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Assisted dying and the medical profession

Legislation to legalise assisted dying is currently progressing through Parliament. Now I’m a paid-up member of Humanists UK, an organisation which has long campaigned for easing of the legislation around assisted dying (AD), but this is the only issue (so far) where I disagree with their opinion.

The supposed safeguards against abuse in the proposed new law require medical involvement. The request for AD must be signed off by the patient’s own doctor, and also by a second, independent, practitioner. Sound familiar? It should, because it mirrors the requirement included in the 1967 abortion legislation for two doctors to authorise the termination before it is allowed to proceed. The intention was to allow termination only where certain conditions concerning the health of the mother or foetus were met. It was certainly not intended to allow abortion on demand, but 45 years later, that is what we have. i don’t want to get into discussions about abortion here, and I’m certainly not in the Roman Catholic/’pro-life’ camp, but it does illustrate the way in which incremental changes can occur when legislation is less than watertight (as all legislation ultimately is).

This is the ‘slippery slope’ argument advanced by opponents of changes to the AD legislation, and rubbished by its proponents. Fortunately, we don’t have to hark back to 1967 for examples of the way in which mission creep can undo the best of intentions. In 2002, the parliament in the Hague legalised euthanasia for ‘patients experiencing unbearable suffering with no prospect of improvement’. Due no doubt the open-ended and subjective nature of that criterion, a law which was aimed at patients with terminal illness has been applied to, amongst others, young people with mental illness. Perhaps the most disturbing example is the forcible dispatching of a dementia patient who had to be held down while the lethal injection was administered.

In fact, doctors in the Netherlands are becoming less willing to get involved in AD, and the number of cases has begun to decline. Their concern is summed up by Theo Boer, a Dutch ethicist, who said:

“When I’m showing the statistics to people in Portugal or Iceland or wherever, I say: ‘Look closely at the Netherlands because this is where your country may be 20 years from now.’ The process of bringing in euthanasia legislation began with a desire to deal with the most heartbreaking cases – really terrible forms of death, but there have been important changes in the way the law is applied. We have put in motion something that we have now discovered has more consequences than we ever imagined.”

Proponents of law change in the UK will counter with the argument that the new law will stipulate that the patient must be suffering from an inevitably progressive condition which cannot be reversed by treatment, and as a consequence of which they must be reasonably expected to die within six months. While this is a bit more prescriptive than the wording of the Netherlands legislation, it is still open to interpretation – not least, that ‘reasonably expected’. All doctors know that prognosticating on life expectancy is an inexact science, and the popular press delight in reporting the experiences of patients who ‘proved the doctors wrong’. It will not be long before doctors will be expected to authorise AD in patients with conditions which by their nature are difficult to predict, and where patients suffering a relapse and finding continued existence insupportable may well feel differently when in remission. It is also the case that some people suffering from terminal illness will feel pressured – either by their conscience or by their beneficiaries – to go down the assisted dying route in order to avoid being a burden on their carers.

I could go on about the probable effects of any easing of the legislation, but what I want to concentrate on here is the unquestioning acceptance of the fact that doctors will have a central role in this process. Not only are doctors assumed to be responsible for authorising AD, as described above,  the draft legislation also requires the input of the ‘assisting physician’ at every stage of the process. Naturally, the patient’s doctors will have made the diagnosis, assessed the prognosis, and treatment will have been given. But if, when the patient has been counselled concerning further available treatment and likely progression of their disease, they still wish to explore the possibility of AD, any further medical involvement should be limited to the documentation of the discussions held with the patient, and a description of the likely course of their illness and the options for further treatment or palliation. There is nothing in medical training which equips us to rubber stamp or reject the decisions of patients in such a difficult situation. And there is certainly no need to involve medical staff in the prescription or administration of the lethal draught or injection – there are now plenty of examples of non-medical staff prescribing drugs according to an agreed protocol, and if non-medical personnel can be trained to take blood, they can also be trained to give intravenous injections where that is necessary.

Doctors don’t train for six years or more in order to kill patients, and if society wants to establish an AD service, then society needs to set up the necessary infrastructure to deliver it. This would require dedicated premises, not within a hospital but conceivably in the grounds of one, staffed by trained non-medical personnel with the necessary interpersonal skills and knowledge of the legislation and the processes that flow from it. It should allow for the accommodation of non-religious and religious patients in appropriately peaceful surroundings. There will also, of course, need to be a mechanism for delivering the service in patients’ homes. We should not allow the medical profession to be dragged into the termination process in order to allow the pro-change lobby to bury their heads in the sand, and keep their hands clean, if I can be allowed to mix metaphors. The mechanism for providing this infrastructure will need to be set up in parallel with the passage of any new legislation, but I see no sign that anyone is addressing the issue, or has even considered it.

In short, simply passing the legislation currently before parliament without any planning for the implementation process or consideration of its long-term consequences, will result in a confused situation open to abuse, and with the potential to result in even more distress for patients and their loved ones. If doctors wish to retain the trust of patients, without which the practice of medicine is difficult or impossible, they should politely decline to become involved in state-sanctioned killing.