NEW ORLEANS -- Family physicians took a dramatic step in choosing to reject the term "assisted suicide" when characterizing a situation where a patient has decided to end their life and "suffering," and choosing to describe such an action as "medical aid in dying."
"Through our ongoing and continuous relationship with our patients, family physicians are well-positioned to counsel patients on end-of-life care, and we are engaged in creating change in the best interest of our patients," said Michael Munger, MD, president of the American Academy of Family Physicians (AAFP), in a press release.
The AAFP, during its Congress of Delegates (COD) meeting here, on Tuesday adopted a policy stating "that the use of medical aid in dying is an ethical, personal, end-of-life decision when the patient is terminally ill, is suffering and capable of making an informed decision to end his/her suffering," and stressed that such decisions should happen "in the context of the doctor-patient relationship."
End-of-Life Decisions
The Academy stopped short of choosing to directly lobby in support of the matter, instead opting for a "neutral position" regarding whether individual states should allow medical aid in dying. However the Academy stated that it would support laws that protect physicians from criminal prosecution for assisting terminally ill patients in "ending their suffering" in states where such actions are permitted.
The change passed by a two-thirds majority, as is required for any vote that differs from the American Medical Association's ethical policies. The still opposes "assisted suicide."
"Changing our position to 'engaged neutrality' shows that our members can respectfully disagree about medical aid in dying, but still agree about our role in supporting our patients no matter what care they choose at the end of life," said Julia Sokoloff, MD, a member of the Washington Academy of Family Physicians, who introduced the resolution, in a press statement from the advocacy group Compassion and Choices.
While some frame the Academy's actions as breaking with the AMA, the Academy views these actions as a vehicle for further discussion with the AMA, AAFP staff told ڴŮ.
It is only by adopting such a policy of "engaged neutrality" that the AAFP can advocate on the matter at future AMA House of Delegates meetings, Munger explained.
Medical aid in dying is now legal in seven states -- California, Colorado, Hawaii, Montana, Oregon, Vermont, and Washington -- as well as the District of Columbia.
Fighting for Women's Reproductive Access
The AAFP also passed an entire package of advocacy-related provisions without any opposition -- despite serious debate in committees the day earlier -- which included a handful of policies supporting women's access to reproductive services, such as policies rejecting the criminalization of self-induced abortion, opposing "fetal personhood" language, and recommending that medication abortion be removed from the FDA's Risk Evaluation and Mitigation Strategy (REMS) requirements.
The FDA maintains that the is "to mitigate the risk of serious complications associated with Mifeprex" in three ways: by mandating that healthcare providers who prescribe mifepristone be certified in the Mifeprex REMS, by ensuring the drug is only dispensed in "certain healthcare settings" or under the supervision of certified prescribers, and by requiring providers to share information about the potential serious complications they could encounter when using the drug.
Those advocating to remove REMS restrictions on mifepristone argued, in a committee meeting on Monday, that the REMS creates an unnecessary burden on physicians who wish to offer medication abortion to patients.
The consequences of that "burden" are disproportionately felt by women of color and those living in poverty who tend to have less access to such services, said Cadey Harrel, MD, an alternate delegate from Arizona. Harrel also argued that low-dose aspirin has a greater risk of complication than mifepristone, and highlighted a
The congress also approved policy opposing any legislative efforts to "criminalize self-induced abortion." Again, in committee discussions, supporters of the resolution pointed out that such policies disproportionately affect women of color.
And the Academy also adopted a policy opposing the use of "nonscientific language" in reproductive health such as that related to "fetal personhood."
As Kandie Tate, MD, a delegate from Washington, D.C., noted, using "nonscientific language with patients confuses them."
In a committee discussion a day earlier, Wayne Gravois, MD, a delegate from the Louisiana chapter of the AAFP, introduced a resolution opposing elective abortions at and "after 20 weeks gestational age."
He shared the story of one of his own patients, whose mother insisted she get an abortion at 26 weeks, against her own wishes. The mother ultimately gave up after being unable to access an abortion for her daughter in Louisiana. The infant was delivered and adopted, Gravois said.
After multiple members stated their opposition, and perhaps sensing defeat of the resolution, Gravois requested that his policy be referred to the committee for study. Ultimately, the resolution was not adopted.
Maternal Mortality, Paid Family Leave
On the matter of maternal mortality, a resolution introduced by delegates from Oregon, New York, and Texas urging the AAFP to lobby the Accreditation Council for Graduate Medical Education (ACGME) to increase training for complications of maternity care was not adopted; however, a substitute resolution, requiring the development of a task force to report back on evidence-based methods to reduce maternal morbidity and mortality, and strategies to improve education on the topic at the next COD meeting, was approved.
On Tuesday, the full Congress did discuss a resolution centered around supporting a comprehensive national paid family leave of 12 weeks. The reference committee assigned to review the policy endorsed the idea and recommended it be adopted; however, the policy was extracted for debate by the full congress.
Douglas Curran, MD, a delegate from Texas, who opposed the resolution, asked that it be referred to the board for study. A lot of small community practices are "struggling," he said.
"We want to do the right thing, but this is a very complicated issue, and we ought to look to see how it's going to affect our rural and small practices," Curran added.
Erica Roshanravan, MD, a delegate from the member constituency, opposed referral and pressed the Congress to adopt the measures as a matter of health equity. Many low-income women cannot afford unpaid leave, she said.
Scott Dunn, MD, a delegate from Idaho, also supported referral, saying that having to pay all of a dozen new physicians, male and female, 12 weeks of paid leave would be a "substantial hindrance."
Ultimately the resolution was not adopted and was instead returned to the appropriate committee for additional study.