longstanding opposition. Jeff Blackmer, MD, the association’s vice president for medical professionalism, said the change followed a series of town hall meetings. “We started to get a sense from the membership, from the public, that we needed to nuance our position a little bit,” he said. The association had previously said the legality of assisted suicide was ultimately up to society to decide, but recognized that its existing policy would effectively bar physicians from participating even if the practice was legalized. “And we realized that probably wasn’t a very helpful or pragmatic or nuanced position to be taking, especially as we saw that this case was working its way through the court system and we felt there was a fairly good chance that it would overturn the law,” Dr. Blackmer said. The association wanted to be in a position to say that it would respect and protect the rights of members who did not want to participate in assisted suicide, meaning that it also had to recognize the rights of members who did want to participate—approximately 27% according to a recent poll. A resolution at the association’s general council meeting in August 2014 pledged new support to those members, provided they acted within the bounds of existing legislation. “And that’s also allowed us to really participate actively in the discussion around what that law should look like,” Dr. Blackmer said.
CYTOSOURCE
In Debating the Right to Die,
By Bryn Nelson, PhD Edited By Terence J. Colgan, MD
CYTOSOURCE
Debating the Right to Die
CONTINUED from previous page
diverged from its parent organization with a pro-bill editorial that stated, “It’s the right thing to do, and most people want it.”1 The Royal College of Physicians also acknowledged a “shift in opinion” among its members, with growing support for assisted suicide among the terminally ill. In response to a reporter’s question about the American Medical Association’s stance, a spokesperson pointed to an opinion from the AMA Code of Medical Ethics that was last updated in 1996, 1 year before Oregon’s precedent-setting law took effect. The opinion asserts, in part: “Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.” However, the spokesperson deferred to the California Medical Association on questions concerning that state’s pending End of Life Option Act, and subtle signs suggest that the historical opposition may be softening. In 2009, 2010, and 2013, the California Medical Association’s house of delegates debated but ultimately rejected proposals to take a neutral stance on physician-assisted suicide, according to spokesperson Molly Weedn. “We’re currently ‘oppose unless amended’ on the bill,” she said. Exactly what those amendments are remains to be seen. She suggested that the right ones wouldn’t take the association to “a full support” of the bill but would remove its opposition.
Aid in Dying What It Is Called and Where It Is Legal
A
lthough wording is a sensitive topic, most medical organizations use the blanket term “physician-assisted death” to refer to any involvement of a medical provider in the voluntary death of a patient. More specifically, “physician-assisted suicide” refers to a medical provider prescribing a lethal dose of painkilling medication for a patient but not administering the drugs. The practice (also called “physician aid in dying” or “medical aid in dying”) is legal in Switzerland and in parts or all of 5 US states: Oregon, Washington, Vermont, Montana, and New Mexico. In December 2015, it will also be legal in the Canadian province of Quebec, whereas jurisdictions ranging from California to Great Britain are considering similar legislation. Most, but not all, laws require patients who receive aid in dying to be terminally ill. In cases of euthanasia, a medical provider both prescribes and administers the lethal medication. This practice is legal only in Belgium, Luxembourg, and the Netherlands. Canadian officials say it is not yet clear whether a national law currently being hashed out by legislators will only permit physician-assisted suicide or also extend to euthanasia.
Should Physicians Be Involved? In response to lingering discomfort over “the idea of physicians playing an active role in ending patients’ lives,” a 2012
the profession and the CMA and individual doctors shouldn’t have anything to do with this,” Dr. Blackmer said. The CMA,
‘We’ve heard from some of our members who very clearly feel like the profession and the CMA and individual doctors shouldn’t have anything to do with this.’ —Jeff Blackmer, MD commentary in The New England Journal of Medicine proposed an alternative system that would remove physicians from direct involvement in assisted dying.2 Terminally ill patients could instead go to an “independent authority” for the lethal prescription of painkillers. However, that idea has not been widely embraced. “We’ve heard from some of our members who very clearly feel like
however, has highlighted several reasons why physicians who are comfortable with the procedure should be involved, such as helping to ensure continuity of care for patients at the end of life. “Rather than just having people parachute in for this one procedure, ideally it would become part of the continuum of care,” Dr. Blackmer said. A 2014 commentary in the Canadian Medical Association Journal goes further
in arguing that physicians and patients should be better prepared for the potential new reality. “We need to start to answer some challenging questions in preparation for the possibility that physicianassisted death will be available in Canada soon,” the editorial asserted.3 James Downar, MD, the editorial’s lead author and a critical care and palliative care physician at Toronto General
‘One of the biggest safeguards, in my mind, is the idea that the person who performs assisted death can offer something else.’ —James Downar, MD Hospital, said clear rules and guidelines, proper monitoring and oversight, direct physician involvement, and multiple endof-life choices for patients could help to prevent abuses. “One of the biggest safeguards, in my mind, is the idea that the person who performs assisted death can offer something else,” said Dr. Downer, who also serves as co-chair of the Advisory Council of Physicians of Dying with Dignity Canada. If the responsibility is instead outsourced to someone who does not provide palliative care or prescribe comfort medication, he said, patients could end up with fewer options, especially if they subsequently change their mind about assisted death. As with abortion, Dr. Blackmer emphasizes that no physician should be compelled to learn about or perform assisted suicide, and he notes that the CMA clearly affirms the right of physicians to conscientiously object. He also acknowledges that valid arguments exist on both sides regarding whether any physicians should participate. “At the end of the day,” he said, “we just decided that there were many more advantages to having physicians involved than to try and step aside altogether.”
References 1. Delamothe T, Snow R, Godlee F. Why the Assisted Dying Bill should become law in England and Wales. BMJ. 2014;349:g4349. 2. Prokopetz JJ, Lehmann LS. Redefining physicians’ role in assisted dying. N Engl J Med. 2012;367:97-99. 3. Downar J, Bailey TM, Kagan J, Librach SL. Physicianassisted death: time to move beyond yes or no. CMAJ. 2014;186:567-568. DOI: 10.1002/cncy.21568
Content in this section does not reflect any official policy or medical opinion of the American Cancer Society or of the publisher unless otherwise noted. © American Cancer Society, 2015.
3 328
Cancer Cytopathology Cancer Cytopathology
June 2015 June 2015
As laws legalizing physician-assisted suicide gain ground in Canada and elsewhere, physicians readjust their stance to retain a say This is Part 1 of a 2-part series on the medical profession’s recalibrated response to physician-assisted death. n November 2014, cancer patient Brittany Maynard ended her life after an incurable brain tumor left the 29-yearold woman with severe headaches, seizures, and increasing debilitation. Ms. Maynard had moved from California to Oregon to access the state’s Death with Dignity Act, which permits physicianassisted suicide among terminally ill patients. While Ms. Maynard’s decision reignited a simmering debate in the United States over the right to die, parallel battles were playing out in Canada, Great Britain, Australia, and other countries. Public support for legalizing assisted
XXXX / FOTOLIA
I
Cancer Cytopathology Cancer Cytopathology
death in most developed nations has long outpaced support from the medical community. However, over the past few years, more physicians have begun supplementing questions concerning whether the practice should ever occur with pragmatic queries about how it might be done in a way that protects both patients and physicians.
The Debate in Canada The shift has been most apparent in Canada, where the Supreme Court of Canada voted unanimously in February 2015 to reverse its 1993 ban on physician-assisted suicide, reasoning that the “right to life” also allows a patient to end it. The court stayed its decision for a year, however, giving the country’s parliament time to regulate the practice.
June June2015 2015
Opinions in the United States and Great Britain In Great Britain, a recent poll of more than 5000 adults found that an overwhelming 82% supported a proposed Assisted Dying Bill that would allow assistance in dying for a terminally ill and mentally competent person with an expected survival of 6 or fewer months. Reflecting a far lower level of support among medical professionals, the British Medical Association and the Royal College of Physicians both announced their opposition to the bill, patterned after Oregon’s 1997 Death with Dignity Act. However, The BMJ
327 2
Debating the Right to Die
a Shift in Tone Among Physicians
As the case wended its way through the courts in 2014, the Canadian Medical Association (CMA) publicly retreated from its longstanding opposition. Jeff Blackmer, MD, the association’s vice president for medical professionalism, said the change followed a series of town hall meetings. “We started to get a sense from the membership, from the public, that we needed to nuance our position a little bit,” he said. The association had previously said the legality of assisted suicide was ultimately up to society to decide, but recognized that its existing policy would effectively bar physicians from participating even if the practice was legalized. “And we realized that probably wasn’t a very helpful or pragmatic or nuanced position to be taking, especially as we saw that this case was working its way through the court system and we felt there was a fairly good chance that it would overturn the law,” Dr. Blackmer said. The association wanted to be in a position to say that it would respect and protect the rights of members who did not want to participate in assisted suicide, meaning that it also had to recognize the rights of members who did want to participate—approximately 27% according to a recent poll. A resolution at the association’s general council meeting in August 2014 pledged new support to those members, provided they acted within the bounds of existing legislation. “And that’s also allowed us to really participate actively in the discussion around what that law should look like,” Dr. Blackmer said.
CYTOSOURCE
In Debating the Right to Die,
By Bryn Nelson, PhD Edited By Terence J. Colgan, MD
CYTOSOURCE
Debating the Right to Die
CONTINUED from previous page
diverged from its parent organization with a pro-bill editorial that stated, “It’s the right thing to do, and most people want it.”1 The Royal College of Physicians also acknowledged a “shift in opinion” among its members, with growing support for assisted suicide among the terminally ill. In response to a reporter’s question about the American Medical Association’s stance, a spokesperson pointed to an opinion from the AMA Code of Medical Ethics that was last updated in 1996, 1 year before Oregon’s precedent-setting law took effect. The opinion asserts, in part: “Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.” However, the spokesperson deferred to the California Medical Association on questions concerning that state’s pending End of Life Option Act, and subtle signs suggest that the historical opposition may be softening. In 2009, 2010, and 2013, the California Medical Association’s house of delegates debated but ultimately rejected proposals to take a neutral stance on physician-assisted suicide, according to spokesperson Molly Weedn. “We’re currently ‘oppose unless amended’ on the bill,” she said. Exactly what those amendments are remains to be seen. She suggested that the right ones wouldn’t take the association to “a full support” of the bill but would remove its opposition.
Aid in Dying What It Is Called and Where It Is Legal
A
lthough wording is a sensitive topic, most medical organizations use the blanket term “physician-assisted death” to refer to any involvement of a medical provider in the voluntary death of a patient. More specifically, “physician-assisted suicide” refers to a medical provider prescribing a lethal dose of painkilling medication for a patient but not administering the drugs. The practice (also called “physician aid in dying” or “medical aid in dying”) is legal in Switzerland and in parts or all of 5 US states: Oregon, Washington, Vermont, Montana, and New Mexico. In December 2015, it will also be legal in the Canadian province of Quebec, whereas jurisdictions ranging from California to Great Britain are considering similar legislation. Most, but not all, laws require patients who receive aid in dying to be terminally ill. In cases of euthanasia, a medical provider both prescribes and administers the lethal medication. This practice is legal only in Belgium, Luxembourg, and the Netherlands. Canadian officials say it is not yet clear whether a national law currently being hashed out by legislators will only permit physician-assisted suicide or also extend to euthanasia.
Should Physicians Be Involved? In response to lingering discomfort over “the idea of physicians playing an active role in ending patients’ lives,” a 2012
the profession and the CMA and individual doctors shouldn’t have anything to do with this,” Dr. Blackmer said. The CMA,
‘We’ve heard from some of our members who very clearly feel like the profession and the CMA and individual doctors shouldn’t have anything to do with this.’ —Jeff Blackmer, MD commentary in The New England Journal of Medicine proposed an alternative system that would remove physicians from direct involvement in assisted dying.2 Terminally ill patients could instead go to an “independent authority” for the lethal prescription of painkillers. However, that idea has not been widely embraced. “We’ve heard from some of our members who very clearly feel like
however, has highlighted several reasons why physicians who are comfortable with the procedure should be involved, such as helping to ensure continuity of care for patients at the end of life. “Rather than just having people parachute in for this one procedure, ideally it would become part of the continuum of care,” Dr. Blackmer said. A 2014 commentary in the Canadian Medical Association Journal goes further
in arguing that physicians and patients should be better prepared for the potential new reality. “We need to start to answer some challenging questions in preparation for the possibility that physicianassisted death will be available in Canada soon,” the editorial asserted.3 James Downar, MD, the editorial’s lead author and a critical care and palliative care physician at Toronto General
‘One of the biggest safeguards, in my mind, is the idea that the person who performs assisted death can offer something else.’ —James Downar, MD Hospital, said clear rules and guidelines, proper monitoring and oversight, direct physician involvement, and multiple endof-life choices for patients could help to prevent abuses. “One of the biggest safeguards, in my mind, is the idea that the person who performs assisted death can offer something else,” said Dr. Downer, who also serves as co-chair of the Advisory Council of Physicians of Dying with Dignity Canada. If the responsibility is instead outsourced to someone who does not provide palliative care or prescribe comfort medication, he said, patients could end up with fewer options, especially if they subsequently change their mind about assisted death. As with abortion, Dr. Blackmer emphasizes that no physician should be compelled to learn about or perform assisted suicide, and he notes that the CMA clearly affirms the right of physicians to conscientiously object. He also acknowledges that valid arguments exist on both sides regarding whether any physicians should participate. “At the end of the day,” he said, “we just decided that there were many more advantages to having physicians involved than to try and step aside altogether.”
References 1. Delamothe T, Snow R, Godlee F. Why the Assisted Dying Bill should become law in England and Wales. BMJ. 2014;349:g4349. 2. Prokopetz JJ, Lehmann LS. Redefining physicians’ role in assisted dying. N Engl J Med. 2012;367:97-99. 3. Downar J, Bailey TM, Kagan J, Librach SL. Physicianassisted death: time to move beyond yes or no. CMAJ. 2014;186:567-568. DOI: 10.1002/cncy.21568
Content in this section does not reflect any official policy or medical opinion of the American Cancer Society or of the publisher unless otherwise noted. © American Cancer Society, 2015.
3 328
Cancer Cytopathology Cancer Cytopathology
June 2015 June 2015
