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Report from: APA Working Group on Assisted Suicide and End-of-Life Decisions
 CHARGE C: Consider and make recommendations on whether it might be appropriate for APA to take a position on the issue of assisted suicide and end-of-life decisions Position on End-of-Life Decisions The issues of assisted suicide and end-of-life decisions will be discussed separately in this section. End-of-life decisions will be discussed first as assisted suicide is subsumed under this topic. Position on End-of-Life Decisions Guiding Principles Psychologists can make significant contributions to improve the quality of end-of-life care and decision-making by actively engaging in these issues in the contexts of practice, education, research, and public policy. As psychologists begin to work in the end-of-life arena more fully and consistently, their actions should be guided by a set of working principles and values. The report of the Institute of Medicine (IOM) on end-of-life issues (Field & Cassel, 1997, pp. 22-23) articulated a set of principles that can serve as an excellent guide for organizing thinking and action in many disciplines, including psychology. These principles are as follows:
Building upon these principles, the IOM report identified four broad deficiencies in end-of-life care, each of which deserve attention from psychologists (pp. 264-265). First, errors of omission and commission occur too frequently at the end of life. Caregivers frequently "fail to provide palliative and supportive care known to be effective" and they often "do what is known to be ineffective and even harmful." Second, there continue to be "legal, organizational, and economic obstacles [that interfere with] excellent care at the end of life." Third, "the education and training of physicians and other health care professionals fails to provide them with the knowledge, skills, and attitudes required to care well for the dying patient." Fourth, existing knowledge of how people die and how to meet their needs during this stage of life is inadequate. Top of Page IOM Recommendations and Implications for Psychologists Recognizing these deficiencies, the IOM report made seven recommendations, many of which are appropriate to the discipline of psychology as it becomes more knowledgeable and involved in this area. Implications for psychologists of each recommendation in the IOM report are indicated.
Top of Page Conclusion The discipline of psychology and individual psychologists have much to offer in increasing the quality of care at the end-of-life for dying individuals and their families. Many of the specific assets that psychology can bring to the table are referred to in previous recommendations of this Report to the Board of Directors. However, it is clear that psychology must make the end-of-life period a priority if it is to assume significant responsibilities and become an active participant in research, education, practice, and policy formation. The historical absence of the discipline makes it imperative that this subject receive focused attention by the American Psychological Association. Top of Page Recommendations
Top of Page Position on Assisted Suicide Assisted suicide is one of the most controversial issues of our time. This section of the Report to the Board contains a brief summary of the arguments commonly used to support positions either for or against assisted suicide as an end-of-life choice. Material for the arguments borrows heavily from other sources (Abeles & Barlev, 1999; Battin, 1996; Callahan, 1992; Canetto, 1995; Canetto & Hollenshead, 1999; Gallagher Thompson & Osgood, 1997; Hendin, 1994, 1995; Kass & Lund, 1996; National Council on Disability, 1998; Miller, 1996; Mishara, 1999; Sanson et al., 1998). The section includes a review of assisted suicide data from Oregon and the Netherlands and the differing interpretations placed on these data. It also summarizes data from a variety of other studies on assisted suicide. The section concludes with a recommendation concerning the position APA should take on assisted suicide. Arguments supporting or opposing assisted suicide are generally made from several frames of reference. These include ethical and moral arguments, legal arguments, medical arguments, and arguments regarding safeguards and the slippery slope. Top of Page Arguments in Support of Assisted Suicide Ethical and moral arguments include the principle of self determination to control the time, place, and nature of one's death, placing quality at the end of life above the sanctity of life. Other factors include the desire to preserve dignity and personhood in the dying process and opposition to prolonging life by using sophisticated medical technology when it is recognized that care is futile. Closely related to self determination is the principle of autonomy. This principle states that persons should have the right to make their own decisions about the course of their own lives whenever they can. By extension, they should also have the right to determine the course of their own dying as much as possible. According to these arguments, even when choices are socially shaped they should be respected as autonomous as long as there is appropriate evaluation of decisional capacity. No person should have to endure terminal suffering that is unremitting, unbearable, or prolonged. When the burdens of life outweigh the benefits because of uncontrollable pain, severe psychological suffering, loss of dignity, or loss of quality of life as judged by the patient, and when the circumstances are not remediable, the dying person should be able to ask for and receive help in assisted suicide. It is further argued that assisted suicide for incurably ill persons experiencing extreme suffering can be distinguished from euthanasia used for the purpose of genocide on the grounds that it is based on principles of dignity, honor, and respect and is chosen and enacted by the dying individuals, rather than being forced on them against their will. Legal arguments state that it would be in the best interest of dying patients to be able to regulate practices that are currently being used covertly for assisted suicide. Such regulations would also provide safeguards for practitioners who are currently complying illegally with patient requests out of compassion. Medical arguments contend that competent terminally ill patients wishing to choose assisted suicide may feel abandoned by physicians who refuse to assist. The criticism that medical doctors agreeing to assist in suicide would be violating the Hippocratic Oath is refuted on several grounds. First, the original Oath prohibiting killing also prohibited abortions, surgery, and charging teaching fees, all of which have been modified to meet contemporary realities. Second, assisted suicide, unlike euthanasia, does not involve the ending of life by a physician, as it is the dying person himself or herself who takes the steps to end his or her life. Third, the Oath requires physicians to take all measures necessary to relieve suffering, and some interpret this to include assisted suicide when that is the only way suffering can be relieved. The argument regarding safeguards and the slippery slope holds that it is possible to protect people from abuse through appropriate regulation which would provide oversight by a combination of state legislation and professional regulation by palliative care consultants and ethics committees that would include professionals and community representatives. Several models for safeguards have been proposed and typically include confirmation of diagnosis, prognosis, treatment options, and decision-making capacity; assessment for alternative means of alleviating suffering; nondirective counseling; education of physicians; and education of the public. It is further argued that widely utilized and commonly accepted legal end-of-life interventions such as withholding or withdrawing treatment, double effect, and terminal sedation are also subject to the slippery slope or to abuse and yet are considered to be controllable by standards of care and appropriate regulation and oversight. Likewise, financial concerns may be a factor in requests for legal interventions as well as in requests for assisted suicide and yet are not considered as a justification for prohibiting these other interventions. The safeguards argument posits that involving mental health professionals to provide appropriate and comprehensive treatment planning would improve quality of care and reduce the potential for abuse regarding all end-of-life interventions that may affect the time of death. Regarding the issue of depression which, if treated, could change a terminally ill person's request for assisted suicide, it is pointed out that first, treatment of depression does not always change the desire for assisted suicide, and second, psychologists can play a major role in assessment and treatment of depression and other psychological factors that may affect judgment and requests for a variety interventions that affect the time of death including but not limited to assisted suicide. Top of Page Arguments in Opposition to Assisted Suicide Report to the Board begin with the principle of protection of the socially and economically disadvantaged. Concerns are raised that persons whose autonomy and well-being are compromised by poverty or by membership in a stigmatized social group, (such as women, persons with disabilities, ethnic, sexual, and other minorities, and ill older persons in general) will be coerced into assisted suicide. The pressure to choose suicide may not be explicit and personal, because persons who experience stigma may internalize a diminished sense of entitlement to resources, and may be the ones who most strongly argue for their own demise. The principle of individual choice in dying is viewed as a fiction in a highly stratified society, such as the United States, where access to basic health care is highly variable and dependent upon personal income and private insurance. Many seriously ill persons may not have the resources necessary for implementation of the choice to live. From within this perspective, the individual paradigm of decision making, with its emphasis on independence and choice, is seen as obscuring the reality that decisions about care at the end of life are typically made by physicians with some consultation with family members and with cost containment being an important factor in these decisions. Another ethical argument opposing assisted suicide comes from the principle of respect for human life and the related beliefs that killing is wrong, even if a person consents to it. Some, who see assisted suicide as similar to euthanasia, believe that moral objections to assisted suicide are strengthened by examining historical precedents, specifically the experience of Nazi Germany in which "undesirable" groups of people (including Jews, persons with disabilities, and sexual minorities) were put to death. Legal arguments against assisted suicide include concerns about civil suits resulting from premature or unnecessary termination of life following a diagnostic error or incorrect prognosis. There are also concerns about enforcement of legal procedures devised to prevent against misuse, abuse, and improper application or coercion in assisted suicide. Medical arguments against assisted suicide include the possibility of misdiagnosis, the potential availability of new treatments, and the probability of incorrect prognosis. Because medicine is fallible and research is ongoing, incorrect diagnoses may result in unnecessary requests for assisted suicide or in requests that are carried out just before the introduction of a new treatment that could prolong life. Another medical argument is that requests for assisted suicide may indicate that improved palliative care, aggressive pain management, and better psychosocial support are needed. Further, there is serious concern that the availability of assisted suicide may create a disincentive to providing appropriate but costly medical treatments or to improving the quality and availability of palliative and hospice care. In addition, the American Medical Association has asserted that physician-assisted suicide is fundamentally incompatible with the physician's role as healer and that it poses serious societal risks, such as ill persons' feeling abandoned or losing trust in the health care system if providers participate in this practice. Finally, it is argued that physicians are barred from helping persons to die because of the Hippocratic Oath, which states that doctors should not kill. The argument against assisted suicide regarding safeguards and the slippery slope maintains that once assisted suicide is accepted as an available option for competent terminally ill adults, it may be permitted for ever-larger groups of persons, including the nonterminally ill, those whose quality of life is perceived to be diminished by a physical disability, persons whose pain is emotional instead of physical, and so forth. Critics point to the fact that permitting euthanasia and assisted suicide, as is done in the Netherlands, does not prevent violation of procedures (e.g., failure to report) or abuse (e.g., involuntary euthanasia).It is further contended that adequate safeguards are not possible. For example, requiring written requests to be repeated over a period of time and witnessed by two unrelated witnesses while at the same time involving at least two physicians and a psychiatrist's or psychologist's examination is unrealistic. Persons at the end of their lives typically have neither the energy nor the ability to meet such conditions. A related argument is that the option of assisted suicide for mentally competent, terminally ill people could give rise to a new cultural norm of an obligation to speed up the dying process and subtly influence end-of-life decisions of all sorts. Top of Page What Experience Teaches: Oregon and the Netherlands The Oregon Experience When controversy surrounds an issue, psychologists have been trained to turn to research and data for enlightenment. However, in the area of assisted suicide, which only recently has been explicitly legalized in the United States in the state of Oregon, there is an understandable dearth of research. Nevertheless, the experience with assisted suicide in Oregon is relevant to the recommendations in this report. It is, therefore, worth exploring in some depth.
Other sections of the law are designed to provide safeguards for the practice. For example, the written request must be witnessed by two unrelated persons; there must be a consulting physician; the patient must make an informed decision; the attending or consulting physician can request a referral to a licensed psychologist or psychiatrist if they suspect that a psychiatric condition or depression may be causing impaired decision- making; and family notification is recommended. A study of Oregon's first year of legalized assisted suicide analyzed data for all terminally ill Oregon residents who received prescriptions for lethal medications (Chin et al., 1999; see also Coombs Lee & Werth, in press). A total of 23 persons receiving prescriptions were reported to the Oregon Health Division; 15 died after taking the medications, six died from the underlying illnesses, and two were still alive as of January 1, 1999. The 15 assisted suicides accounted for five out of every 10,000 deaths in Oregon in 1998. Eight of the 15 were male and seven were female, and all were of European American descent. Only four of the candidates had psychological or psychiatric consultations. The researchers reported that the primary factor cited by the physicians of those who requested assisted suicide was the importance of autonomy and personal control. No person who chose assisted suicide had expressed financial concerns to their doctors, nor was pain associated with the illness cited as a major factor. The researchers concluded that requests for and use of lethal prescriptions to end life were associated with views on autonomy and control rather than fear of pain or economic concerns. The only statistically significant differences between those who died by lethal medication and matched controls were that the former were more likely to be divorced or never married and they were higher in physical functioning. Advocates for and opponents of assisted suicide have different reactions to these findings. Advocates view these results as evidence that independence and autonomy are strong personal values for persons seeking assisted suicide. Opponents argue that if those persons had better psychosocial support and close caregivers they may not have chosen to die at that time. Advocates also interpreted the difference in physical functioning to demonstrate values of independence and control. Opponents expressed concerns about the influence of internalized negative views concerning physical disabilities and suggested that with more time to adjust to disabilities, as well as better services and less social stigma, these individuals might have chosen to live longer. There has been criticism of the study and its conclusions on methodological grounds (Foley & Hendin, 1999). All information about the cases was provided by the physicians; thus, there are no data in the study from the individuals who died of assisted suicide or their family members, so there are only anecdotal discussions (e.g., Coombs, Lee, & Werth, in press; Reagan, 1999) of the psychological motivations of the person requesting assisted suicide and the interpersonal cultural context in which the decision to use the Death with Dignity Act developed. Information about the health of patients is limited to diagnosis and prognosis and no data are available regarding the basis on which the physicians made the diagnoses and prognoses. There is no independent way to ascertain how adequately physicians addressed palliative and hospice care options, how thoroughly they assessed the reasons for requests for assisted suicide, or whether they were fully informed about the economic and social circumstances of patients. The report also does not indicate the basis on which physicians referred the four patients for psychiatric or psychological evaluation and what, if any, assessments were conducted following referral. The report of the second year of the Oregon Death with Dignity Act was released in late February, 2000 (Sullivan et al., 2000a, b). The document updated the 1998 data and provided information for 1999. The analyses for the second year report included 26 people who received prescriptions and used them in 1999 as well as one person who received the medication in 1998 but did not use it until 1999. The median age of these 27 people was 71, 16 were male, 26 were European Americans, and 17 had cancer. All of them had health insurance and 21 were enrolled in hospice prior to death. One person became unconscious before consuming all the prescribed medication and, as a result, took 26 hours to die. Two others took more than 11 hours to die. The relatively long period from when the medication was taken to when death occurred would have been considered a "clinical problem" in the Netherlands (Groenewoud et al., 2000); however, variations in the length of time from ingestion to death are expected (Schnabel & Schnabel, 1998). The 27 people who died were demographically similar to the people who used the Act in 1998, except they were significantly more likely to be married. These individuals were demographically similar to other Oregonians who died of similar diseases except they were significantly more likely to be college educated. Ten of the 27 people who used the Act had been referred for a mental health evaluation. These 27 people accounted for nine out of every 10,000 deaths in Oregon in 1998.Similar to 1998, the most frequent concerns recorded by physicians about those who died of assisted suicide were loss of autonomy and decreasing ability to participate in activities that made life enjoyable. The 1999 report also contained the results of interviews with family members of 19 people who died between mid-September, 1998 and mid October, 1999. These significant others cited individual concerns about losing autonomy, losing control of bodily functions, and physical suffering. Nearly 75% of the family members also volunteered that the dying person wanted to control the time and manner of death. Another research study related to the Oregon Death with Dignity Act was released at the same time as the second year report. This article examined physicians' experiences with the Act (Ganzini et al., 2000). The researchers reported that their survey of all eligible Oregon physicians revealed that 144 of the respondents (65% response rate) had received 221 requests for assisted suicide under the Act. Twenty-nine of these individuals received medication and 17 used the prescription to die. Twenty percent had symptoms of depression and none of these received a prescription. Physicians implemented substantive palliative care interventions for 68 patients, 10 of whom eventually used the prescribed medication; 46% of those who received an intervention changed their minds about using the Death with Dignity Act, Whereas only 15% of those who did not receive a substantive intervention decided against assisted suicide. The data contained in the second year report (Sullivan et al., 2000a, b) and in the Oregon physician experience study (Ganzini et al., 2000) are too new to have been broadly examined by proponents and opponents of the Oregon law (see Nuland, 2000). However, just as the data from 1998 were used by both sides of the debate to bolster their arguments, the same process is bound to happen with the new reports.Top of Page The Netherlands Experience A second example of differential interpretation of data concerning assisted suicide is apparent in the research published on assisted suicide and euthanasia in the Netherlands. Before discussing the data, it must first be noted that the policy and practice of assisted suicide, and the context of such practice in the Netherlands, are different from those of assisted suicide in the United States (Griffiths, Bood, & Weyers, 1998). Unlike the United States, both assisted suicide and euthanasia are decriminalized and permissible in the Netherlands under prescribed circumstances. Also, in the Netherlands, there is universal health coverage; the population is more homogeneous, with a smaller range of cultural diversity; and family doctors have typically known their patients for long periods of time. Thus, it is difficult to generalize from Dutch policy and practice to the situation in the United States. However, with these differences in mind, it is useful to examine the data from the Netherlands. A 1991 article summarized the findings of a nationwide study of physicians reporting on their practice of assisted suicide and euthanasia in the Netherlands (van der Maas, van Delden, Pijnenborg, & Looman, 1991). This report indicated that out of the roughly 130,000 deaths that occurred in the Netherlands in 1990, 2300 (1.8%) were the result of euthanasia. Another 400 (0.3%) were assisted suicides. The report found that in the 2700 cases reviewed, the medical guidelines were met. This means that the patients were mentally competent adults who were suffering without alternatives and who requested assisted suicide or euthanasia voluntarily, consistently, and repeatedly over a reasonable time. The requests were documented. According to the reporting physicians, the patients were suffering intolerably with no prospect of relief and the primary doctors consulted with another physician not involved in the case. However, the report also noted that there were an additional 1,000 deaths (0.8%) caused by euthanasia in which the patient was not concurrently competent, a clear violation of the guidelines. About a quarter of the physicians admitted causing death without an explicit request. Opponents of assisted suicide in the United States point out that data that is based on physician's reports is unreliable. They also argued that the deaths of the 1000 people who were not concurrently competent was evidence that the slippery slope is occurring. They suggested that further erosion of the guidelines could occur, resulting in involuntary euthanasia being performed on older adults, persons with disabilities, and adults who were not mentally competent (Gomez, 1991; see also Angell, 1996). Proponents of assisted suicide, referring to the same data, pointed out that the results showed a very cautious use of euthanasia and assisted suicide, accounting for only a small fraction of the total deaths. Moreover, only one in three people who requested assisted suicide and euthanasia were granted it, which did not indicate any great trend on the part of physicians to accede to such requests. With regard to the 1,000 persons who died from euthanasia without any consent, interviews with the attending doctors indicated that over half had earlier stated a desire for euthanasia and that most were "moribund" at the time euthanasia was performed, so that these were cases of euthanasia without concurrent consent (i.e., nonvoluntary) rather than euthanasia without any consent (i.e., involuntary). A follow-up study, completed in 1995, focused on two issues. The first was whether a slippery slope existed with regard to medical care at the end of life (van der Maas et al., 1996). The second concerned the efficacy of a new notification procedure designed to enable better monitoring of euthanasia and assisted suicide that became law in 1994 (van der Wal et al., 1996). The authors of the first report concluded that there was little evidence of a slippery slope occurring. Dutch doctors seemed to "continue to practice physician-assisted dying only reluctantly and under compelling circumstances" (Angell, 1996, p. 1677). The notification procedures, however, had only partial success. The numbers of reported physician-assisted deaths increased but doctors found the procedures unduly difficult and were still concerned about the legal status of admitting to euthanasia. Critics of assisted suicide in the U.S. have challenged the findings of the second study. They disagreed with the conclusion that there is no evidence that "physicians in the Netherlands are moving down a slippery slope" (Hendin, Rutenfrans, & Zylicz, 1997, p.1720). They pointed out that in the past two decades, the Netherlands has moved from considering assisted suicide . . . to giving legal sanction to both physician-assisted suicide and euthanasia; from euthanasia for terminally ill patients to euthanasia for those who are chronically ill; from euthanasia for physical illness to euthanasia for psychological distress; and, from voluntary euthanasia to nonvoluntary and involuntary euthanasia. (p. 1720) These opponents of assisted suicide also reanalyzed the data and showed an increase over time in the estimated number and percentage of deaths caused by active physician intervention. Thus, the results of the same study have been interpreted in widely different ways depending on the point of view of those studying the data. As was the case with the Oregon data, the meaning and implications of the Netherlands data have varied.Top of Page Other Related Studies In addition to research conducted where assisted suicide is legal or decriminalized (e.g., Oregon and the Netherlands), there have been other studies conducted where the practice continues to be illegal. Predictably, only a few involved terminally ill people who actually died as a result of assisted suicide. These studies (Back et al.,1996; Canetto & Hollenshead, 1999; Preston & Mero, 1996) indicate that pain plays a minor role in the reasons why people die by assisted suicide; factors such as concerns about loss of control, perceived loss of dignity or sense of self, and suffering other than physical pain appear to be crucial issues (Wilson et al., 1998). Some investigations on end-of-life decisions have included people who are terminally ill (Breitbart, Rosenfeld, & Passik, 1996; Brown, Henteleff, Barakat, & Rowe, 1986; Chochinov, Wilson, Enns, & Lander, 1998; Chochinov et al., 1995; Ganzini et al., 1998; Rabkin, Remien, Katoff, & Williams, 1993; Suarez-Almazor, Belzile, & Bruera, 1997; Wilson et al., in press). The results of several of these studies reveal that high levels of clinical depression and hopelessness, low perceived levels of social support, the perception that suffering is inevitable, and the perception of being a burden are associated with increased interest in assisted suicide or a desire to die. Similarly, some studies of chronically, but not necessarily terminally, ill individuals (e.g., Emanuel, Fairclough, Daniels, & Clarridge, 1996) have found that depression is an important influence on the desire for assisted suicide Whereas others (e.g., Sullivan, Rapp, Fitzgibbon, & Chapman, 1997) have found that symptom level is more important than the degree of depression in determining the acceptability of assisted suicide. Furthermore, some research has revealed that concerns about costs (together with age and depression) can influence a person's decision to give up on life-extending measures (e.g., Covinsky et al., 1996). A retrospective study of Dr. Kevorkian's cases also showed that general psychological distress and concerns about being a burden were common among the women who died with his assistance (Canetto & Hollenshead, 1999). There have been a few investigations of the impact of assisted suicide on significant others (Cooke et al., 1998; Jamison, 1995; Ogden, 1994). This research indicates that loved ones of people who have died by assisted suicide are not necessarily traumatized by their awareness of or involvement in the actions that lead to death. Rather, it appears as though concern about legal repercussions can lead to significant anxiety, and that trauma can occur if loved ones felt obligated to take an active role in the death in unanticipated ways because the planned method was unsuccessful. Research involving health care professionals is also relevant to this discussion (the Resource Guide will contain a review of surveys of attitudes of health care providers about assisted suicide). For example, some evidence suggests that physicians tend to under-recognize depression (Conwell & Caine, 1991; Peruzzi et al., 1996). In addition, primary care physicians underestimate older persons' preferences for life-extending care while hospital-based physicians (emergency and critical care physicians), like family surrogates, overestimate older persons' preferences for life-extending care (Coppola, Ditto, Danks, & Smucker, in press). In addition, there are data indicating that physicians' training and experience with serious medical illness affects their perception of the desirability of different options. Specifically, clinicians with the least exposure to seriously ill and dying patients are more willing to endorse assisted suicide and/or euthanasia than oncologists; this is also true for social workers, compared to nurses (Bachman et al., 1996; Portenoy et al., 1997). Other factors that contribute to greater willingness to support assisted suicide are a limited knowledge of pain management (Portenoy et al., 1997) and a conservative attitude toward resource use (Sulmasy, Linas, Gold, & Schulman, 1998). Finally, there is evidence to suggest that the majority of those willing to serve as consultants to evaluate a person's competence for assisted suicide favor the practice (Fenn & Ganzini, 1999; Ganzini, Fenn, Lee, Heintz, & Bloom, 1996). This may be the result of the fact that many health professionals who are opposed report that they would refuse to participate in the process. Bias in the mental competence evaluation may result, because those who support assisted suicide as an option may be more willing to find a dying person's judgment to be unimpaired while opponents indicate that even if they found the person's judgment to be unimpaired, they would attempt to prevent the person from receiving assisted suicide. Top of Page Conclusion Reasonable and well-informed people come to different conclusions on the meanings and implications of the data concerning assisted suicide. These positions grow out of different philosophies, value systems, and life experiences, and each can represent high levels of moral development. Individuals may strongly oppose or support assisted suicide, believing that it is the appropriate position of compassionate and socially responsible citizens. Both proponents and opponents of assisted suicide agree that there are costs and benefits to permitting versus banning the practice. However, they differ in their assessment of these relative costs and benefits. Furthermore, the current state of understanding of all of the issues surrounding assisted suicide is incomplete. The data that do exist are far from definitive and the lack of consensus on the interpretation of these data contribute to the differences in opinion about assisted suicide. Finally, there currently is no way of identifying the sequelae of legalizing assisted suicide in the United States, which remains a diverse culture with unequal access to medical care. Given the current state of the discourse on assisted suicide, it seems premature for the discipline of psychology to take a stand supporting or opposing assisted suicide. Top of Page Recommendations The Working Group, like similar committees formed by other associations, found a variety of views about assisted suicide represented in its membership. There will inevitably be similar differences of opinion in the general membership of the APA. Thus, recommending a position that either endorsed or opposed assisted suicide would not reflect the opinion of the Working Group nor of psychologists as a whole. The Working Group therefore recommends that the APA:
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