By Sally Barker and Zoë Fritz

The Westminster Parliament is currently considering Kim Leadbeater’s Terminally Ill Adults (End of Life) Bill, which would make doctors both gatekeepers and facilitators of an assisted death for eligible terminally ill adults.

The legislation proposes that doctors are involved at several stages of the process. Firstly, they must listen to and understand the individual’s concerns and reasons for wanting assistance, and discuss any alternative solutions. Secondly, they must assess the capacity of a patient to decide to end their life, and determine that that wish is clear, settled and informed, and the patient’s own. Thirdly, they must be able to provide evidence in terms of the individual’s condition, prognosis and treatments.  Finally, they are being asked to assist in the death itself, by prescribing and providing the lethal drugs, and to be present up until the time of death to assist as required.

We agree that doctors are well-placed for the first three of the proposed roles, with similar duties being recognised competencies of good medical practice: doctors must regularly explore patients’ ideas and concerns, assess capacity and provide evidence. However, we argue that the final role – that of direct facilitation of death – not only falls outside medical competencies but is in opposition to it. We refer to this final role as that of an ‘assisted dying practitioner’.

There are two main claims that are made about why doctors should take on the role of an assisted dying practitioner (ADP): a) that the role of doctors and ADPs are similar because of their shared goals to uphold autonomy and reduce suffering, and b) that the practical skills required of ADPs are specific and exclusive to a doctor’s training. We suggest that both of these claims are false. We further argue that asking doctors to take on the role of ADP will alter the doctor- patient relationship at an individual and societal level, as well as potentially adversely affect recruitment to the profession.

The role and goal of doctors has evolved over time, but the goals of healing, relieving suffering, and preventing disease remain largely consistent. However, there has been recent discussion as to whether such intentions can be combined into a singular, ultimate goal that defines the profession as whole. One suggestion is that that ultimate goal of a medical doctor is cure, broadly interpreted as incorporating disease prevention, treatment, and in supporting patients to ‘live well until you die’.  An inability to cure does not negate cure as medicine’s ultimate goal but rather necessitates distinction between the goals and the ‘business’ or competencies of medicine — an act may fail to cure without necessarily being considered something other than medicine, as long as the business remains directed towards the goal in question. There are principles which must be followed while achieving this goal – including respecting patient autonomy and practicing beneficence – but these govern practice as opposed to defining what constitutes it. The ultimate goal of an ADP, meanwhile, is to provide an assisted death. If assisted dying has been accepted within societal norms as a beneficent and autonomy-upholding practice (as is the premise of the Bill), overlap with the guiding moral principles of medicine is neither surprising, nor significant. The goals of an ADP and doctor, however, remain irreconcilably opposed.

The second argument is that doctors are best placed to become ADPs because they already have the skills to undertake this task. We think this is false. No medical practitioner in the UK currently has prior experience in the appropriate selection, prescription and administration of intentionally lethal drugs. Vets (whose goal, interestingly, has explicitly been argued to be comfort) have more experience in this than doctors do, but it is likely that whoever becomes an ADP will need to have specific training (accompanied by a programme of research) in order to best undertake the role. It is true that doctors are experienced in providing holistic medical care at the end of life, but this is not exclusive to the profession: death doulas, for example, although recently established, arguably receive more relevant training and expertise in providing psychosocial and cultural support.

To summarise; requiring doctors to act as ADPs is not a neutral act. We suggest that to add a duty to the role of the doctor which is antithetical to their overall goal of cure disrupts the defining characteristic of being a doctor and will fundamentally change the perception of what it is to be a doctor. This will have repercussions on who applies to do medicine, how doctors are trained, how they interact with patients, and how they are regulated. The role of an ADP is philosophically and legally singular and should be recognised as such. We do not advocate for or against assisted dying but propose that, if it is to be taken forward in England and Wales, society would be more appropriately served by considering the role of an ADP as a novel profession whose goals, competencies, research base and regulation can be established independently.

Authors: Sally Barker¹  and Zoë Fritz² 

Affiliations: ¹King’s College London, ²THIS Institute, University of Cambridge

Competing Interests: None to declare