MEDICAL AID IN DYING

To affirm that a pharmacist’s decision to participate or decline to participate in medical aid in dying for competent, terminally ill patients, where legal, is one of individual conscience; further,

To reaffirm that pharmacists have a right to participate or decline to participate in medical aid in dying without retribution; further,

To take a stance of studied neutrality on legislation that would permit medical aid in dying for competent, terminally ill patients.

Rationale

Medical aid in dying (also called physician-assisted dying, physician-assisted suicide, physician aid in dying, physician-assisted death, hastened death, medically assisted dying, and death with dignity) has been legal in some areas of the U.S. since Oregon passed its Death with Dignity Law in 1995. By 2016, one sixth of U.S. citizens lived in a jurisdiction in which medical aid in dying was available, and more states were contemplating legislation to legalize it. Experience in Oregon and elsewhere demonstrates that pharmacists in those jurisdictions may be confronted with the difficult ethical question of whether to participate in medical aid in dying.

For purposes of this policy position, ASHP adapts a common definition of medical aid in dying: the practice in which a physician provides a prescription for a lethal dose of medication to a terminally ill, competent patient at the patient’s request that the patient can self-administer at a time of his or her choosing to end his or her life. ASHP notes that many of the terms commonly used to describe this practice ignore the patient care and dispensing roles of pharmacists as well as the roles of other healthcare professionals, such as hospice nurses, in providing care for patients requesting medical aid in dying. ASHP recognizes the utility of a term such as “medical aid in dying” that addresses the roles of all healthcare providers involved in or affected by the practice but acknowledges the term’s ambiguity regarding self-administration of the lethal dose. ASHP therefore explicitly distinguishes medical aid in dying from all forms of euthanasia, which is not the subject of this policy.

ASHP takes a position of studied neutrality on whether pharmacists should participate in medical aid in dying. Studied neutrality has been defined as “the careful or premeditated practice of being neutral in a dispute” and has as it goals “to foster a respectful culture among people of diverse views and to guide action that does not afford material advantage to a [particular] group.” (Johnstone M-J. Organization Position Statements and the Stance of ‘‘Studied Neutrality’’ on Euthanasia in Palliative Care. J Pain Symp Manag. 2012; 44:896-907.) ASHP respects the diversity of views of its members and other pharmacists on medical aid in dying and adopts a position of studied neutrality to promote patient autonomy and access to care and to protect pharmacists’ professional integrity and comity.

The Code of Ethics for Pharmacists states that “a pharmacist promises to help individuals achieve optimum benefit from their medications [and] to be committed to their welfare” and that “a pharmacist promotes the right of self-determination and recognizes individual self-worth by encouraging patients to participate in decisions about their health.” In pharmacist decision-making about participation in medical aid in dying, those principles may clash. Self-determination dictates that patients should be free to exercise their ethical and legal right to choose or decline any legally available treatment. Many healthcare professionals, and their organizations (including the American Medical Association, the American College of Physicians, and the American Nurses Association), question whether death is ever an acceptable therapeutic goal. Others (including the American Academy of Hospice and Palliative Medicine and the American Psychological Association) acknowledge in their statements of neutrality that society may determine that medical aid in dying falls within a spectrum of treatments and withholding of treatments that has as its goal the relief of suffering through a compassionately hastened death, even while recognizing the risks of such a practice.

Pharmacists, like other healthcare professionals, have a right to examine and act on the moral and ethical issues involved in providing care to patients. ASHP policy position 0610, Pharmacist’s Right of Conscience and Patient’s Right of Access to Therapy, outlines the rights and responsibilities of pharmacists and other pharmacy employees who decline to participate in therapies that they find morally, religiously, or ethically troubling, including the right to reasonable accommodation of their right to conscience in a nonpunitive manner. Procedures should be in place to ensure that healthcare organizations can provide mission-compatible care to patients, and that healthcare providers practicing there are not a barrier to the organization’s ability to provide that care. In adopting its position of studied neutrality on pharmacist involvement in medical aid in dying, ASHP recognizes that adopting a position in favor of participation would infringe on the moral and ethical prerogatives of pharmacists. ASHP similarly recognizes that a stance against participation would make the same infringement and in addition present the risk of legal or professional sanction for pharmacists who participate in medical aid in dying where it is legal.

ASHP also takes a position of studied neutrality on whether medical aid in dying should be legally permitted for competent, terminally ill patients. ASHP recognizes that society may interpret the principle of patient autonomy to include the right to therapies that some may find morally, religiously, or ethically troubling, including medical aid in dying. Recognizing as well the role of healthcare professionals as guardians against practices that would undermine patient autonomy, ASHP advocates that, when permitted, medical aid in dying only be available to competent, terminally ill patients who freely and knowledgeably make that choice.

ASHP joins other healthcare professional organizations in noting that medical aid in dying is inextricably linked with hospice, palliative, and other end-of-life care. ASHP will therefore continue to advocate that patients receive appropriate pharmacist care at the end of life, including pain management, support in dying, and hospice and palliative care.