American Psychiatric Association Releases Formal Position Statement on Euthanasia

By Wendy S. Salkin

End of Life Care, NIH

Image Source: NIH Consensus Development Project

Last month, the American Psychiatric Association (APA) released a position statement on medical euthanasia. The statement, approved by the APA Assembly in November and approved by the Board of Trustees in December, states:

The American Psychiatric Association, in concert with the American Medical Association’s position on medical euthanasia, holds that a psychiatrist should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death.

According to the APA Operations Manual, APA position statements “provide the basis for statements made on behalf of the APA before government bodies and agencies and communicated to the media and the general public.”

For those who are wondering, What’s the American Medical Association’s [AMA] position on medical euthanasia?, here is your answer: From Section 8 of Chapter 5 (“Opinions on Caring for Patients at the End of Life”) of the AMA Code of Ethics:

Euthanasia is the administration of a lethal agent by another person to a patient for the purpose of relieving the patient’s intolerable and incurable suffering.

It is understandable, though tragic, that some patients in extreme duress—such as those suffering from a terminal, painful, debilitating illness—may come to decide that death is preferable to life.

However, permitting physicians to engage in euthanasia would ultimately cause more harm than good.

Euthanasia is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks. Euthanasia could readily be extended to incompetent patients and other vulnerable populations.

The involvement of physicians in euthanasia heightens the significance of its ethical prohibition. The physician who performs euthanasia assumes unique responsibility for the act of ending the patient’s life.

Instead of engaging in euthanasia, physicians must aggressively respond to the needs of patients at the end of life. Physicians:

(a) Should not abandon a patient once it is determined that a cure is impossible.

(b) Must respect patient autonomy.

(c) Must provide good communication and emotional support.

(d) Must provide appropriate comfort care and adequate pain control.

It is important to note, as Charles Lane points out in his December 15 op-ed in The Washington Post, “At last, American psychiatrists speak out on euthanasia,” the practice at issue in these position statements is not the comparatively more familiar physician-assisted suicide that is “practiced in U.S. states such as Oregon, which can only involve physicians prescribing lethal doses to patients suffering from physical ailments certifiably expected to cause death within six months.” By contrast, medical euthanasia is a practice not limited to “cases of terminal physical illness,” but rather “encompass[es] non-terminal illnesses including psychiatric conditions such as depression or bipolar disorder.” So far, this move by the APA has received comparatively little attention. This is perhaps owing to the fact that, as Lane points out, “this is of little immediate practical effect in the United States, because non-terminal cases are not eligible for assisted death.”

But, there have been some responses to the statement by the APA in popular media. For instance, Live Action News, the press hub of Live Action—an organization self-described as “a non-profit human rights organization dedicated to ending abortion and protecting the right to life”—published an article entitled “The American Psychiatric Association releases statement against euthanasia” on the December 20 in which it lauds the APA’s decision to “bravely…reveal[] their opposition to psychiatrist participation in euthanasia and assisted suicide for the non-terminally ill.” The article’s author, Cassy Fiano, concludes by “hop[ing that], as the assisted suicide movement continues to grow in the United States, the APA will continue to speak out against it and be heard.” The APA position statement also got press in Michael Cook’s article on BioEdge, “American Psychiatric Association takes historic stand on assisted suicide and euthanasia,” which was later republished on National Right to Life News Today, and LifeNews.com. Having read the 50+ comments posted by readers over at BioEdge, I have decided not to reproduce them here, but encourage interested readers to brave the storm. The APA’s recent statement also caught the eye of blogger SBrickmann, who published “US Psychiatrists Say ‘No’ to Euthanasia” on December 20 on the blog maintained by Women of Grace, a Catholic organization the mission of which is described as “seek[ing] to transform the world one woman at a time by affirming women in their dignity and vocation as daughters of God and in their gift of authentic femininity™ through ongoing spiritual formation.” Which is all to say that the APA’s statement seems to have been taken up as a sign of changing tides in end-of-life care by at least a few anti-abortion news and advocacy outlets.

Not everyone seems satisfied with the APA’s recent statement, as psychiatrist and Christian Medical Association member Karl Benzio described the APA’s statement as “a ‘passive endorsement’ of physician-assisted suicide for terminally ill patients…a ‘diplomatic straddling of the fence.’”

Cook points out that “[t]he World Psychiatric Association (WPA) is considering making a similar statement.” A look at the WPA’s Madrid Declaration on Ethical Standards for Psychiatric Practice, however, suggests that the WPA has already taken a stand on medical euthanasia. In the section of the Declaration entitled, “Guidelines Concerning Specific Situations,” the WPA Ethics Committee “recognizes the need to develop a number of specific guidelines on a number of specific situations,” including euthanasia, about which it declares:

A physician’s duty, first and foremost, is the promotion of health, the reduction of suffering, and the protection of life. The psychiatrist, among whose patients are some who are severely incapacitated and incompetent to reach an informed decision, should be particularly careful of actions that could lead to the death of those who cannot protect themselves because of their disability. The psychiatrist should be aware that the views of a patient may be distorted by mental illness such as depression. In such situations, the psychiatrist’s role is to treat the illness.

Still, it will be interesting to see if the WPA Ethics Committee decides to expand on this part of its declaration at a subsequent meeting of its General Assembly.

In the meanwhile, we’ll have to see what further action, if any, the APA takes on the matter of medical euthanasia for non-terminal illnesses and whether the APA’s statement has any impact on ongoing research, conversations, and deliberations in Canada concerning the legal and ethical statuses of medical euthanasia.

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About Wendy Salkin

Wendy S. Salkin is a doctoral candidate in the Department of Philosophy at Harvard University and a 2013 graduate of Stanford Law School. Her primary research is in social and political philosophy, moral philosophy, and philosophy of law. She also works on questions in feminist philosophy, bioethics, and health law. She is writing a dissertation on informal political representation under the supervision of Tommie Shelby, T.M. Scanlon, Richard Moran, and Eric Beerbohm. She has served as a law clerk to the Honorable Judge Rosemary Barkett and the Honorable Judge Adalberto Jordan on the United States Court of Appeals for the Eleventh Circuit, and as a legal adviser to Judge Barkett on the Iran-United States Claims Tribunal in The Hague. During 2015-2016, she was a graduate fellow at the Edmond J. Safra Center for Ethics at Harvard University. During 2016-2017, she is a student fellow at the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School. For more on her work, please visit her website: wendysalkin.com.