Most physicians are willing to talk with patients about medical aid in dying, but fewer are willing to serve as an attending or consultant, according to a survey of more than 500 Colorado physicians treating terminally ill patients.1
“Medical aid in dying is among the most, if not the most, contentious issue in medicine and policy today, stemming in part from the ethics of the practice,” says Eric G. Campbell, PhD, lead study author and director of research at the Center for Bioethics and Humanities at the University of Colorado.
Medical aid in dying is under policy consideration in many states. “We asked, ‘What can be learned from the Colorado experience to inform policymakers who are making decisions about medical aid in dying right now?’” Campbell says.
Campbell and colleagues also want policymakers to make decisions based on empirical evidence vs. relying on only advocacy and special interest groups (either for or against the practice). In Colorado, medical aid in dying was legalized in 2019. “A lot of the debate was not based on evidence and is often owned by interest groups with deeply entrenched policy positions whose opinions on medical aid in dying may not reflect the reality of the people experiencing it,” Campbell explains.
Of physicians surveyed, 81.1% were willing to discuss medical aid in dying with patients, 88.3% were willing to refer a patient for medical aid in dying, 46.3% were willing to be a consultant, and 28.1% were willing to be an attending.
As far as actual experience with medical aid in dying, 52.3% had discussed it with a patient, 27.3% had referred a patient, 12.8% had been a consultant, and 8.5% had been an attending. Among physicians who had been either a medical aid in dying consultant or attending, 75% reported it was time-consuming, and 46.9% reported it was ethically challenging. “The data challenged some commonly held beliefs and myths about medical aid in dying,” Campbell reports. One such belief is there is a shortage of physicians willing to provide medical aid in dying. “The data suggest that there’s a more than adequate supply of people who are willing, able, and prepared to provide medical aid in dying services,” Campbell notes.
While only 8.5% of respondents had served as a medical aid in dying attending, 28.1% said they were willing to do so. Another oft-cited concern is that patients might need to obtain medical aid in dying services from physicians who had never treated those patients. In fact, the data showed more than 80% of medical aid in dying attendings and consultants had provided care to patients seeking the service.
Medical aid in dying consultants and attendings largely reported the experience to be professionally rewarding and emotionally fulfilling. However, all the physicians reported multiple barriers to participation. “Some physicians were concerned about being known as a medical aid in dying provider. But that was not the most prominent barrier to providing medical aid in dying,” Campbell observes.
Lack of knowledge was the most commonly reported barrier (47%). “Going forward in Colorado, providing education to physicians about medical aid in dying is clearly indicated by the data,” Campbell says. “Education needs to be unbiased and should not be colored by entrenched beliefs about the acceptability, or lack thereof, of medical aid in dying.”
Advocacy groups might underestimate the barriers physicians face, or might overestimate the extent to which providing medical aid in dying is professionally rewarding. Notably, 41% reported ethical concerns were a “moderate” or “large” barrier to participation. It remains unclear what the ethical barriers are and whether the physicians were able to resolve them.
One obstacle is medical aid in dying typically occurs in the outpatient setting, where physicians lack access to ethicists. None of the survey respondents who practiced only in the inpatient setting had ever provided medical aid in dying.
“Given that medical aid in dying almost universally occurs outside of the inpatient setting, and given that ethics consults are almost universally within the inpatient setting, there’s a need for someone to provide ethical guidance to medical aid in dying practitioners who are doing this in the community,” Campbell offers.
In states where physician aid-in-dying is legal, physicians are ethically obligated to inform certain patients about the option, argues Wayne Shelton, PhD, MSW, co-author of a paper on this topic.2 Ten states and Washington, DC, have legalized physician-assisted suicide to date.3 Shelton predicts that number is likely to grow in the coming years. “The whole possibility of aid in dying is evolving and is becoming more acceptable in American society,” he says.
Still, not all doctors are comfortable talking about this subject. End-of-life discussions already are fraught with difficulty, particularly when physicians are talking about switching from curative care to comfort care.
“Doctors, for all kinds of reasons, may shy away from having those difficult discussions with patients,” says Shelton, professor of medicine and bioethics at the Alden March Bioethics Institute at Albany Medical College.
Traditionally, the option of aid-in-dying has not been a part of end-of-life discussions. Some physicians fear bringing up something that is not legally permitted in their state. Even in states where the practice is legal, providers may be wary of bringing up something that may carry stigma. Still other physicians may be reluctant to bring up medical aid in dying because they believe it is morally wrong.
“But it seems that the more it becomes a viable ethical and legal option, the more doctors have an obligation to bring it up when appropriate,” Shelton says. Even if physicians do not bring it up, the patient or a family member might do so — and providers will need to respond appropriately. Part of that response might include educating patients and family about the fact the patient can be kept comfortable even without aid in dying. Some still will request the service, and physicians need ethical responses to those requests.
“It’s hard to say that physicians have an obligation to make referrals for something they feel is wrong. It’s a matter of their own judgment and ethical perspective,” Shelton says. “But generally speaking, if someone is really insistent that they want help in dying, to guide patients in the direction to accomplish their goal in a legal way, it seems that it would be ethically appropriate to do that.”
At Albany Medical College, faculty are preparing the next generation of providers to be more adept in managing this controversial issue before it comes up in clinical practice. “We ask medical students to think about this possibility and how they feel about helping someone with this type of service,” Shelton reports. “This will become a more common issue that physicians will have to address more head-on in the future.”
REFERENCES
- Campbell EG, Kini V, Ressalam J, et al. Physicians’ attitudes and experiences with medical aid in dying in Colorado: A “hidden population” survey. J Gen Intern Med 2022;Jan 11:1-8.
- Zhou YMJ, Shelton W. Physicians’ end of life discussions with patients: Is there an ethical obligation to discuss aid in dying? HEC Forum 2020;32:227-238.
- ProCon.org. States with legal physician-assisted suicide. Last updated Dec. 14, 2021.
Considered one of the most controversial subjects in medicine, some physicians might talk with patients about medical aid in dying, but providing the service could be a different story — for several reasons, both ethical and practical.
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