APA Policies on End of Life Issues and Care: APA Resolution on Assisted Suicide

Whereas the issue of assisted suicide is complex, involving areas of ethics, religion, medicine, psychology, sociology, economics, the law, public policy, and other fields; and

Whereas in the United States there is significant social stratification related to cultural, ethnic, economic, gender, and religious differences; and

Whereas these differences in our society are associated with an equally diverse range of views regarding assisted suicide; and

Whereas in the United States decisions about assisted suicide are made in the context of serious social inequities in access to resources such as basic medical care; and

Whereas autonomy is an important guiding principle in the law and in psychological and medical aspects of decision-making, but in and of itself is insufficient to capture the full range of complex medical, familial, social, financial, psychological, cultural, spiritual, and legal issues involved in the practice of assisted suicide; and

Whereas there is increasing public support for assisted suicide, but this support is weakest among groups who express concerns about being pressured to die (i.e., older adults, people with less education, women, and ethnic minorities) (Blendon, Szalay, & Knox, 1992); and

Whereas reasonable, well-informed people starting from different positions about costs and gains associated with assisted suicide disagree about the potential effects of legalizing the practice; and

Whereas people with different values and priorities can reach different conclusions about the advisability of assisted suicide; and

Whereas some evidence suggests that there are fluctuations in the will to live (Chochinov, Tataryn, Clinch, & Dudgeon, 1999) and in wishes regarding life-sustaining treatments (Weisman, Haas, & Fowler, 1999); and

Whereas pain and clinical depression are frequently under-treated, which can lead to suffering that may result in requests for assisted suicide (Foley, 1995); and

Whereas evidence suggests that some people rescind their requests for assisted suicide when they receive more aggressive and comprehensive care (Ganzini et al., 2000); and

Whereas psychological, familial, social, and financial factors seem to be more important than physical factors in requests for assisted suicide (Breitbart, Rosenfeld, & Passik, 1996; Emanuel, Fairclough, Slutsman, & Emanuel, 2000; Sullivan, Hedberg, & Fleming, 2000); and

Whereas little empirical data exist to determine the effects of assisted suicide on survivors and on society (Cooke et al., 1998); and

Whereas the empirical database, legal developments, and policy discourse related to assisted suicide are evolving rapidly;

Therefore, be it resolved that the American Psychological Association take a position that neither endorses nor opposes assisted suicide at this time.

However,
Given that psychologists have many areas of competence, including assessment, counseling, teaching, consultation, research, and advocacy skills that could potentially enlighten the discourse about assisted suicide, end-of-life treatment, and support for dying persons and their significant others; and

Given that psychologists could be instrumental in helping health care providers to understand and cope with the concerns and needs of dying individuals and their families; and

Given that practicing psychologists may receive requests to be involved in the education of various groups regarding assisted suicide; and

Given that there is one state in which assisted suicide is legal and psychological or psychiatric assessment and consultation is required under certain circumstances; and

Given that practicing psychologists may be part of multidisciplinary end-of-life care teams including ones exploring requests for assisted suicide;

Let it be further resolved that the American Psychological Association will assist in preparing the profession to address the issue of assisted suicide by taking the following actions:

Advocate for quality end-of-life care for all individuals; and

Encourage and promote the development of research on assisted suicide; and

Monitor legal, policy, and research developments that may require or encourage psychologists to involve themselves in assisted suicide cases; and

Promote policies that reduce suffering that could lead to requests for assisted suicide; and

Promote psychologists' involvement in research on ethical dilemmas faced by clinicians and researchers dealing with issues related to assisted suicide; and

Promote psychologists' participation in multidisciplinary teams and ethics committees involved with reviewing end-of-life requests; and

Encourage psychologists to obtain training in the area of ethics as it applies to end-of-life decisions and care; and

Encourage practicing psychologists to inform themselves about criminal and civil laws that have bearing on assisted suicide in the states in which they practice; and

Encourage practicing psychologists to recognize the powerful influence they may have with clients who are considering assisted suicide; and

Encourage psychologists to identify factors leading to assisted suicide requests (including clinical depression, levels of pain and suffering, adequacy of comfort care, and other internal and external variables) and to fully explore alternative interventions (including hospice/palliative care, and other end-of-life options such as voluntarily stopping eating and drinking) for clients considering assisted suicide; and

Encourage practicing psychologists to be aware of their own views about assisted suicide, including recognizing possible biases about entitlement to resources based on disability status, age, sex, sexual orientation, or ethnicity of the client requesting assisted suicide; and

Encourage psychologists to be especially sensitive to the social and cultural biases which may result in some groups and individuals being perceived by others, and/or being encouraged to perceive themselves, as more expendable and less deserving of continued life (e.g., people with disabilities, women, older adults, people of color, gay men, lesbians, bisexual people, transgendered individuals, and persons who are poor).

References

Blendon, R. J., Szalay, U. S., & Knox, R. A. (1992). Should physicians aid their patients in dying? The public perspective. Journal of the American Medical Association, 267, 2658-2662.

Breitbart, W., Rosenfeld, B. D., & Passik, S. D. (1996). Interest in physician-assisted suicide among ambulatory HIV infected patients. American Journal of Psychiatry, 153, 238-242.

Chochinov, H. M., Tataryn, D., Clinch, J. J., & Dudgeon, D. (1999). Will to live in the terminally ill. Lancet, 354, 816-819.

Cooke, M., Gourlay, L., Collette, L., Boccellari, A., Chesney, M. A., & Folkman, S. (1998). Informal care givers and the intention to hasten AIDS-related death. Archives of Internal Medicine, 158, 69-75.

Emanuel, E. J., Fairclough, D. L., Slutsman, J., & Emanuel, L. L. (2000). Understanding economic and other burdens of terminal illness: The experience of patients and their caregivers. Annals of Internal Medicine, 132, 451-459.

Foley, K. M. (1995). Pain, physician-assisted suicide, and euthanasia. Pain Forum, 4, 163-178.

Ganzini, L., Nelson, H. D., Schmidt, T. A., Kraemer, D. F., Delorit, M. A., & Lee, M. A. (2000). Physicians' experiences with the Oregon Death with Dignity Act. New England Journal of Medicine, 342, 557-563.

Sullivan, A. D., Hedberg, K., & Fleming, D. W. (2000). Legalized physician-assisted suicide in Oregon -- The second year. New England Journal of Medicine, 342, 598-604.

Weisman, J. S., Haas, J. S., & Fowler, F. J. (1999). The stability of preferences for life sustaining care among persons with AIDS in the Boston Health Study. Medical Decision Making, 19, 16-26.