The Magazine

First, Do Harm . . .

A betrayal of the hospice movement.

Mar 19, 2007, Vol. 12, No. 26 • By WESLEY J. SMITH
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The American Academy of Hospice and Palliative Medicine has just released a position statement on the issue of physician-assisted suicide, in which it abdicates its core professional responsibility. On the impropriety of permitting doctors to help kill their patients, the association has assumed a position of "studied neutrality."

One of the AAHPM's stated missions is to engage in "public policy advocacy" for hospice and palliative care. Assuming a neutral stance on what may be the most important public policy controversy of our day involving dying people is both a cowardly act and a backdoor repudiation of the long-established philosophy of hospice care, which promises to respect the intrinsic value of each patient's life and to care for dying patients until their natural deaths.

In its "Position Statement on Physician Assisted Death" (PAD is the reigning euphemism for physician-assisted suicide, allowing doctors to pretend they are not participating in the intentional killing of patients), the AAHPM approaches the entire topic with willful naiveté. For example, it states:

Excellent medical care, including state-of-the-art palliative care, can control most symptoms and augment patients' psychosocial and spiritual resources to relieve most suffering near the end of life. On occasion, however, severe suffering persists; in such a circumstance a patient may ask his physician for assistance in ending his life by providing Physician-assisted Death.

But Oregon's experiment with state-sanctioned assisted suicide has demonstrated that "severe suffering" is not the cause for most requests for assisted suicide. Rather, patients usually ask for lethal prescriptions due to loss of autonomy, fear over being a burden to their families, losing the ability to engage in enjoyable activities, and losing dignity. These are all important issues, and it is incumbent upon doctors to help patients overcome them. But they do not reflect the severe physical suffering the AAHPM presumes would cause their patients to request assisted suicide.

The association's naiveté is further on display in its proposed "guidelines" to prevent abuses in assisted suicides. It advises physicians practicing in regions where assisted suicide is legal to use "great caution" before helping kill their patients. Such caution should "include assurance" that

* the patient has received the best possible palliative care. The permissibility of PAD is dependent upon access to excellent palliative care. No patient should be indirectly coerced to hasten his death because he lacks the best possible medical and palliative care.

* requests for PAD emanate from a patient with full decision-making capacity.

* all reasonable alternatives to PAD have been considered and implemented if acceptable to the patient.

* the request is voluntary. Safeguards should focus in particular on protection of vulnerable groups including the elderly, frail, poor, or physically and/or mentally handicapped. Coercive influences from family or financial pressure from payors cannot be allowed to play any role.

Here's the thing: Few of these "assurances" are legally required in Oregon, where assisted suicide is already legal. Nor will they be required if pending legislation in California and Vermont to allow physician-assisted suicide becomes law. For example, none requires that suicidal patients actually receive the best possible palliative care before ending their lives. Nor are any meaningful steps required to ensure that the patient is not under "coercive influences from family or financial pressure."

To see how ephemeral such "assurances" really are, consider the 1999 assisted suicide of Oregon Alz heimer's and cancer patient Kate Cheney. (See my "Suicide Unlimited in Oregon," in the November 8, 1999, WEEKLY STANDARD.) Because Cheney was demented, the doctor from whom she requested poison pills sent her to a psychiatrist for evaluation, who determined that Cheney did not possess the "very high capacity required to weigh options about assisted suicide." Moreover, she found that Cheney "does not seem to be explicitly pushing for this" and that Cheney's daughter was the primary advocate for the proposed suicide. Accordingly, the psychiatrist recommended against issuing a lethal prescription.

As has happened in other cases in Oregon, a doctor disapproving of an assisted suicide proved a mere bump in the road. Cheney's daughter simply asked another doctor for a different opinion. The psychologist to which Cheney's HMO then sent her also expressed worries that the request "may be influenced by her family's wishes," but nevertheless recommended in favor of the assisted suicide. In the end, it didn't matter that two independent mental health professionals found familial pressure was being exerted on Cheney; she received the lethal prescription.

The AAHPM properly urges that "medical practitioners carefully scrutinize the sources of fear and suffering leading to the request" for assisted suicide "with the goal of addressing these sources without hastening death," along with practice guidelines for accomplishing these important goals. But this promotion of good medical practice rings hollow given the association's explicit neutrality on assisted suicide, which in effect grants member doctors permission to help kill their patients without threatening their good standing with the association.


Such terminal nonjudgmentalism is a profound abandonment of the organization's professed goal of promoting proper hospice care--a philosophy that unequivocally opposes assisted suicide. Perhaps more egregiously, it abandons patients--whose lives depend on ethical doctors acting energetically to relieve suffering while abiding by the Hippocratic Oath's sacred duty to "neither give a deadly drug to anybody who asked for it, nor . . . make a suggestion to this effect."

Wesley J. Smith is a senior fellow at the Discovery Institute, an attorney for the International Task Force on Euthanasia and Assisted Suicide, and a special consultant to the Center for Bioethics and Culture.