CHAPTER  7



                        DEVELOPING PROFESSIONAL

                           MEDICAL STANDARDS                page 149



          The medical profession has traditionally established standards

    of conduct that govern its members.  The standards are set in a

    variety of ways, including statements by professional bodies such as

    the American Medical Association, the actual practice of physicians,

    expert opinion by physicians, and clinical research findings.  The

    standards also generally adhere to parameters or policies

    established by the criminal and civil law.  By delineating the

    boundaries of appropriate medical conduct, professional standards

    provide guidance to physicians on many aspects of clinical practice,

    including physicians' duties to patients, the patient-physician

    relationship, and ethical dilemmas posed by treatment decisions.



          Ultimately, the responsibility for establishing guidelines for

    medical practice rests with the medical profession itself.  However,

    certain ethical principles have emerged from the Task Force's

    deliberations on assisted suicide and euthanasia that provide a

    useful framework within which such guidelines can be formed.  The

    Task Force believes that professional standards should recognize the

    provision of effective pain relief and palliative care, including

    treatment for depression or referral for treatment, as a basic

    obligation all physicians owe to their patients.  The Task Force has

    also concluded that the legal prohibitions against euthanasia and

    intentional or reckless suicide assistance provide valuable guidance

    for professional standards of conduct.



          The medical profession should not simply restate legal

    principles in setting professional standards on these sensitive

    issues.  In particular, concepts such as <169>intention<170> and

    "recklessness" must be applied in the context of the profession's

    own standards of accepted medical care.  By addressing these

    concepts in ways that are relevant to concerns that routinely arise

    in clinical practice, the medical profession can assist physicians

    who care for seriously and terminally ill patients and enhance the

    care provided to these patients.









    page 150              WHEN DEATH IS SOUGHT







          The principles identified by the Task Force are set forth

    below.  The Task Force believes that these principles will offer

    important guidance for physicians while respecting the need for

    professional judgment in formulating treatment recommendations.





        * Physicians have a professional obligation to provide

          appropriate pain relief and palliative care.



        * Physicians have a professional obligation to assess and treat

          depression or refer patients for treatment.



        * Physicians should not refrain from discussing a patient's

          suicidal thoughts, and indeed should explore, discuss, and

          respond to a patient's indications of suicidal thinking.  This

          is an important aspect of care and also may facilitate

          prevention of suicide.



        * Physicians should not perform euthanasia or assist a patient

          to commit suicide.  However, the provision of medication that

          may hasten a patient's death is ethically and professionally

          acceptable, provided the medication is not intended to cause the

          patient's death or to assist the patient to commit suicide, and

          the medication is provided in accord with accepted medical

          standards.



        * A physician may appropriately provide medication in the face

          of a known risk of suicide, provided that the benefits of the

          medication outweigh the risk and the physician has considered

          the comparable benefits and risks of alternative treatment

          options.



        * The provision of medication used by a patient to commit

          suicide does not, in itself, establish that the physician

          intended to assist the patient to commit suicide.  Rather, an

          evaluation of the physician's intent must take into account a

          range of factors, such as the physician's reasons for providing

          the specific amount and type of medication, and whether the

          amount and type of medication could have served a legitimate

          medical purpose for the particular patient in light of

          identified treatment goals.



          The Task Force encourages professional medical societies to

    expand on these principles by formulating guidelines for the care

    and treatment of seriously ill patients.  Such guidelines should

    recognize that suicide assistance and euthanasia are not permitted,

    but must also seek to promote the appropriate provision of pain

    relief.  Reducing misunderstanding and unwarranted fears of

    professional sanctions for providing pain medication should be a











    CHAPTER 7 -- DEVELOPING PROFESSIONAL MEDICAL STANDARDS   page 151





    central goal of professional standards.  The guidelines should

    recognize that, as with other treatments, physicians should document

    their decisions about pain medication and the reasons for those

    decisions.



          In New York State, the State Board for Professional Medical

    Conduct has a special obligation to apply professional medical

    standards in particular cases to determine whether a physician has

    breached accepted standards of care and, if so, to determine the

    penalty that should result.  The board should determine the penalty

    from the full range of penalties available, weighing the particular

    circumstances of each case.







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