Ethics network takes on physician-assisted suicide
Policies and guidelines open dialogue
When physicians and their ethics committee colleagues in the San Francisco area talk about the possibility of legalized physician-assisted suicide, they now are prepared to do more than speculate about how the practice would be followed. Earlier this year, the city’s Bay Area Network of Ethics Committees (BANEC) developed a set of guidelines and orders for "physician-hastened death."
"We wanted the guidelines to be on the table when the issue of physician-assisted suicide gets more serious in this state," says Robert Brody, MD, a BANEC member and medical director at the Visiting Nurses Association Hospice in San Francisco. "Our work codifies safeguards. It is not about being pro or con on the issue of assisted suicide. It is amoral."
Brody contends that the current environment surrounding end-of-life care breeds confusion and mistrust. "Terminal sedation, for instance, happens all the time. We just don’t call it that," he says.
Members of the ethics network began meeting to discuss the guidelines in mid-1996. "In many respects, the model for decision making that we developed is more important than the actual documents," Brody says.
Taking a preventive approach
The group created a process in which different viewpoints and opinions from a multidisciplinary group of professionals representing a continuum of care could be heard and used. "We viewed this mainly as the preventive approach," Brody says. BANEC members contend that by asking how physician-assisted suicide will be implemented now, they will prevent problems in policy direction if and when PAS is legalized.
The end product is a set of strict guidelines that includes a requirement of a second opinion, preferably from a physician "recognized to have expertise in palliative end-of-life care." The patient considering assisted suicide must be evaluated by a hospice program and/or physician and waive a right to palliative care. The guidelines also recommend that any physician-assisted suicides be registered in a system similar to tumor registries.
BANEC included experts in medicine, ethics, oncology, and hospice when developing the guidelines. They reviewed the decision of the U.S. District Ninth Circuit Appeals Court that overturned the state of California’s right to prohibit physicians from assisting patients in suicide.1 This was one of the two appeals decisions before the U.S. Supreme Court.2
Nearly 80 members of the ethics network were involved in the initial process. Three drafts of the documents were circulated among the membership and at a consensus conference of the Stanford University Center for Biomedical Ethics in Palo Alto, CA, last fall.
Brody says the group hopes that bringing the issues in the guidelines to the forefront will encourage doctors to ask questions and take actions such as offering hospice care more often.
"The idea shouldn’t be that doctors just say, Yes, I’ll help you end your life,’" he explains. Although assisted suicide is illegal in every state including California patients still ask doctors for help in ending life. Brody says doctors should do a better job of answering that question when it arises.
"Doctors should be asking where this request is coming from, offering good hospice care, relieving psychosocial pressures and other suffering before assisted suicide is even talked about." With this backdrop, Brody says the ethics network is not concerned that no institution has sought to implement even the legal segments of the guidelines since they were published earlier this year.3
The guidelines are a model for possible guidelines that institutions may implement, says Steve Heilig, MPH, BANEC coordinator. "There is little fundamental disagreement about the right of individuals to comprehensive care at the end of life," Heilig says. In fact, the guidelines are written using that title. (A copy of the guidelines is inserted in this issue.)
"Without sanctioning the practice of physician-assisted suicide, we have given professionals a reason and a way to talk about the issue," he says. "Whether assisted suicide is ever legal or not in California, these policies are useful."
In drafting the guidelines, the ethics network sought a balance "between overly onerous restrictions and the existing laissez-faire, underground’ practice," Heilig says. The group wrote stricter safeguards for areas in which there were significant differences of opinion. The group used majority rule rather than unanimous approval.
Heilig and Brody believe that the California voters will be asked to approve physician-assisted suicide again in the near future, perhaps as early as next year. As for the U.S. Supreme Court decision in late June, Brody says the justices basically left the situation "exactly where it was before" the decision.
Back to the states
Since the U.S. Supreme Court let laws banning assisted suicide stand in both Washington state and New York state but did not ban assisted suicide outright, many legal experts say the high court has given the issue back to the states. (See story on court opinion, Medical Ethics Advisor, August 1997, p. 85.)
"The Supreme Court encouraged dialogue, and that is exactly what the Bay Area Network of Ethics Committees did," Heilig says. Brody says the Court’s ruling "spearheaded action," but the real reason hospitals and other providers cannot take a wait-and-see attitude is that the issue will not go away, "as long as we keep hearing the name Jack Kevorkian in the news."
References
1. Washington v. Glucksburg, 135 LEd2d 11228 (1996).
2. Quill v. Vacco, 80 F3d716 (2nd Cir) 1127 (1996).
3. Heilig S, Brody R, Marcus FS, et al. Physician-hastened death: Advisory guidelines for the San Francisco Bay area from the Bay Area Network of Ethics Committees. Western J of Med 1997; 166:370-378.
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