End-of-Life Choice, Palliative Care and Counseling

AMA Opposition and the Path Aheadby Barbara

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Working for social change, we run a long race through a wood, dark and deep. The milestones tick by, yet still the path leads ahead into the thicket. We long to break into a clearing and see the finish line ahead.

Over fifteen years ago I enlisted in the fight to secure our right to control the timing and manner of death should end-of-life suffering become unbearable. We have come far in those years. Nearly two-thirds of Americans believe the law should empower terminally-ill, competent patients to choose how they will end their lives.

With the public on our side, we must overcome the resistance of a few powerful opponents. Conservative religious activists oppose us, as they stand in the way of other social change. They hold firm religious beliefs about life’s end and seek to impose them on others through secular law.

But they alone could not stop us if they were not joined by the American Medical Association. The AMA’s outspoken opposition to aid in dying has been cited by the Supreme Court and influences lower courts, state medical societies, and most important, legislatures.

Our society naturally defers to physicians in the matter of prescribing potent medicines. We have invested them as the keepers of, and expect them to manage, those medicines. Yet we chafe at our deference to the medical establishment when they withhold a vitally important choice from some patients.

To ask, “why do our doctors oppose what the majority of Americans support?” misstates the question. The AMA claims to speak for doctors, and the media often echo that assertion, yet barely a quarter of the nation’s physicians are AMA members.

Many medical and public health organizations have policies that support aid in dying, including the American Medical Women’s Association, the American Medical Student Association, the American College of Legal Medicine and the American Public Health Association. The Oregon experience has persuaded medical leaders throughout the nation that legalization of aid in dying improves end-of-life care rather than harms it. The majority of physicians see it as part of their role as reliever of suffering when a cure is not possible. The position of the AMA Council on Ethical and Judicial Affairs however, remains a tired platitude, frozen in time for the last fourteen years: physician aid in dying “is fundamentally incompatible with the physician’s role as healer.”

When pollsters ask individual doctors whether they would support legalized physician aid in dying, their answer is a resounding yes. A number of surveys show nearly two-thirds of doctors are supportive, close to the percentage of Americans in general. Even among those doctors who are members of the AMA, only one out of three opposes legalization. In fact a majority of physicians report they would want aid in dying available to them if they were faced with a terminal illness. Imposing a reverse golden rule, the AMA prevents doctors from helping others to choose what they would want for themselves.

With so many doctors supporting it, who stands against empowering dying patients? Four hundred thirty physicians in the AMA House of Delegates craft its policy. Among those 430 physicians, opposition to end-of-life choice is strong and fierce. Why does the AMA leadership stand in the way of change? We can only speculate on their motive but it helps to ask what benefit the AMA sees in keeping it illegal.

The answer lies in the fact that legalization empowers patients. It empowers them to discuss end-of-life treatment. Legal aid in dying gives qualified patients the power to ask their doctors about their options and to request a prescription for life-ending medication. If their doctor will not honor their choices, legalization gives patients the power to transfer their care to a doctor who will. It breaks the bonds that hold them hostage to the religious beliefs of their doctor. Patients however, do not gain power by taking it from physicians. In my experience, legalizing aid in dying is not a zero sum equation for doctors. It empowers both patients and their physicians to speak frankly, practice medicine safely and face inevitable sadness openly.

Where physician aid in dying remains illegal, the AMA controls both doctors and their patients. Sadly, the AMA has long opposed progress in medical practice and treatment that empowers patients and removes physicians from the absolute center of the decision-making process. The AMA opposed all forms of medical insurance and delayed Medicare enactment for years with its vigorous opposition. It opposed birth control for women and the use of anesthesia during childbirth. Patients fought in court for informed consent, the right that guarantees they must understand treatments and alternatives before agreeing to them.

As with these past struggles, advocates for empowering patients through aid in dying have faced opposition from the AMA and its affiliates that is vigorous and even ruthless. The California legislature debated a Death with Dignity bill in 2007. That bill would be the law today if it were not for the efforts of the California Medical Association, who deployed all their lobbying power in Sacramento to defeat it, twisting the arms of legislators in a raw display of political muscle.

The AMA’s opposition to patient empowerment is frustrating, even infuriating, but predictable. Gloria Steinem has famously said, “Power can be taken, but not given. The process of the taking is empowerment in itself.” At Compassion and Choices we have learned over the years from countless patients facing the end of life, that by embracing that end and making active decisions they forcefully take that power unto themselves. In the same way, as advocates, we cannot expect a small yet potent group of AMA leaders to willingly grant us the change we seek. We must take it ourselves.