This blog was commissioned following a debate on assisted dying at the BMA ARM. It is part of a collection of blogs on the topic. Jacky Davis argues that the BMA should move to a neutral position on assisted dying. Sheila Hollins et al argue that the BMA is right to reject a neutral position. In this piece Ilora Finlay et al say that doctors should be wary of assisted dying.
Why should doctors be wary of what is being called “assisted dying.” Well, let’s pass over the obvious problem—that giving patients the means to kill themselves cuts right across the “do no harm principle” in medicine. Let’s look at some of the practical issues.
After nearly 20 years of legalised physician-assisted suicide in Oregon, only one in three doctors there is prepared to undertake this in practice. [1] So it’s not surprising that there is “doctor shopping,” in which patients whose doctors refuse to assist their suicides seek out or are “introduced to” a minority of willing ones who have never met them before and know nothing about them beyond the referral letter or notes. In 2015 one Oregon doctor handed out no less than 27 prescriptions for lethal drugs. [2]
The same could be expected here. A survey of 1,000 UK GPs last year revealed that only one in seven would be prepared to conduct a full assessment of a request for assisted suicide—that is, to go beyond diagnosis and prognosis and decide whether the applicant had mental capacity, had a truly settled wish and was free from pressure. [3] That’s hardly surprising. Doctors often know little of patients’ lives beyond the clinical encounter—for example, what family dynamics might be at work in the background or what undisclosed fears lurk within or how prone the patient is to depression or mood swings. These are vitally important questions, but they are social rather than medical ones; and, with home visits rarer than they once were, most doctors are in no position to make knowledge-based assessments of them.
Even clinical assessments are imprecise. Prognosis is notoriously difficult and diagnostic errors are not uncommon. And few doctors can confidently assess capacity for such a major decision as to end one’s life prematurely, free of any coercion or depression.
Then there are the implications for doctors themselves—for it’s on their already-heavily-loaded shoulders that the complex burden of assessments would be dumped. Onto doctors would fall the responsibility over what constitutes “assistance” beyond the law if a person was for whatever reason unable to ingest the lethal overdose. Doctors would have to state if life expectancy really is under six months, when they know full well the margin of error is huge.
Yes, there would be a “conscience clause” in any “assisted dying” law, but that wouldn’t prevent a glass ceiling in much of clinical practice. Doctors who object to performing abortion can avoid obstetrics and gynaecology. But people become terminally ill and die in every branch of medicine. How long before those who feel that to engage in “assisted dying” is incompatible with their role in suicide prevention find their refusal makes them an unattractive colleague?
The survey of medical opinion, to which I have referred, showed that, while only one in seven GPs would be willing to assess a patient for assisted suicide, 39 per cent might be prepared to engage to the extent of providing a professional opinion on the strictly-medical aspects of an application—but not to assess and decide on the request as a whole. The most complex eligibility issues are more social and societal than clinical, such as whether there were any coercive pressures on a person, voluntariness and whether a wish is truly settled. Even the clinical ones such as prognosis are impossible to verify other than in hindsight.
The lobbyists tell us that under their proposals it is the court that would decide. But, if you read their proposals carefully, you will see that’s not true. What they are proposing is that doctors should carry out all the assessments—social as well as medical—and make the decisions. The court is there just to run the rule over the process. It won’t do.
If the advocates of legalising “assisted dying” want the BMA to be neutral, they should stop trying to medicalise what is to a large extent a social rather than a medical issue.
Ilora Baroness Finlay of Llandaff, Claudia Camden-Smith , Scott A Murray, Rob George, Chris Walker, Angela Moore, Stella Woodward, Claud Regnard, David Oliver, Craig Gannon, Kathy Myers, Idris Baker.
References:
[1] Ganzini, Lessons from Legalized Physician-Assisted Death in Oregon and Washington, Palliative Care and Ethics, Edited by Quill TE and Miller FG, OUP 2014, Page 270
[2] The Oregon health department annual reports on the Death with Dignity Act.
[3] The MedeConnect Poll in 2015
Competing interests:
IF is co-chair of Living and Dying Well and a crossbench Peer in the House of Lords
RG is President Association for Palliative Medicine GB & Ireland
IB is consultant in Palliative Medicine and chair, Ethics Committee, Association for Palliative Medicine
DO is a board member of European Association for Palliative Care
KM is a a board member of Care not Killing
CG is a consultant in Palliative Medicine, Medical Director, Princess Alice Hospice, Esher, Visiting Reader, University of Surrey, Guildford Ethics Committee member, Association for Palliative Medicine GB & Ireland
CC-S, SM, CW, CR, SW, AM: none declared.