An APA position opposing physician-assisted suicide (PAS) has brought a challenge from three members of the APA Board of Trustees.

In October APA signed onto an American Medical Association amicus curiae brief opposing a right to PAS, and in January the Supreme Court heard arguments on the issue. A ruling is expected by the end of the Court's term this summer. A month after AMA submitted the brief, a broad coalition of mental health care providers, including former APA presidents Lawrence Hartmann, M.D., and Judd Marmor, M.D., and Treasurer Fred Gottlieb, M.D., submitted a brief supporting a right to PAS.

Opponents of the APA position have pointed out that APA had signed onto the AMA brief without subjecting the issue to the lengthy deliberative process involved in developing and approving an official APA position paper.

The opposition is "a testimonial to the diversity within APA," said another former APA president, Jerry Wiener, M.D. "APA is an organization composed of many people with strong, independent positions." Wiener backs the official APA position against PAS.

For at least five years, APA has taken a public stance against PAS, even in the absence of an official position paper. APA supports the AMA Code of Medical Ethics and the recent amicus curiae brief to the Supreme Court, as well as comments to the mass media stating APA's opposition to assisted suicide. Former APA president Joseph T. English, M.D., was APA's representative to the AMA Coalition on Physician-Assisted Suicide, which met in Chicago last August to help prepare the anti-PAS amicus.

"Both the AMA and APA are supporting a position on this issue that is as old as the profession of medicine and the historical records to be found about it sustain," English commented. "The Hippocratic Oath itself says the first responsibility of the physician is to maintain human life and never have the possibility of a physician harming a patient, let alone terminating a patient's life."

The AMA amicus draws a sharp distinction between providing patients with adequate medication to alleviate pain--even where such medication might hasten death--and deliberately ending a patient's life, English noted.

"Part of the reason a patient is comfortable with that awesome power of the physician is the tradition of trust between patient and physician we've always tried to nurture," said English. "There is a tremendous difference between what a physician does in cooperating with a patient to alleviate pain and suffering and deliberately ending life."

As APA chair and delegate to the AMA Section Council on Psychiatry, said English, he found that the AMA sees inadequate pain relief as one of the major problems of modern medicine.

The cost pressures of managed care pose a special danger should physician-assisted suicide be legitimized, said English. "The most effective form of managed care is physician-assisted suicide," he noted. In the Netherlands, said English, some patients are being urged to accept assisted suicide rather than go to a nursing home.

"Once the physician steps over the line [that] has been the tradition of medicine from its origin, it is then subject to the power of the state," he continued. "If it's the terminally ill today, then who tomorrow? The implications of the physician abandoning that historic principle of ethics has awesome implications for society."

The dissent shows the strength of APA as a democratic institution, English observed. "I have always known APA, with few exceptions, to be a very democratic organization." In a democratic society "dissent is not only tolerated but welcomed" and through open debate serves to educate and inform. But those dissenting must respect that the position taken by the Board represents the position of APA, English added.

In addition to Hartmann, Marmor, and Gottlieb, signatories included William Pollin, M.D., former director of the National Institute on Drug Abuse, and George Washington University psychiatric faculty members Richard Palmer, M.D., and E. James Lieberman, M.D.

Pollin summarized the issues in an interview with Psychiatric News last month.

The formal statements of the AMA and other medical organizations "do not speak for all or even most responsible American physicians," Pollin asserted. "In some cases, we believe that these policy statements represent a precipitous administrative response, initiated and acted upon without consultation with or solicitation of the opinion of their respective memberships." This was "clearly the case" with APA, said Pollin.

There is a psychiatric rationale for a right to PAS, according to Pollin. For most people, the worst anxiety associated with death is "not the fear of the fact of dying per se, but fear of the uncertain circumstances leading up to death," such as pain, loss of control, and loss of dignity. "Such fears gravely weaken an individual's ability to cope with illness and stress, and can thereby shorten life."

Given that such anxiety may both shorten life and cause needless suffering, the "apparent dichotomy or difficult choice presented to the physician" pitting the responsibility to sustain life against that to reduce suffering is false and unnecessary, said Pollin.

Privacy and freedom of choice are nowhere more necessary and appropriate than in dealing with "life's most solemn moment: our own departure from it," Pollin contended. He rejected the "slippery slope" argument as wrongly assuming that "if the Supreme Court supports lifting the ban on PAS, no one will be there to monitor and critically appraise the details of what follows next."

The APA position "appears to place the physician's role totally subservient to the state in this issue," APA Treasurer Gottlieb told Psychiatric News. The AMA brief emphasized "the prohibitive rather than the regulatory" authority of the state over the physician's ethics and autonomy, said Gottlieb. "I would argue very strenuously that the position that APA has taken is wrong."

While the state can provide "helpful regulatory mechanisms, . . .absolute prohibition, ultimately will fail," Gottlieb asserted. APA should work with the AMA to help physicians take overt, rather than covert, responsibility in this area and to "work out mechanisms whereby we can help our patients make the transition at the time of death when healing is impossible."

The evolving sophistication of medical technology has "increased the moral and ethical complexity" of medical decision making, he added. "To take those decisions out of the hands of physicians by simple legal fiat is wrong, and I don't think we should be a party to that. That is my quarrel with the AMA brief."

The Board of Trustees "acted unusually hastily in taking such an important action," said past president Hartmann. By signing on to the AMA amicus, the Board sidestepped the normal deliberative process, Hartmann noted. He urged APA to "ask its DB's, the Assembly, and the Ethics Committee to rethink its position in this area."

APA can respect the AMA without always following its positions, said Hartmann. "In this case we might come to a significantly different position from the AMA. On this issue many of us speak from our basic life philosophies rather than our psychiatric orientation."

APA should take the issue "seriously and debate it and not just take an amicus stance just because there is external pressure," said Hartmann. The decision-making process "was much too brief and much too precipitous. On this very important issue I think we were wrong to decide anything so fast, and I think what we decided was wrong."

As "respectful allies of our patients we" may be called on to relieve unbearable suffering, even if that sometimes means helping a patient end his or her life, Hartmann asserted. He noted that "even in the AMA preamble there are large gray areas of ethical commandments" in which the imperative to reduce suffering is upheld even if it should hasten the end of life. Prolonging life "at any cost is not the job of the physician," Hartmann observed.

APA was under "some time pressure" because many had not expected that the Supreme Court would agree to hear the issue so soon, said English. "For us to be effective, we had to make a decision as to whether to join the brief."

But English agreed with the dissenters that under less-pressured circumstances it would be preferable to subject such controversial issues to the scrutiny of both the Board and Assembly, with the full deliberative process involved in reviewing an APA position paper.

The notion that the broader constituency should have a say on such issues is one held by many members on other important social and ethical issues, particularly abortion, English noted. "We need not be selectively democratic."

A number of prominent psychologists and social workers also signed the brief, which was titled "Brief of the Washington State Psychological Association, the American Counseling Association, the Association for Gay, Lesbian and Bisexual Issues in Counseling, and a Coalition of Mental Health Professionals as Amici Curiae in Support of Respondent."

The "respondent" was Timothy Quill, M.D., an activist who is known for having written an essay for the March 7, 1991, New England Journal of Medicine in which he admitted to prescribing barbiturates to a patient he knew intended to use them to commit suicide.

(Psychiatric News, March 7, 1997)