Is it possible for doctors to be neutral on physician-assisted suicide?


Earlier this month the American Academy of Family Physicians (AAFP) broke ranks with the American Medical Association (AMA) by adopting a position of “engaged neutrality” on assisted suicide and euthanasia.

The AMA, an umbrella group for dozens of American medical associations, opposes “aid in dying”. Its official position is that “Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.”

But at its Congress of Delegates in New Orleans the AAFP, the second largest component society of the AMA with more than 131,400 members, repudiated this. A super-majority of the delegates voted to adopt a position of “engaged neutrality” and to reject the use of the terms "assisted suicide" or "physician-assisted suicide".

"Through our ongoing and continuous relationship with our patients, family physicians are well-positioned to counsel patients on end-of-life care, and we are engaged in creating change in the best interest of our patients," said the AAFP president Michael Munger, a physician from Kansas.

Neutrality – as historians know well – is a murky concept. Costa Rica is neutral and has no military. Moldova is neutral and is home to the Russian 14th Army.

So what in the world is “engaged neutrality”?

According to bioethicists John Frye and Stuart Youngner, of Case Western Reserve University, “engaged neutrality” is a policy which encourages doctors to minimize the harm of physician-assisted suicide, thereby moving beyond a mere endorsement of palliative care. This allows doctors to study potential problems and to improve existing policies. For example, they wrote, “the Royal Dutch Medical Society trains the consulting physicians, supports in-depth review of each case, and publishes clinical guidelines for professionals that include narrative examples of questionable cases and how to respond to them.”

In other words, “engaged neutrality” is the medical equivalent of Moldovan political neutrality; it’s not neutrality at all.

And in fact, it is impossible to be neutral about physician-assisted suicide, as several distinguished doctors and ethicists, including Daniel Sulmasy and Baroness Ilora Finlay, argued earlier this year in the Journal of General Internal Medicine.

They give several reasons why neutrality should be opposed.

First, the notion of becoming neutrality to accommodate different views or uncertainty might be reasonable if it were only an internal issue. But a statement by a professional organisation – especially one with more than 130,000 members like the AAFP – has political and social consequences which reverberate far outside the Congress of Delegates.

Neutrality is not neutral. To change from opposition to neutrality represents a substantive shift in a professional, ethical, and political position, declaring a policy no longer morally unacceptable; the political effect is to give it a green light. Logically, neutrality implies, “We are not opposed.” When the California Medical Society became neutral on PAS, the newspapers rightly reported, “California Physicians End Opposition to Aid-in-Dying Bill.”

Second, doctors have no business being neutral about matters of life and death. This is at the heart of their profession. They have to take a stand.

... professions have a positive ethical responsibility to take public stances on issues that are central to the meaning of their work. Neutrality on PAS, in this light, seems an abdication of professional responsibility. Each profession has a duty to define the ethical parameters of its practice within the public sphere, subject to the political limits necessary to sustain and promote the common good.

Third, medical associations can still be opposed even if doctors can perform physician-assisted suicide legally in some jurisdictions (like California, Oregon, Washington, Hawaii, Montana, Vermont, Colorado, and the District of Columbia). The fact is that very few doctors engage in PAS – why should they force their professional association to become “neutral”? The authors point out that doctors can participate in capital punishment in 30 American states. The ethical code of the AMA forbids any involvement in the death penalty, but there are doctors who routinely ignore this. Nonetheless, the authors note,

This fact does not affect the ethical opposition that the profession takes, nor has organized medicine felt compelled to give instructions on how to execute prisoners well for those few members who do this.

Fourth, disagreement among members does not require adopting a position of neutrality. Medicine is a field of fierce debate, with some doctors actively opposing their associations’ positions. But no one is calling upon the AMA to adopt a position of “engaged neutrality” on mammogram screening.

Finally, the call for neutrality undermines doctors’ special role as professionals.

Part of the concept of a profession is that it should define its ethics independently of the state, the market, and the vicissitudes of popular opinion. Adopting a position of neutrality implies that organized medicine is avoiding taking responsibility for defining its fundamental ethical principles.

The authors point out that it is inconsistent to tell doctors to be neutral about physician-assisted suicide but still demand that they remain as gatekeepers in a legalised system. Why are they needed at all?

In fact, the call for “neutrality”, let alone “engaged neutrality”, is just a clever way to breach the defences of opponents of assisted-suicide and euthanasia. In the lead-up to World War II, Denmark, Norway, Belgium, the Netherlands, Luxembourg, Lithuania, Latvia and Estonia were all neutral. And then, suddenly, they weren’t.

Michael Cook is editor of MercatorNet. 

* Daniel P. Sulmasy, MD, PhD , Ilora Finlay, FRCP, FRCGP, FMedSci, Faith Fitzgerald, MD, Kathleen Foley, MD, Richard Payne, MD, and Mark Siegler, MD. "Physician-Assisted Suicide: Why Neutrality by Organized Medicine Is Neither Neutral Nor Appropriate." Journal of General Internal Medicine, August 2018. 




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