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CHICAGO -- The House of Medicine's longstanding division on physician-assisted suicide resurfaced at the American Medical Association (AMA) House of Delegates meeting, but with a fresh note of impatience this time around.

At issue was what to do with a report from the AMA's Council on Ethical and Judicial Affairs (CEJA), which was issued in response to resolutions at the 2016 and 2017 annual meetings that asked the council to "study the issue of aid-in-dying with consideration of data collected from the states that currently authorize aid-in-dying, and input from some of the physicians who have provided medical aid-in-dying to qualified patients," as the report put it. "CEJA was further asked to consider the need to distinguish between 'physician-assisted suicide' and 'aid-in-dying.' "

After much discussion, the report was adopted Monday by a vote of 360-190. Delegates also voted 392-162 to reaffirm current AMA policy on assisted suicide, which was part of a "sunset report" on AMA policies from 2009, and was in concert with the stance laid out in the CEJA report.

Pleas to Move Forward

In it, the council had noted that arguments for and against participating in aid-in-dying or physician-assisted suicide were "fundamentally unchanged" since the council's earlier report on the issue in 1991. However, it remains a thorny issue -- even down to the terminology used. "The council recognizes that choosing one term of art over others can carry multiple, and not always intended messages. However, in the absence of a perfect option, CEJA believes ethical deliberation and debate is best served by using plainly descriptive language. In the council's view, despite its negative connotations, the term 'physician-assisted suicide' describes the practice with the greatest precision."

"We've heard this so many times, what is the message from membership if we continue?" said M. Zuhdi Jasser, MD, of Phoenix, speaking for the Arizona delegation at Sunday's meeting of an AMA reference committee that was considering the issue. "Let's accept the CEJA report, support their conclusions, and move forward as an organization."

"We urge that the report be adopted and not referred back," said Jeremy Lazarus, MD, speaking on behalf of CEJA. "If this report is filed, we'll be able to put it up on our website and include [two opinions] which outline why CEJA provides a home for both those who support physician-assisted suicide and those who oppose it ... That is what CEJA has tried to proffer before you."

The two opinions Lazarus referred to included , which states that "permitting physicians to engage in assisted suicide would ultimately cause more harm than good. 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. Instead of engaging in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life."

The other opinion, of the AMA's Principles of Medical Ethics, states that "Physicians are expected to uphold the ethical norms of their profession, including fidelity to patients and respect for patient self-determination ... Preserving opportunity for physicians to act (or to refrain from acting) in accordance with the dictates of conscience in their professional practice is important for preserving the integrity of the medical profession as well as the integrity of the individual physician, on which patients and the public rely. Thus physicians should have considerable latitude to practice in accord with well-considered, deeply held beliefs that are central to their self-identities."

A "Violation of Natural Moral Law"

The report's bottom line: leave in place the AMA's current policy, which takes the more-harm-than-good position. Opponents of physician-assisted suicide favored adopting the report.

"[The report] clearly speaks the truth as to what this involves -- it is directly enabling a patient to end his or her life," said Diane Gowski, MD, of Clearwater, Florida, an alternate delegate for the Society of Critical Care Medicine, who was speaking on behalf of the Chest Caucus. "We would not give our patients a gun or revolver ... so we should not be supplying them with lethal drugs. Physician-assisted suicide violates natural moral law. We urge the AMA to stand firm, as any change from the current position will only confuse the public as to the intention and role of their physicians."

At the House of Delegates meeting on Monday afternoon, Shane Macaulay, MD, of Kirkland, Wash., spoke for the Washington delegation in favor of adopting the report. "Oregon legalized assisted suicide in 1997 with repeated assurances that it would stay contained and would not become euthanasia," he said. "Just last month, the Oregon state House of Representatives approved a bill to allow patient death by lethal injection, showing the inevitable progression from assisted suicide to euthanasia once physicians have accepted the idea that taking a patient's life is permissible."

"In Canada, assisted suicide and euthanasia were legalized only 3 years ago, and in the 3 years we've debated this topic here, euthanasia has become a runaway contagion in Canada, with over 4,000 deaths last year," he continued. "These alarming developments show us that the wheels are coming off bus on assisted suicide. We do not have the luxury of time to continue to fail to act on the CEJA report while the real-world situation deteriorates. Unless we're willing to embrace widespread euthanasia, we must accept the CEJA report and reaffirm this policy now as a firewall against what is [happening in] Canada."

"The Enemy is Terminal Suffering"

On the other side of the issue, David Grube, MD, of Philomath, Oregon, speaking for himself at the reference committee meeting in favor of referring the report back to the AMA Board of Trustees, noted that his state has had a law legalizing aid-in-dying for 20 years. "Our end-of-life care is really unsurpassed in the nation," said Grube, who is also the national medical director of Compassion & Choices, a group that advocates for physician aid-in-dying. "It's a rarely-used request from patients, and yet it's a response we can give to them when they're suffering. The enemy is not death, but the enemy is terminal suffering; responding to that in ways that provide comfort is what matters the most."

Rohan Khazanchi, of Omaha, who was speaking for himself at the House of Delegates session Monday, said that "All physicians and physicians in training are committed to the best interests of our patients, including respect for human dignity. We recognize that medical issues at end of life are complicated, sensitive and constantly evolving. We agree at this point in time, the AMA Code of Medical Ethics must accommodate diverse perspectives, and believe further changes must be made in order to achieve this. These changes are absolutely essential to provide physicians with proper ... protections."

The issue also was very divisive for the House of Delegates' Medical Student Section, which came out in favor of a resolution to change the AMA's position to one of "engaged neutrality" -- neither for nor against physician aid-in-dying. "The Medical Student Section of the AMA does not speak for me on this issue," Matt Becker, a medical student from Indianapolis, said at Sunday's reference committee meeting. "I would argue that choosing to kill oneself is contrary to the human condition and never morally acceptable. I also express concern for the autonomy of those coerced into suicide, which is a legitimate concern, especially with regard to the progression to euthanasia. If even one person is killed due to coercion, that amounts to murder."

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