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"It ain’t gonna happen!" That’s what the chair of the APA Ethics Committee told me when I asked whether APA would alter its policy that assisted suicide is unethical. APA and the AMA had supported a repeal of Oregon’s Death With Dignity Act in a recent ballot measure. On November 4, with the highest turnout in the nation, the voters of Oregon reaffirmed the assisted suicide law in a landslide. The legal injunctions have now been removed, and the law is in effect.
Psychiatrists cannot prescribe lethal medication under the law, but there is a requirement for psychiatric evaluation if there is a suspicion that an individual suffers from depression or another psychiatric disorder that might cause impaired judgment. There is now the ironic possibility that a psychiatrist could be accused of an APA ethics violation for conducting a psychiatric evaluation in compliance with state law.
There are many unanswered questions regarding the conflict between APA policy and state law. During the campaign over the ballot measure, for example, it was argued that the Oregon district branch must oppose the Death With Dignity Act or risk disciplinary action from APA. There was even a failed attempt to have the APA Board of Trustees order the Oregon district branch to support repeal.
Because of so many bitter debates over the ramifications of APA policy, many of us in Oregon looked to the APA Ethics Committee for guidance. The committee would only reiterate AMA policy on assisted suicide, however, and refused to comment directly on the issue of whether a district branch could remain neutral or even support the legalization of assisted suicide. The Oregon Psychiatric Association (OPA) ultimately remained neutral and has not (to my knowledge) suffered any disciplinary action.
The intransigence of the Ethics Committee is unfortunate for several reasons. Surveys show a majority of psychiatrists believe assisted suicide is ethical under some circumstances facing the terminally ill. Polls show the public supports a right to be aided in dying for competent, terminally ill people who are in unbearable suffering. The public is sufficiently informed to know that aid in dying under the Death With Dignity Act is completely different from emotional suicides in those who are medically well. In fact, the more the issue is debated, the stronger the support for aid in dying becomes. Most important, the passage of the Death With Dignity Act has been associated with a documented improvement in the care of the terminally ill.
When Oregon voters narrowly passed the nation’s first assisted suicide law in 1994, opponents of assisted suicide predicted a slippery slope of ever-worsening treatment of the terminally ill. This prediction has proved wrong. Oregon now leads the nation in referrals to hospice care, in utilization of narcotics for pain relief, and in the percentage of terminally ill who die in their own home rather than in the hospital.
Bringing the issue of dying out of the closet has helped improve palliative care in Oregon, yet APA will still use its name to oppose similar legislation in other states.
Of course there is a precedent for medical specialty societies altering policy on a medical procedure previously considered unethical. APA and the AMA both originally opposed a woman’s right to have an abortion. The same slippery-slope arguments being used against assisted suicide were used to oppose legalization of abortion. Both sides in the abortion debate agree that the ideal situation is to prevent unwanted pregnancies, but the medical specialty societies correctly decided that abortion should be a matter of conscience between a woman and her physician. Only through legalization and medical oversight could the practice of abortion be optimized. A similar situation exists with assisted suicide.
Both sides in the assisted suicide debate agree that the ideal situation is for terminal care to be improved so that a person never need ask for aid in dying. APA should recognize that assisted suicide, like abortion, is a matter of conscience. APA should work to provide safeguards for a practice that a majority of the public supports.
It is too soon to tell if there will be another parallel to the controversy over abortion. Some in our society are so opposed to abortion that they have resorted to harassment, violence, or even murder of physicians who participate. The medical specialty societies have defended physicians’ right to participate in abortion and be free from harassment for acting in compliance with the law.
If APA persists in calling psychiatric participation in assisted suicide unethical, this could be construed as tacit approval for harassment of psychiatrists who participate. Will the APA Ethics Committee alter its position on assisted suicide and defend the right of APA members to act in compliance with the law? "It ain’t gonna happen!"