• 2018 Congress of Delegates

    COD Addresses Medical Aid in Dying, Institutional Racism

    October 10, 2018, 03:05 pm Chris Crawford New Orleans –Delegates to the 2018 Congress of Delegates here addressed a number of issues related to direct patient care and other  clinical topics, including medical aid in dying and institutional racism in health care.

    Medical Aid in Dying

    During the Oct. 9 business session, delegates approved a substitute resolution offered by the Reference Committee on Health of the Public and Science to adopt a position of "engaged neutrality" toward medical aid in dying as a personal end-of-life decision in the context of the physician-patient relationship.

    Per AAFP Bylaws, taking this stance required a two-thirds majority vote of the COD (which it received) because it differed from AMA Code of Medical Ethics Opinion 5.7 on the topic.

    The reference committee said in its report that the substitute resolution captured the spirit of four original resolutions addressing the subject that were introduced by the California, New Mexico, New York and Washington chapters.

    "The action taken today allows the AAFP to advocate for engaged neutrality on this subject at future AMA House of Delegates meetings," said AAFP President Michael Munger, M.D., of Overland Park, Kan. 

    Ravi Grivois-Shah, M.D., testifies during a reference committee hearing

    General registrant Ravi Grivois-Shah, M.D., of Tucson, Ariz., gives emotional testimony about one of four resolutions on medical aid in dying brought before the Reference Committee on Health of the Public and Science during the 2018 Congress of Delegates, saying his mother had just passed away.

    "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," he added.

    The substitute resolution also called on the AAFP to reject use of the phrase "assisted suicide" or "physician-assisted suicide" in its own formal communications and to direct the Academy's delegation to the AMA to promote the same action in the House of Delegates.

    Background information from one of the original resolutions stated that medical aid in dying currently is authorized in Washington, D.C., and seven states: California, Colorado, Hawaii, Montana, Oregon, Vermont and Washington.

    During the HOPS reference committee hearing on Oct. 8, delegates provided testimony on medical aid in dying, including some personal experiences.

    General registrant Ravi Grivois-Shah, M.D., of Tucson, Ariz., spoke in support of one of the medical aid in dying resolutions, explaining that his mother had passed away two weeks before the conference from complications of breast cancer.

    Grivois-Shah's mother entered hospice care just before Labor Day weekend and they discussed how she wanted to die.

    "I was shocked that she was open to talking about taking control of how she would end her life if it got to that point," he said.

    However, Grivois-Shah continued, medical aid in dying isn't currently legal in Arizona.

    "But I really wished she had that option, to be able to talk to her physician and have more control over the situation," he said. "I hope that in the future, I can have that control of the situation with my father, for myself and my family. I think this is a personal decision that everyone needs to decide on their own when the time comes, what the right choice is for them."

    Story Highlights

    New Jersey AFP delegate Arnold Pallay, M.D., of Montville, also spoke in support of the resolution, saying that 10 minutes before coming to the hearing, he received a phone call from a patient of more than 25 years who was in the hospital in the end stage of his life and was calling to ask permission to let go.

    "We have to understand the power of family physicians," he said. "We have an ethical, personal role in our patients' lives. We can't be opposed to something that some people think is valuable. I think we have to have a more neutral stake in this difficult area."

    Institutional Racism in Health Care

    Another resolution delegates adopted during the business session called on the AAFP to create a policy opposing segregation of patient care within the health care system and health care institutions by race, insurance status or other demographics.

    Additionally, this resolution tasked the Academy to develop materials and provide education through The EveryONE Project to increase awareness about how racism is manifested through institutional policies and how segregated care within the health care system is a cause of racial disparities in health outcomes.

    General registrant and resolution co-author Daniel Neghassi, M.D., of New York, N.Y., said that despite progress made since the civil rights movement of the 1960s, racism and segregation still exist in the health care system today.

    "For example, many hospitals have one set of outpatient facilities for those with private insurance and another set of clinics for people with Medicaid or without insurance, who tend to be people of color," said Neghassi. 

    General registrant Daniel Neghassi, M.D., of New York, N.Y., (far left) discusses a resolution he co-authored that asked the AAFP to adopt a policy opposing segregation of patient care within the health care system by race, insurance status or other demographics.

    "These clinics have less funding, patients have to wait longer, and they lack continuity of care, as well," he added. "This is racial segregation using insurance as a proxy."

    Neghassi continued that in the hospital system in New York City, black people were 50 percent more likely to be received at a public hospital than an academic medical center.

    "This had nothing to do with insurance or location," he said. "The public hospitals are underfunded, they see more patients without insurance and they don't get the same portion of charity care funding as other facilities. No wonder their outcomes are different."

    Neghassi noted that the AAFP does have policy against discrimination in all forms, but this resolution focuses specifically on institutional racism and segregation in the health care system.

    General registrant Bernard Richard, M.D., of Greenfield, Ind., (far left) speaks in support of a resolution advocating to end insurers' practice of denying life and disability insurance to HIV-negative patients who choose to protect themselves by using pre-exposure prophylaxis.

    "This might not be happening in your neck of the woods," he said. "But the fact that this is happening anywhere in our country is wrong. Our Academy should take a stand."

    New physician constituency alternate delegate Meshia Waleh, M.D., of Estherville, Iowa, also spoke in favor of the resolution.

    "This resolution supports the AAFP and its support of health care for all, and amongst the subtle discrepancies or segregation that occurs, that is against what the AAFP stands for," she said.

    As a new physician, Waleh said she has seen the value in increasing awareness of this issue and offering education to highlight the problems that need to be addressed.

    Finally, North Carolina delegate Karen Smith, M.D., of Raeford, testified in support of the measure, saying unconscious bias and health inequity continue to be pervasive in the health care system, and it can feel too overwhelming to make a difference.

    "We need to empower our everyday working family physicians to be part of the solution, so maybe we can make a difference with this problem," she said.

    Additional Issues

    Delegates also adopted measures that called on the AAFP to

    • advocate to end insurers' practice of denying life and disability insurance to HIV-negative patients who choose to protect themselves by using pre-exposure prophylaxis,
    • develop a task force to review evidence-based methods to decrease maternal morbidity and mortality,
    • support efforts to establish and study the outcomes of pilot safe-injection facilities in the United States,
    • advocate for a national immunization registry for children and adults that may be accessed online, and
    • provide education for members to use evidence-based, nonpharmacologic interventions to treat pain.

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    Additional Resources
    2018 Congress of Delegates: Day Two
    2018 Congress of Delegates: Day One