Controversy surrounding a physician's role in lethal prescriptions has existed for millennia (asamonitor.pub/3ZjISdJ). Today, some form of medical assistance in dying is a legal end-of-life option for roughly 200 million patients worldwide (Ann Palliat Med 2021;10:3540-53). Anesthesiologists are unfortunately associated with the world of lethal prescriptions, as evidenced by a 2006 U.S. District Court ruling that ordered California to “have a physician, specifically an anesthesiologist, personally supervise” the administration of a lethal injection for capital punishment (N Engl J Med 2006;354:1221-9). An anesthesiologist's decision to participate in physician-assisted dying requires evaluation of one's personal moral principles, which vary greatly on this issue. Opioids and benzodiazepines, medications that are routinely administered during anesthesia, are commonly prescribed at the end of life. As a result, even if an anesthesiologist does not participate in physician-assisted death as part of their individual practice, the discussion remains germane because of the specialty's perceived connection to the practice (Can J Anaesth 2016;63:326-9; asamonitor.pub/3XlpnyX).
“It is nearly impossible to separate physician-assisted dying from legal, moral, or ethical controversy. An individual physician's moral boundaries remain even when the practice is legal. The ethical concepts of autonomy, beneficence, justice, and nonmaleficence each apply, while equal, valid consideration must be given to the physician's own moral agency.”
Academic and legislative definitions
The terminology surrounding medical assistance in dying is not consistently applied in academic literature nor in state or national legislation (Ann Palliat Med 2021;10:3540-53; Yale J Biol Med 2019;92:747-50). Here, we will use “medical assistance in dying” as an umbrella term that includes “euthanasia” and “physician-assisted death,” among others (see Table for definitions of the terms used in this article) (Ann Palliat Med 2021;10:3540-53). We realize that any term may produce some opposition, so we seek primarily to align the definitions with the established terms in ethical literature. Some terms that are more common in academic use have alternate meanings in legislation, even though each seeks to define the same phenomenon. “Euthanasia,” as defined in the Table, is illegal throughout the United States and is therefore beyond the scope of this article.
In contrast, physician-assisted death is now legal in 11 U.S. jurisdictions. The legal term used is often “medical assistance in dying,” but the process is the same as what this article refers to as “physician-assisted death” (Ann Palliat Med 2021;10:3540-53; asamonitor.pub/3TnFIlA).
Physician-assisted death in the U.S. and Canada
Ten states (California, Colorado, Hawaii, Maine, Montana, New Jersey, New Mexico, Oregon, Vermont, and Washington) and the District of Columbia have legalized the practice of physician-assisted death for terminally ill patients. Oregon was the first to do so in 1994; most recently, New Mexico legalized it in 2021. Montana is unique because the legalization comes through a State Supreme Court ruling, not an act of the state legislature. New bills like those described above are routinely introduced in statehouses nationally, though none since New Mexico's have been enacted.
For a patient's request for physician-assisted death to be considered, most state laws stipulate that a patient's life expectancy must be six months or less. Other requirements vary and may include ensuring that the individual is an adult with decision-making capacity, the request has been made voluntarily, and the individual making the request is physically able to self-administer the prescribed medication(s). Importantly, these laws require that each patient must self-administer their prescription. State laws further emphasize several aspects of patient education, including the choice to opt out at any time during the process.
Medical assistance in dying is growing more popular abroad. Canada's law, originally passed in 2015, recently came under renewed scrutiny as Ottawa considered the extension of federally funded physician-assisted death for physically healthy patients suffering from mental illnesses. The proposal, scheduled to take effect in March 2024, was delayed until 2027 after a strong and negative public response (asamonitor.pub/3zgNXJo).
Ethical considerations
It is nearly impossible to separate physician-assisted dying from legal, moral, or ethical controversy. An individual physician's moral boundaries remain even when the practice is legal. The ethical concepts of autonomy, beneficence, justice, and nonmaleficence each apply, while equal, valid consideration must be given to the physician's own moral agency. (asamonitor.pub/3TnFIlA; Surg Endosc 2021;35:2217-22). The question of whether a patient's autonomy outweighs a physician's obligation to nonmaleficence is central to such discussions.
Some readers may remember an anonymous physician's experience of providing medical assistance in dying titled “It's Over, Debbie,” which was published in JAMA in 1988 (JAMA 1988;259:272). The case described an exhausted resident cross-covering on the gynecology-oncology service at a private hospital. The resident was called to the bedside overnight for a young woman with intractable vomiting and end-stage ovarian cancer. In response, the resident personally administered 20 milligrams of intravenous morphine with the intention to “give her rest.” The patient became apneic shortly thereafter. The essay, and the decision to publish the essay in the journal, engendered an enormous response (JAMA 1988;259:2142-3). Then, as now, this conversation is reasonable; more broadly, the conversation needs to encompass how patient-centered care can be best provided at the end of life, which is our aim in the present essay. Debbie's case exposed the lack of patient-oriented safeguards when medical assistance in dying was done without a strong patient-physician relationship, patient education, or psychological evaluation.
The ethical doctrine of double effect can be used to evaluate treatments for patients at the end of their life. The principle describes how an unintended negative consequence can be permissible if an action is the means to a separate, intended outcome (Philos Ethics Humanit Med 2023;18:7; St. Thomas Aquinas Summa Theologica: Complete English Edition in Five Volumes. 2000). It is classically applied in the administration of opioids, either to provide analgesia or relieve air hunger, in perimortem patients. By considering the character of the positive effect (comfort), a clinician may be able to tolerate a negative side effect (apnea) so long as the intention is not euthanasia. The doctrine includes four criteria to justify a negative, unintended effect:
The act itself (in this case, prescription) must be a moral good, or at least indifferent
The decision-maker must not intend the negative effect but may allow it
The negative effect must not be the means to achieving the positive effect
The intended effect must be proportionally desirable to accept the negative effect's severity.
In considering the clinical status of moribund patients, maybe with widespread metastases or other incurable symptoms, physicians will approach each patient individually. Strong respect for colleagues' moral boundaries in this area can minimize disruptions to care and ensure the patient's wishes remain the focus of management discussions. Regardless of one's subspecialty or the legal status of physician-assisted dying locally, anesthesiologists may need to discuss these end-of-life scenarios with patients, colleagues, and families.
Disclaimer:
The opinions expressed in this article are those of the authors alone and should not be construed as ASA policy or legal advice.
William J. Shearon, BS, ASA Committee on Ethics, and Medical Student, University of Missouri School of Medicine, Columbia, Missouri. X: @WillieShearon
Peter A. Goldstein, MD, ASA Committee on Ethics, ASA Committee on Research, Professor of Anesthesiology, Professor of Anesthesiology in Neuroscience, and Professor of Medical Ethics in Medicine, Weill Cornell Medicine, New York, New York.
Rachel A. Hadler, MD, Vice Chair, ASA Committee on Palliative Care, Member, ASA Committee on Ethics, Assistant Professor of Anesthesiology, Division of Critical Care, Emory University School of Medicine, Atlanta, Georgia, and Attending Physician, Palliative Care Service, Division of Geriatrics and Extended Care, Atlanta VA Medical Center, Atlanta, Georgia.
Lara R. India, MD, ASA Committee on Ethics, ASA Committee on Palliative Care, and Assistant Professor of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin.
Ike I. Eriator, MD, MPH, MBA, ASA Committee on Ethics, ASA Committee on Membership, and Professor of Anesthesiology, University of Mississippi Medical Center, Jackson, Mississippi.
Michael Souter, MBChB, DA, FRCA, FNCS, Chair, ASA Committee on Ethics, Member, ASA Committee on Trauma and Emergency Preparedness, and Professor of Anesthesiology and Pain Medicine, and Neurological Surgery, University of Washington, Seattle, Washington.