Euthanasia and Physician-Assisted Suicide are Unethical Acts.

The following article was published in the May 2019 edition of the World Medical Association Journal. (Link)

This article is written by Dr's Ewan Galigher, Maria Gigolini, Alana Cormier, Sinéad Donnelly, Catherine Ferrier, Vladimir A Gorshkov-Cantacuzéme, Sheila Harding, Mark Komrad, Edmond Kyrillos, Timothy Lau, Rene Leiva, Renata Leong, Sephora Tang and John Quinlan.

The World Medical Association (WMA), the voice of the international community of physicians, has always firmly opposed euthanasia and physician-assisted suicide (E&PAS) and considered them unethical practices and contrary to the goals of health care and the role of the physician [1]. In response to suggested changes to WMA policy on this issue, an extensive discussion took place among WMA Associate Members. We, representing a voice of many of those involved in this discussion, contend that the WMA was right to hold this position in the past and must continue to maintain that E&PAS are unethical.
 
The Central Issue Under Debate is the Ethics of E&PAS
 
The question is whether it is ethical for a doctor to intentionally cause a patient’s death, even at his or her considered request. The fact that E&PAS has been legalized in some jurisdictions and that some member societies support these practices has no bearing on the ethical question. What is legal is not necessarily ethical. The WMA already recognizes this distinction, for example, by condemning the participation of physicians in capital punishment even in jurisdictions where it is legal. The WMA should be consistent in this principle also with respect to E&PAS.

E&PAS Fundamentally Devalues the Patient
 
This devaluation is built into the very logic of E&PAS. To claim that E&PAS is compassionate is to suggest that a patient’s life is not worth living, that her existence is no longer of any value. Since the physician’s most basic tasks and considerations are to ‘always bear in mind the obligation to respect human life’ and ‘the health and well-being of the patient’ [2, 3], E&PAS must be opposed. E&PAS distorts the notion of respect for the patient. On the one hand it claims to help suffering persons, while on the other hand it eliminates them. This is a profound internal contradiction; the ethical priority is to respect the fundamental intrinsic worth of the person as a whole.
 
E&PAS Puts Patients at Risk
 
Patients are autonomous agents but are not invulnerable to their need for affirmation from others, including their physician. Amidst the overwhelming fears of those who suffer (4, 5), a free autonomous decision to die is an illusion. Particular concern exists for those who may feel their life has become a burden due to changing perceptions of the dignity and value of human life in all its different stages and conditions, and an explicit or implicit offer of E&PAS by a physician profoundly influences the patient’s own thinking. The troubles of human relationships within families, the presence of depression, and problems of abuse and physician error in an already stressed medical system, make muddy waters even more turbulent [6]. Evidence shows that societies cannot always defend the most vulnerable from abuse if physicians become life-takers instead of healers [1, 6]. The power of the therapeutic relationship cannot be underestimated in the creation of patient perceptions and choices.

E&PAS Totally Lacks Evidence as ‘Medical Treatment’

The consequences of E&PAS are unknown as both physicians and patients have no knowledge of what it is like to be dead. Advocates of E&PAS place blind faith in their own assumptions about the nature of death and whether or not there is an afterlife when arguing that euthanasia is beneficial. E&PAS is therefore a philosophical and quasi-religious intervention, not a medical intervention informed by science. Doctors should not offer therapy when they have no idea of its effects—to offer E&PAS is to offer an experimental therapy without any plans for follow-up assessment. Therefore, key elements in any medical intervention such as informed consent are simply not possible without knowing what stands on the other side of death. Rather than a standard medical discussion of alternatives based on scientific data or clinical experience, the discussion must leave the clinical domain and enter the domain of speculation. This is not an exercise in informed-consent. This is not the accepted medical ethics of medical practice. All this is, in part, why E&PAS cannot be a medical procedure.
 
These Weighty Moral Considerations are Supported by the Ethical Intuition of the Global Medical Community
 
Only a small minority of physicians support E&PAS. The vast majority of doctors around the world wish only to foster the will to live and to cope with illness and suffering, not to facilitate acts of suicide or to create ambiguity around what constitutes a medical treatment. We must remember that
the four regional WMA symposia demonstrated that most doctors would never be willing to participate in euthanasia. Even the insistence of E&PAS proponents on (a) using ambiguous language such as ‘Medical Assistance in Dying’ to describe their practice and (b) avoiding mention of E&PAS
on death certificates suggests that they share to some degree this fundamental ethical intuition about killing patients.
 
Acceptance of E&PAS Undermines Boundaries Between End-Of-Life Care Practices That do not Intend Death (palliative care, withholding/withdrawing lifesustaining therapy) and Those that do Intend Death (E&PAS)
 
Confusion is created at a societal level about what constitutes “medical treatment,” especially when language such as “medical assistance in dying” or “voluntary assisted dying” is used. This renders the reality of such acts and their application unclear. As many patients share our conviction that deliberately causing death is wrong, a misunderstanding of the distinction between E&PAS and palliative care may lead to rejection of palliative care or insistence on futile life-sustaining therapies. The availability of E&PAS also distracts from the priority of providing social services and palliative care to those who are sick and dying [7].

The WMA’s Code of Ethics Strongly Influences Standards for the Practice of Medicine Around the World and Neutrality on E&PAS by the WMA Would be Interpreted Globally as Tacit Approval
 
A change in the WMA statement would imply a tacit endorsement of E&PAS and render the WMA complicit with such practices [8, 9]. Neutrality by professional medical organisations on E&PAS is perceived by society, governments and the international pro-euthanasia lobby as that organisation’s acceptance of them as medical practice, rather than as a response to a societal/political agenda. Those who seek international approval to justify these practices will create a silencing of the majority of the community, which has real medical, societal and ethical concerns around E&PAS and their effects on society internationally.
 
WMA policy on E&PAS reflects that which is in place in hundreds of jurisdictions with widely divergent legal and political traditions. While it may be tempting to placate some member societies so as to avoid dissension, we must not destabilize medical ethics around the world. We must continue to characterize E&PAS as unethical even if it conflicts with the demands of the state or influential groups backed by the law. We must not let imperfect law trump good medical ethics. Undoubtedly many doctors who perform E&PAS believe themselves to be acting nobly; but it does not follow that they should expect others to affirm their views or not to oppose them; nor are they wronged by existing WMA policy. Any society that insists on transforming suicide from a freedom to a right, should stand up a different profession with the duty to fulfil that new right, as killing does not belong in the House of Medicine.
 
Neutrality on E&PAS has Serious Consequences for Physicians who Refuse to Participate 

In jurisdictions where E&PAS is legalized, physicians who adhere to the long-standing Hippocratic ethical tradition are suddenly regarded as outliers, as conscientious objectors to be tolerated and ultimately excluded from the profession [10]. A neutral stance by the WMA would compromise the position of the many medical practitioners around the world who believe these practices to be unethical and not part of health care. In some jurisdictions it is illegal not to refer for these practices, creating a dystopic situation where the doctor who practises quality end-of-life care needs to conscientiously object in order to do so, and may be coerced to refer for E&PAS. Neutrality from the WMA would promote the contravention of the rights and ethical practice of these doctors, undermining their ethical medical position at the behest of a societal demand that can fluctuate with time.
 
In sum, the changes currently being debated, arising from political, social, and economic factors, have been rejected time and again and most recently by the overwhelming consensus of WMA regions. The present debate represents a crucially important moment for the WMA that must not be squandered. Given the influence of the WMA and the profound moral issues at stake, neutrality should not be an option. The WMA policy must continue to stand as a beacon of clarity to the world, bringing comfort to patients and support to physicians around the globe. The WMA should not be coerced into promoting euthanasia and assisted suicide by making its stance neutral.
 
References 
1. Leiva R, Friessen G, Lau T. Why Euthanasia is Unethical and Why We Should Name it as Such. WMJ. 2018 Dec; 64 (4) pages 33-37. [Cited 2019 Feb 05]. https://www.wma.net/wpcontent/uploads/2019/01/wmj_4_2018_WEB.pdf
2. WMA INTERNATIONAL CODE OF MEDICAL ETHICS. WMA [Internet] [cited2019 Feb 05]. https://www.wma.net/policiespost/wma-international-code-of-medicalethics
3. WMA DECLARATION OF GENEVA. WMA [Internet] [cited 2019 Feb 05]. https://www.wma.net/policies-post/wma-declarationof-geneva
4. Zaorsky NG et al. Suicide among cancer patients. Nat Commun. 2019 Jan 14;10 (1):207. [cited 2019 Feb 05]. https://www.nature.com/articles/s41467-018-08170-1
5. Rodríguez-Prat A et al. Understanding patients’ experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography. BMJ Open. 2017 Sep 29;7(9):e016659. [Cited 2019 Feb 05].https://bmjopen.bmj.com/content/7/9/e016659.long
6. Miller DG, Kim SYH. Euthanasia and physician-assisted suicide not meeting due care criteria in the Netherlands: a qualitative review of review committee judgements. BMJ Open. 2017 Oct 25;7(10):e017628. [cited 2019 Feb 05].https://bmjopen.bmj.com/content/7/10/e017628. long
7. The Canadian Society of Palliative Care Physicians-KEY MESSAGES RE HASTENED DEATH [Internet] [cited 2019 Feb 05]. https://www.cspcp.ca/wp-content/uploads/2015/10/CSPCP-Key-Messages-FINAL.pdf
8. Sulmasy DP, Finlay I, Fitzgerald F, et al. Physician-assisted suicide: why neutrality by organized medicine is neither neutral nor appropriate. J Gen Intern Med 2018; 33: 1394-1399.
9. Canadian Medical Association softens stand on assisted suicide. Globe and Mail. AUGUST 19, 2014 [Internet] [cited 2019 Feb 05]. https://www.theglobeandmail.com/news/national/canadian-medical-association-softens-stance-onassisted-suicide/article20129000/
10. Euthanasia in Canada: A Cautionary Tale. WMJ 2018 Oct; 64 (3), p 17-23. [cited 2019 Feb 05].https://www.wma.net/wp-content/uploads/2018/10/WMJ_3_2018-1.pdf (Institutional affiliations are provided for identification purposes only and do not imply endorsement by the institutions.)