22 Mar, 17 | by miriamwood
Guest Post: Mara Buchbinder
Why do so many people assume that any clinical communication about aid-in-dying (AID, also known as assisted suicide), where it is legal, ought to be patient-initiated? Physician participants in my ongoing study tend to assume that physicians should wait for patients to initiate discussions of AID. The clinical ethics literature on communication about AID has reinforced this expectation by focusing on how to respond to patient requests. Consequently, bioethics has largely remained silent on whether there is a professional duty to inform terminally ill patients about AID laws and their clinical and legal requirements.
As a medical anthropologist, I pay attention to such gaps in professional discourse, as they often indicate ideas that are so taken for granted that they escape formal expression. In this case, bioethics’ silence on professional obligations to inform patients about AID suggests to me that initiating such a discussion is widely viewed as dangerous. But why? My recent article in the Journal of Medical Ethics began with this puzzling question.
In the United States, where my research is based, in addition to many other Western societies, there is a pervasive cultural stigma against talking about death, as described in the Institute of Medicine’s 2014 Report on Dying in America. Yet there is something bigger at stake here for physicians, who may be more accustomed than most people to talking about death and dying: the idea that mentioning the possibility of hastening one’s death can be deeply injurious to the patient and the patient-provider relationship.
Without discounting this possibility, my article begins with the assumption that there may still be good reasons for physicians to inform terminally ill patients about AID where it is legal. I do not take a position on whether or not there is an affirmative duty to inform in all cases, as I believe that this determination will depend on the clinical context. However, AID laws are designed to give patients choices in end-of-life care, and choices are only meaningful if patients are aware of them. How should physicians approach patients who may not know enough about AID to understand it as an end-of-life option where they live?
Rather than take it for granted that communication about AID ought to begin with a patient’s request, the article examines the possibility of an affirmative duty to inform patients about AID in light of ethical concerns about professional responsibilities to patients and the patient-provider relationship. Who ought to be informed? What are the potential harms and benefits of initiating such a discussion? What information should be included? How should information be communicated? I suggest, for example, that steps may be taken to minimize undue influence when initiating such discussions by attending to framing strategies and contextualizing cues.
Addressing these issues leads us away from questions about physicians’ rights of conscientious refusal, which have dominated the clinical ethics literature, and toward broader ethical and practical questions surrounding clinical communication about AID. As AID legalization movements continue to gain momentum worldwide, physicians will be called on to take on a greater role in patient education, whether they want to or not. It will be critical for bioethics to think beyond patient requests and tackle thorny ethical questions surrounding the physician’s duty to inform.