Great Britain Ponders Physician-Assisted Suicide

September 24, 2014

Parliament's House of Lords in the United Kingdom (UK) is debating a bill that legalizes physician-assisted suicide, and so are British physicians, who are weighing the traditional injunction to "do no harm" along with the modern principle of patient autonomy.

Illustrating a professional split, the British Medical Association (BMA) opposes the bill as possibly paving the way toward voluntary and even nonvoluntary euthanasia, while BMJ, published by a BMA subsidiary, favors it. "People should be able to exercise choice over their lives, which should include how and when they die, when death is imminent," stated an editorial published on July 2.

Based on a precedent-setting law in Oregon, the UK's Assisted Dying Bill would allow a physician to prescribe a lethal drug to a terminally ill adult who requests it, provided he or she meet certain qualifications. It represents an effort to navigate around a 1961 law that decriminalized the act of suicide in England and Wales, but made it an offense punishable by up to 14 years in prison to help someone take his or her life.

The Assisted Dying Bill would apply to only England and Wales, not Scotland or Northern Ireland, which have their own laws regarding suicide. The House of Lords is approaching a yet unscheduled vote; if approved, the bill then would go before the House of Commons.

The UK's Supreme Court is helping to bring the issue to a head. In June, the court upheld the nation's 53-year-old Suicide Act as it pertained to physicians lending assistance in the cases of 3 separate plaintiffs. However, a narrow majority said the court had the authority to declare that the law violates the right of privacy as defined by the European Convention on Human Rights, and 4 of the 9 justices said that this question is better left to lawmakers. The court's president, Lord David Neuberger, warned that if Parliament failed to settle the matter, the court might do so in a future case, and possibly in favor of assisted-suicide proponents.

One of the cases before the court involved a man who experienced a debilitating brain-stem stroke and then sought protection for caregivers who would help him take his life at an assisted-suicide clinic in Switzerland, where the practice is legal. According to a recent study in BMJ, 20% of people who travel to these clinics in Switzerland from other countries are Britons.

What to call the service of these clinics — assisted dying or assisted suicide — figures into the debate in Great Britain. Emergency physician Paul Teed, a member of the steering committee of Health Professionals for Assisted Dying, rejects the word-choice of "suicide" to describe the bill in the House of Lords because the intended beneficiaries already are dying. "They have a terminal illness," Dr. Teed told Medscape Medical News.

In contrast, BMA president and palliative physician Baroness Ilora Finlay, a member of the House of Lords, doesn't hesitate to say "assisted suicide." Addressing her parliamentary chamber in July during a 10-hour debate, Dr. Finlay said that the terminally ill deserve proper palliative care "and not the quick fix of offering the medical equivalent of a loaded gun."

Dr. Finlay does not lack for professional allies in the fight. A UK research firm called Medix polled 600 physicians earlier this year and found that 60% oppose the Assisted Dying Bill. In contrast, 73% of Britons surveyed by the research firm YouGov said the bill should become law.

What the Bill Says

The template for the Assisted Dying Bill is the Death with Dignity Act passed by Oregon lawmakers in 1994 and implemented in 1998. Washington and Vermont have enacted similar laws. Physician-assisted suicide also is implicitly legal in Montana, according to that state's supreme court, because nothing in Montana law or public policy prohibits the practice.

Proponents of the Oregon law have not always triumphed in transplanting it elsewhere. Massachusetts voters rejected it in 2012, and in 2013, Maine lawmakers said no.

Some state medical societies, reflecting the stance of the American Medical Association, have campaigned against the idea of letting physicians prescribe lethal drugs to dying patients, saying that it runs counter to the role of the physician as healer. One exception to this opposition in organized medicine is the American Medical Women's Association.

The Assisted Dying Bill incorporates the main features of the legislation debated so extensively in the United States. Like Oregon's law, the UK bill requires that the patient's regular physician (the "attending") and an independent one confirm and agree that the patient has a terminal illness leaving him or her in all likelihood only 6 more months to live. Furthermore, the 2 physicians must be satisfied that the person is competent, acting voluntarily, and making an informed decision. As part of informed consent, the patient must be told about the availability of palliative and hospice care.

And like the Oregon law, the Assisted Dying Bill attempts to prevent hasty actions. The patient must not receive the lethal drugs prescribed by the attending physician until 14 days after the independent physician countersigns the patient's written declaration to end his or her life. Patients can revoke their declarations at any time.

The UK bill differs from the Oregon template in several respects. Under the UK bill, for example, a nurse or some other sort of assisting clinician must be present while the patient takes the lethal drug. If need be, the assistant can help the patient "ingest or otherwise self-administer the medicine, but the decision to self-administer the medicine and the final act of doing so must be undertaken by the person for whom the medicine has been prescribed."

This active role for a clinician, Dr. Finlay told Medscape Medical News, is one reason why she calls the law "a whisker away from euthanasia." (Dr. Finlay said she did not want to be represented as a spokesperson for the BMA or Cardiff University School of Medicine, where she teaches, because Medscape Medical News would not agree to let her review her quotes before publication.)

Putting Vulnerable People at Risk, or Protecting Them?

In a brief filed with the House of Lords, the BMA stated that the proposed law could endanger vulnerable members of society. "Old and disabled people might be seen as burdensome and put under pressure to end their lives," the association said. It warned of the danger of self-imposed pressure, as evidenced by Oregon's experience with physician-assisted suicide. From 1998 through January 22, 2013, 40% of patients who took advantage of the law said one of their end-of-life concerns was being a burden on family, friends, and caregivers, according to Oregon's Public Health Authority.

Others aren't as fearful, pointing to the admissions by former opponents of the Oregon law that it has not led to the abuses they feared. The authors of the recent editorial in BMJ noted that the 71 deaths by physician-assisted suicide in 2013 amounted to 0.2% of all Oregon deaths. Extrapolating that figure to England and Wales, they concluded that physician-assisted suicide would be a rare event for the average general practice of 9300 patients, occurring once every 8 or 9 years.

Supporters of the Assisted Dying Bill also argue that, far from putting vulnerable people at risk, the legislation would offer safeguards for a practice that is already occurring, but covertly so. "It's happening in the medical profession, but it's not recognized and talked about," said Dr. Teed.

Some terminally ill people choose to die violently and alone by their own hand without a physician involved, while still others enlist the aid of spouses, siblings, or children, he added. "That's a horrible scenario. And loved ones risk prosecution for murder."

Britons who travel to the assisted-suicide clinics of Switzerland are in loosely regulated waters, he added. At some clinics, patients need not be terminally ill, but only suffering from an intolerable incapacitating disability, or unbearable psychological suffering. Dr. Teed questions the protections afforded to these visitors, or those with a terminal illness. "Are they getting palliative care?" he said.

Opponents of the bill contend that high-quality and compassionate palliative care could reduce the demand for physician-assisted suicide. Dr. Finlay said it is not surprising that the bill has commanded majorities in opinion polls. "Historically, doctors have not always done well by people who are dying," she told Medscape Medical News.

Dr. Teed said he is a believer in palliative care, too, but noted that for a very small percentage of terminally ill patients, it will not prevent a "bad death." It's that small slice of the population that ought to have the option of a physician prescribing a lethal drug, he said. Other supporters of the bill point to Oregon's track record as proof that palliative care and physician-assisted suicide are not mutually exclusive. Of patients who died under the Death With Dignity Act from 1998 through 2013, 90% were enrolled in a hospice program.

The Assisted Dying Bill faces a long and uncertain legislative journey. The possibility of passage is not lost on the BMA. In the event physician-assisted suicide became legal, "there should be a clear demarcation between doctors who would be involved in it, and those who would not be involved," according to a policy statement posted on the BMA Web site.

Speaking on her own behalf, Dr. Finlay said doctors don't have to be involved at all.

"It's been put as if you need doctors to do this," she said. "You don't. Why not have lawyers and philosophers do it? You could license anybody to prescribe the lethal drugs.

"I don't think it's a part of clinical care."

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