Remarks delivered by MMS President Richard V. Aghababian, MD, at a session of the Lahey Clinic Medical Ethics Lecture Series, on September 19, 2012.
Thank you Dr. Steinberg … and a very good afternoon to all of you.
As the president of the Massachusetts Medical Society this year, I'm here to share the policies that my fellow members and I crafted after extensive debate on this matter. I will attempt to explain the reasoning for our policy.
Our House of Delegates examined this issue very carefully over the course of this year, as we have since several times since 1999.
We did not arrive at our decision hastily. We had considerable debate, but in the end, the vote clearly demonstrated a lack of support for physician-assisted suicide.
I believe that we all came away with respect for both sides of the issue, and we acknowledged that there are reasonable arguments on both sides of the issue. Materials are now on the Medical Society's website, and have been mailed to all of our Massachusetts-based members.
We all understand that medicine's treatment of patients at the end of the life remains problematic. Here are some symptoms:
- A disproportionate amount of the health care dollar is spent during the last year of life. Some feel that some of this money could be used more wisely.
- The so-called "death panel" debate three years ago unfortunately short-circuited any meaningful discussion at the national level about end of life care.
- Pain at the end of life may not be always well-recognized by patients and doctors. Therefore, treatment may be suboptimal.
- The use of hospice services, where available, may not be requested by physicians, or utilized by patients.
- As the end of life approaches, family members can be at odds with each other, and sometimes even at odds with the terminally ill patient. They may demand the continuance of futile care.
- Patients may have neglected to make their end-of-life issues well known to their doctors and their family members.
The Massachusetts Medical Society recognizes that there is a lot of work to de done - and not just by those of us in medicine.
However, these shortcomings do not justify support for Question 2. They compel us to improve end of life care, not abandon efforts by making the patient feel that suicide is a viable option.
I want to outline the four principal reasons for our opposition to Question 2.
First: The proposed safeguards in the legislation are not sufficient.
The safeguards may sound impressive, but there are several loopholes that are troubling. There is no provision to enforce its safeguards, and there is no oversight over the process, only a statement that punishment will follow criminal behavior.
There is no authority given to any agency to investigate suspicion of wrongdoing.
The only check against abuse is the opinion of the prescribing doctor, which puts the physician in the role of both caregiver and law enforcement officer. This is not appropriate. It's one of the many subtle ways this proposal could undermine the patient-physician relationship.
Worse, physicians are held only to a "good faith" standard. This makes any or all of the safeguards unenforceable.
Another issue is the fact that one of witnesses to the patient's signing of the document declaring his or her will to implement this procedure may be an heir of the patient. This opens the door to the possibility of abuse, even though one of the other witnesses may not be an heir. Why allow any heir to be a legal witness to the signing?
And finally, there is no requirement that there be an independent witness to the administration of the legally prescribed suicide medication.
The second argument against the proposal is that assisted suicide is not necessary to improve the quality of life, at the end of life.
Currently, a patient is legally and ethically free without assistance to refuse lifesaving treatment, or to insist on adequate pain medication. They need no one else's help to do so.
Proper advance directives, which are legally binding in Massachusetts, can address many issues about quality of life at the end stages of a disease.
Palliative and hospice care are wonderful resources that are not utilized at any level close to their potential. Professionals in hospice care are very skilled, very compassionate, and very wise. They serve both the patient and the patient's family, and they do so very well. Both my wife Ann and I have had very favorable experiences with hospice care when caring for our own parents.
In the framework of an existing patient-physician relationship, a physician will understand the wishes of the patient and the concerns of the family, and address these issues with great compassion and professionalism.
The Commonwealth of Massachusetts currently mandates CME credits for education on end of life care for physicians who renew their license. This may not be enough to close the entire gap between what we know about good end of life care and its practice, but it is a start.
The third reason: The law says a physician must certify that a patient is within six months of dying.
I think everyone in this room knows how difficult such a determination can be, especially in complex patients with multiple co-morbid conditions.
The selection of six months seems to be arbitrary. It's very difficult for a physician to predict that date with accuracy. Would a physician's accuracy in predicting this date become another quality measure?
A Harvard physician and sociologist, Nicholas Christakis, recently found that 17 percent of hospice patients he studies outlived their diagnosis. That is more than sampling error. It supports what we know in our gut, which is that making such predictions is very difficult. It's guesswork, informed by our own experience.
Finally, the most fundamental argument: Physician participation in assisted suicide is fundamentally at odds with our duty to be healers.
The legislation allows physicians to opt out of the practice for reasons of personal conscience. But when even some members engage in this activity, it affects us all, and fundamentally changes the dynamic of the patient-physician relationship.
It may introduce the seed of doubt into a patient's mind about the motives of the physicians.
In fact, several advocacy groups for disabled patients are very worried that this could put them in a vulnerable position, and introduce the possibility of coercion or fraud. They maintain these are vulnerable populations, and they deserve unqualified protection.
You may or may not agree with this concern, but it illustrates the point that the patient-physician relationship gets very complicated under a scenario where physician-assisted suicide is legalized, and enshrined in state law and case law.
The AMA's position is that physician participation in assisted suicide would be difficult or impossible to control, and pose grave societal risks.
Our medical society first voted against physician-assisted suicide in 1999. It was reaffirmed in a vote nearly a year ago.
At the same time, we reiterated our commitment to provide physicians who treat terminally ill patients with ethical, medical, social and legal education and resources.
As I acknowledged a moment ago, we need to do more to contribute to the comfort and dignity of the patient and the patient's family, and the MMS is committed to helping our members achieve this goal.
I want to close with a brief comment about one of the arguments that is sometimes posed by supporters of the ballot question.
Their argument is that this issue is about patient centricity, and they say that physicians' concerns are not relevant to the debate. They say that what matters are the patient's wishes and concerns, not ours. That argument has validity, but only to a point.
We do believe that in patient autonomy. We do believe that the physician serves the patient, with the patient's interests foremost. This is, after all, the most personal of all issues.
However, when legislation directs physician behavior, it does become about us, at least to a degree. It becomes about more than just the patient. It becomes a matter for the patient and the physician, and that is a sacred relationship, which has ensured throughout recorded history.
As physicians, we have a duty and the right to speak to the issue of physician-assisted suicide. That is what the Massachusetts Medical Society has done.
Thank you for your attention, I look forward to your questions.
