Benchmark 1 Discussion: Patient Risk Assessment

Medical Ethics

and scientific communities and the right to information about epidemics or outbreaks of disease; persecution of health profession- als for their independent medical or human rights activities; attacks on health facilities and personnel; medical evidence of torture and sexual violence and their severe physi- cal and psychological impacts; reproduc- tive rights and health; collusion of health professionals in human rights violations, including torture and executions; overt ob-

struction of the right to health; discrimina- tion within health systems; and much more. PHR has submitted documentation to this process on human rights violations in Bah- rain, Myanmar, the United States and Zim- babwe, among other countries.

Dozens of organizations worldwide regu- larly send representatives to speak at Hu- man Rights Council meetings on a range of issues. But the credible and influential voice

of the medical community in these halls of power is singularly underrepresented. PHR has been opening a door to these opportu- nities and welcomes company to develop a more robust presence in Geneva as threats against the independence of medical pro- fessionals and the silencing of civil soci- ety become ever more pervasive across the globe.

Susannah Sirkin, Director of Policy, Physicians for Human Rights

Ewan C Goligher Maria Cigolini Alana Cormier Sinéad Donnelly Catherine Ferrier Vladimir A. Gorsh- kov-Cantacuzène

Sheila Rutledge Harding

Mark Komrad Edmond Kyrillos Timothy Lau Rene Leiva Renata Leong Sephora Tang John Quinlan

Euthanasia and Physician-Assisted Suicide are Unethical Acts

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 unethi- cal practices and contrary to the goals of health care and the role of the physi- cian [1]. In response to suggested changes to WMA policy on this issue, an exten- sive 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 re-

quest. 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 consis- tent in this principle also with respect to E&PAS. Benchmark 1 Discussion: Patient Risk Assessment

35

Medical Ethics

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 pa- tient’s life is not worth living, that her existence is no longer of any value. Since the physician’s most basic tasks and con- siderations 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 pa- tient. On the one hand it claims to help suffering persons, while on the other hand it eliminates them. This is a profound in- ternal 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 affirma- tion from others, including their physi- cian. Amidst the overwhelming fears of those who suffer (4, 5), a free autono- mous decision to die is an illusion. Par- ticular 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 differ- ent stages and conditions, and an explicit or implicit offer of E&PAS by a physi- cian profoundly influences the patient’s own thinking. The troubles of human relationships within families, the pres- ence 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 be- come 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. Ad- vocates 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 stan- dard 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 medi- cal practice. All this is, in part, why E&PAS cannot be a medical procedure. Benchmark 1 Discussion: Patient Risk Assessment

These Weighty Moral Considerations are Supported by the Ethical Intuition of the Global Medical Community

Only a small minority of physicians sup- port E&PAS. The vast majority of doctors around the world wish only to foster the will to live and to cope with illness and suf- fering, 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 demon- strated 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 prac- tice and (b) avoiding mention of E&PAS on death certificates suggests that they share to some degree this fundamental ethi- cal 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 life- sustaining therapy) and Those that do Intend Death (E&PAS)

Confusion is created at a societal level about what constitutes “medical treatment,” espe- cially when language such as “medical assis- tance in dying” or “voluntary assisted dying” is used. This renders the reality of such acts and their application unclear. As many pa- tients share our conviction that deliberately causing death is wrong, a misunderstanding of the distinction between E&PAS and pal- liative 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 so- cial 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 prac- tices [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/po- litical agenda. Those who seek international approval to justify these practices will cre- ate a silencing of the majority of the com- munity, 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 jurisdic- tions with widely divergent legal and politi- cal 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 objec- tors to be tolerated and ultimately excluded from the profession [10]. A neutral stance by the WMA would compromise the po- sition of the many medical practitioners

around the world who believe these prac- tices 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 conscien- tiously object in order to do so, and may be coerced to refer for E&PAS. Neutrality from the WMA would promote the con- travention 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 de- bated, arising from political, social, and economic factors, have been rejected time and again and most recently by the over- whelming consensus of WMA regions. The present debate represents a crucially im- portant 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 physi- cians around the globe. The WMA should not be coerced into promoting euthanasia and assisted suicide by making its stance neutral. Benchmark 1 Discussion: Patient Risk Assessment

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/wp- content/uploads/2019/01/wmj_4_2018_WEB. pdf

2. WMA INTERNATIONAL CODE OF MEDICAL ETHICS. WMA [Internet] [cited 2019 Feb 05]. https://www.wma.net/policies- post/wma-international-code-of-medical- ethics

3. WMA DECLARATION OF GENEVA. WMA [Internet] [cited 2019 Feb 05]. https:// www.wma.net/policies-post/wma-declaration- of-geneva

4. Zaorsky NG et al. Suicide among cancer pa- tients. 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 pa- tients’ 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 physi- cian-assisted suicide not meeting due care cri- teria in the Netherlands: a qualitative review of review committee judgements. BMJ Open. 2017 Oct 25;7(10):e017628. [cited 2019 Feb 05].htt- ps://bmjopen.bmj.com/content/7/10/e017628. long

7. The Canadian Society of Palliative Care Physi- cians -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. Phy- sician-assisted suicide: why neutrality by organ- ized 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/ca- nadian-medical-association-softens-stance-on- assisted-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/up- loads/2018/10/WMJ_3_2018-1.pdf

(Institutional affiliations are provided for identification purposes only and do not im- ply endorsement by the institutions.)

Ewan C Goligher MD PhD Assistant Professor

Interdepartmental Division of Critical Care Medicine

University of Toronto E-mail: ewangoligher@gmail.com

Dr Maria Cigolini MBBS(Syd) FRACGP FAChPM

Grad.DiPallMed(Melb) Clinical Director Palliative Medicine,

Royal Prince Alfred Hospital Senior Clinical Lecturer,

University of Sydney New South Wales, Australia

E-mail: Maria.Cigolini@health.nsw.gov.au

Medical Ethics

 

37

Alana Cormier MD CCFP Family Physician, Twin Oaks

Memorial Hospital Assistant Professor, Department of Family Medicine, Faculty of Medicine, Dalhousie

University, Nova Scotia, Canada E-mail: alana.cormier@dal.ca

Sinéad Donnelly MD, FRCPI, FRACP, FAChPM

Consultant physician Internal Medicine and Palliative Medicine,

Module convenor and Clinical lecturer Palliative Medicine, University Otago,

Wellington, Aotearoa New Zealand E-mail: Sinead.donnelly@ccdhb.org.nz

Catherine Ferrier, MD, CCFP (COE), FCFP

Division of Geriatric Medicine, McGill University Health Centre

Assistant Professor of Family Medicine, McGill University

E-mail: catherine.t.ferrier@gmail.com

Vladimir A. Gorshkov-Cantacuzène, BChE, MNeuroSci, MD,

DSc(med), TD, JCD

Director, Department of Clinical Cardioneurology, American Institute

of Clinical Psychotherapists E-mail: hypfoundation@gmail.com

Sheila Rutledge Harding, MD, MA, FRCPC Hematologist, Saskatchewan Health Authority

Professor, College of Medicine, University of Saskatchewan

Saskatoon SK Canada E-mail: sheila.harding@me.com

Mark Komrad MD Faculty of Psychiatry Johns Hopkins,

University of Maryland, Tulane Ethics Committee, American

College of Psychiatrists E-mail: Mkomrad@aol.com

Edmond Kyrillos, MD, CCFP, B. Eng. (Mechanical), Lecturer, Department

of Family Medicine, Faculty of Medicine, University of Ottawa

E-mail: edmond.kyrillos@usherbrooke.ca

Timothy Lau, MD, FRCPC Distinguished Teacher, Associate

Professor, Faculty of Medicine, Benchmark 1 Discussion: Patient Risk Assessment

Department of Psychiatry, Geriatrics, Royal Ottawa Hospital.

E-mail: timlau@sympatico.ca

Rene Leiva, MD CM, CCFP (Care of the Elderly/ Palliative Care); FCFP

Assistant Professor Department of Family Medicine

Faculty of Medicine University of Ottawa

E-mail: Rene.leiva@mail.mcgill.ca

Renata Leong MDcM, MHSc, CCFP, FCFP

Assistant Professor, DFCM, University of Toronto

E-mail: leongr@smh.ca

Sephora Tang, MD, FRCPC Staff Psychiatrist, The Ottawa Hospital

Lecturer, Faculty of Medicine, Department of Psychiatry

University of Ottawa E-mail: sephora.md@gmail.com

John Quinlan MB.BS(Syd) FAFRM MA(ethics)

E-mail: jpquinlan@bigpond.com

Defensive medical practice represents an increasing concern in all over the world. The practice of defensive medicine is main- ly associated to the rising number of medi- cal malpractice lawsuits. It negatively affect the quality of care and waste the limited resources in health sector. The economic burden of defensive medicine on health care systems should provide an essential stimulus for a prompt review of this situ- ation. Defensive medicine in simple words is departing from normal medical practice as a safeguard from litigation. The most

frequent daily practice of defensive medi- cine is performing more unnecessary tests and referring more patients to consultants and hospitalization. Such behavior is an ethically wrong and disagrees with deon- tological duties of the doctor. Investigating the prevalence of defensive medicine in a number of international healthcare set- tings, defensive medicine has been found to be highly prevalent in many countries. Majority of physicians across various specialties tends to adopt a defensive professional culture. Daiva Brogiene

Regional Medical Affairs

The Defensive Medicine isn’t the Best Way to Avoid Mistakes

LITHUANIA

 

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