Peter Lapsley on the assisted dying debate
3 Feb, 09 | by BMJ Group
What interests the public and what is in the public interest can be two rather different things but can come together to argue strongly for change. Such is the case with British law in respect of assisted dying. It is wrong to say, as some do, that the law is adequate as it stands. It is not. The uncertainty that surrounds it is causing great distress to significant numbers of people and may be shortening the lives of some.
The recent increase in media coverage of the subject suggests widespread concern about the legal ‘fudge’ that exists at present. (It is illegal to aid or abet a suicide and anyone convicted of doing so faces up to 14 years imprisonment. As yet, nobody who has travelled abroad with someone intent on suicide has been prosecuted. But the courts will give no assurance that others will not be prosecuted – and perhaps sent to prison - in similar circumstances.)
Clearly, there is a public appetite for a debate on this subject, but the government seems reluctant to allow one – perhaps because they foresee the questions that would inevitably follow any change in the law. If people are to be allowed to ‘aid and abet’ suicide abroad, why should they not be allowed to do so in the UK? And, if suicide may be assisted by clinicians abroad, why should clinician-assisted suicide not be allowed in the UK? And, if clinician-assisted suicide were to be allowed in the UK, why not euthanasia? That may seem a slippery slope, but it may equally be that those are the sorts of questions the public would wish to have answered.
Such a debate should be conducted in Parliament, which has the capacity to change the law if necessary. It seems improper that people in authority should seek to pre-empt or stifle it by stating their personal positions publicly or setting their faces against change.
The debate should be objective and properly informed, and it should examine the principles surrounding the issue and the safeguards that would be needed were the law to change, rather than focus on particular disease areas.
Clinicians (especially palliative care clinicians) who become involved in public discussion of this subject or in the debate itself should be circumspect in their contributions. They have a professional predisposition to saving and extending life, and there is a risk that their views may carry undue weight in a matter that is, in truth, more social than medical.
Peter Lapsley is Patient Editor, BMJ
I agree wholeheartedly with Peter Lapsey’s call for debate about the current uncertainties surrounding the law relating to assisted suicide for the terminally ill. He is also wise to point out that this is primarily a social issue. Clinicians do indeed have a cultural imperative to extend life and many augment this with a religious dimension.
The converse is also true. As a palliative care physician I had a duty to uphold the reputation of the hospice where I worked. It would have been inappropriate to become known as the doctor who believes in euthanasia, a reputation which would undoubtedly damaged public confidence in the hospice. Such units have struggled for decades to free themselves of the reputation of being nothing more than death houses.
However, as a retired person I can now give a personal opinion and that is that he law should be changed to remove the threat of a heavy prison sentence for a compassionate act. I have no doubt that very very few people would avail themselves of physician assisted suicide but for those few people, this should be an option.
Similarly, no physician would ever be obliged to act against the dictates of their conscience, but I predict that there would be no shortage of experienced doctors who would agree to help people in this way.
Ian Johnson
February 4th, 2009 at 6:27 pm
I applaud the restrained and sensible comment by Peter Lapsey. One does see things very differently when one is retired, and getting older - I used to speak vehemently and evangelically against euthanasia in any form when I was younger, and saw things in black and white terms. I no longer feel that way. Death is not the most terrible thing, but dying can be, and it is surely the ultimate in compassion for a physician to offer a patient a peaceful, painfree, dignified death, at the time and in the manner of the patient’s choosing. It is after all the patient’s life, and the patient alone has the right to make such a choice.
This most emphatically does not mean that excellent palliative care should not be available for all who need it, both those with malignant and non-malignant conditions. I have worked both in hospices and for many years as a Consultant Geriatrician, and although it was much more of a challenge to provide adequate symptom relief for people with chronic, non-malignant conditions, in a general hospital setting, it did prove possible in most cases. I cannot understnd why doctors are so unwilling to use tiny doses of opiates such as 1mg 4hourly of morphine for elderly COPD sufferers. I have managed many that way, and got them home to a much better quality of life for several months, after they had been referred to me by a Chest Physician for terminal care in hospital!! It needs careful monitoring, and this takes time, of course. But when and if a patient reaches the point at which they can no longer be helped with palliation, then I firmly believe that voluntary euthanasia should be available if the request it.
Hospices in States like Oregaon which have legalised physician assisted suicide have in fact got far better Hospices now than before they did so. Improved Palliative Care will follow legalisation of assisted dying, rather than being ousted by it as some seem to think. I am a committed Christian and do not find anything contradictory in believing in both a God of love and assisted dying. Indeed, I am amazed that anyone who believes in such a God of compassion would ever think otherwise.
Dr Lesley Evans
Retired Consultant Geriatrician
Lesley Evans
February 5th, 2009 at 12:13 pm
Many thanks to Peter Lapsley for this contribution to the debate. End-of-life care is often built around a series of “fudges” – witness talk about “double effect” , “terminal sedation” and the “intention” of the doctor (as opposed to the outcome for the patient). I have great respect for my colleagues in palliative care and think many if not most see their role as symptom control rather than extending life – although length may follow when quality improves.. For a whole variety of reasons – and these will differ to some extent from person to person – they seem to have great difficulty in accepting that for a small group of patients assisted dying is a part of palliative care. The gap between some forms of terminal sedation or withholding/withdrawing treatment or persuading the patient to “let go” and assisted dying really does seem very small. One of the most crucial differences is that “control” is given back to the patient – part of the appeal of assisted dying is that it emphasises that the patient decides when to take the final step.
Although Dignitas provides a useful safety valve for a small group of highly motivated individuals , one could see how patients who have not had really adequate scrutiny as regards the offer of all treatment options etc…- and those checks as outlined in the Joffe Bill – could go there in future. The DPP is in a difficult position and will need to keep his right to prosecution for the time being , until we have a new law or an amendment to the Suicide Act. A statement of when prosecution would be considered would come close to a change in the law and that is perhaps outside his remit. Whatever is done , each step should be seen as a change in its own right – there is no need for any slippery slope unless that is what people choose in the light of experience.
If clinicians are to be – as expected – a crucial part of how any law change will be implemented then they will need to be join in the debate. This applies to those on both sides of the argument – if there is concern about the so-called “vulnerable” , then we need to see how these can be protected adequately . What it is not acceptable is to put forward essentially religious views as though they are medical arguments.
DOI Member of Dignity in Dying
Simon Kenwright
February 5th, 2009 at 5:05 pm
Why should palliative care physicians have to be circumspect in their contibution to this debate?
Surely we have an equal right to our view as everyone else to inform the debate.
David Jeffrey
February 6th, 2009 at 2:40 pm
As a philosophic & intellectual challenge, is it possible to frame suitable safeguards? If so, subject to these, assisted suicide & voluntary euthanasia should be allowed.
DOI Council Member of Friends at the End
Eur Ing Dr Hugh Wynne
February 8th, 2009 at 12:29 am
As a Dutch GP-trainee I read this plea for a debate on assisted dying with interest.
In the Netherlands the law on euthanasia (2002) allows doctors to engage in assisted suicide or euthanasia and not be adjudicated in criminal law, when adhering to the ‘care requirements’. This law and the latter requirements were drawn following extensive debate starting early as the 1960s.
As a doctor in the Netherlands I feel fortunate to be able to offer my terminally ill and suffering patients a dignified end of life, even so when best palliative care practice is insufficient. Instead of focusing on extending life above all, I feel we should except our limitations in curative medicine and acknowledge palliative sedation and euthanasia as part of common medical practice.
Only when we are able to respond to a patient’s wishes beyond the stadium of cure we truly do justice to the values of autonomy and beneficence and avoid the feeling of being cornered with our backs against the wall. As Hippocrates stated: ‘Salus aegroti suprema lex’.
What I would like to know is what values the British government adheres in their reluctance to address the public’s wish for a debate on the issue of assisted dying.
Franca Ruikes
February 8th, 2009 at 2:56 pm
Indeed this is an interesting discussion, which, in the Netherlands, seems to have passed already some years ago.
Euthanasia is now accepted by law in the Netherlands. As a GP, I feel priviliged to live in a country where it is permitted to stand by my patients openly untill the end of life announces, even if patients want death to advance a bit. It is anyhow a miscalculation to assume that the end of life can be made always bearable by the best of palliative medicine.
I agree fully with Peter Palsley that euthanasia and assisted suicide is in fact more a societal than a medical issue. However, in everyday practice, there seems to be one complication. Euthanasia is in fact a medical act, performed by a professional doctor. What we see now in the Netherlands, is the drawback. Patients and their families feel that they have the “right” to have a euthanasia done. This may bring doctors in difficult positions. And indeed it does: see Palliative Medicine, Vol. 21, No. 7, 609-614 (2007). In the Dutch situation, they sometimes feel forced to commit euthanasia, despite of their own objections. This causes considerable mental suffering.
So indeed, a slippery slope. A challenge not to slide down. But avoiding and fearing, both by politicians and professionals, will not help us forward in this socially important matter. Learning from experiences, and being prepared to adjust, is probably the best way to come forward. In the end, “panta rei”.
Dr Henk Schers
February 9th, 2009 at 12:50 am
I would agree with the Patient Editor that the current legal situation regarding assisted dying is unsatisfactory as it stands. There does needs to be much more considerable debate on the subject, and in an ideal world this would take place in Parliament, which has the authority to pass the required legislation.
However, a problem arises in that MPs hold strong views themselves on assisted suicide, and no doubt will be allowed to vote in accordance with their conscience or will vote for whichever side will give them the best chance of being promoted or re-elected! In 2005, Jeremy Purvis’s final proposal for a Scottish bill “to allow for a mentally capable, terminally ill adult the right to receive medical assistance to die” received only five supporters. It is thought that one reason for the lack of support was the impeding elections; MP’s are reluctant to support controversial bills when their parliamentary seat is at stake. In the recent American Primaries, it was interesting how careful (the then) Senator Obama and Senator Clinton were in their comments when asked their opinions on the Oregon law allowing physician assisted suicide. Whilst both applauded the innovative laws on Oregon, as responding to the demands of the people, both were also careful not to say they supported the views!
For this reason, assisted suicide be debated in a much more comprehensive fashion, and it is submitted that what is needed is a national debate followed by a national referendum.
Karen Dyer
February 9th, 2009 at 1:00 pm