Heated Debate as Assisted Dying Bill Inches Closer in UK

Zosia Chustecka

August 19, 2015

As new legislation for assisted dying inches through the parliamentary system in the United Kingdom, doctors are speaking out of both sides of the debate.

"Society has moved beyond its tipping point on the question of assisted dying," says Jacky Davis, MD, chair of Health Professionals for Assisted Dying, and consultant radiologist at Whittington Hospital, London, United Kingdom.

Dr Davis is a leading proponent of the bill and notes that a recent survey (the Dignity in Dying poll, with 5000 respondents) found that 82% of the public in the United Kingdom were in favor.

"One day we will look back, as we do now at other social changes such as the legalization of homosexuality, and wonder how we ever tolerated such cruel attitudes," she writes.

Dr Davis is author of the "pro" opinion piece of a "head-to-head" debate in the British Medical Journal.

But in an opposing viewpoint, Ilora Finlay, MD, professor of palliative medicine at Cardiff University in Wales, and cochair of Living and Dying Well, points out that "most doctors oppose the legalization of what is, in effect, physician assisted suicide."

She cites a survey conducted by the Royal College of Physicians in 2014, which found that 58% of doctors said they were against a change in the law, and 62% agreed that patients can die with dignity within existing legislation so a change is the law is not needed.

If society wants to move ahead with such changes, then society (and courts) should be the vehicle, not the medical profession, Dr Finlay argues.

Sufficient Safeguards?

The proposed legislation, the Marris-Falconer Assisted Dying Bill, is based on the law passed in Oregon in 1997, which has since also been adopted by the states of Washington and Vermont. It bears no relation to the current laws in the Benelux, which were far wider in scope when introduced, writes Dr Davis.

The bill would allow doctors to help terminally ill and mentally competent adults to die by prescribing drugs that patients would administer themselves.

It has already made unprecedented progress through the House of Lords, where an additional safeguard of judicial oversight was added, Dr Davis writes. Now, it is due to be debated (in September) by members of parliament in the House of Commons.

She emphasizes the fact that the legislation is for assisted dying and not assisted suicide: "these patients are not 'suicidal' — they do not want to die, but, faced with imminent death, they want control over it."

Under the proposed legislation, patients themselves make the request for assisted dying, she explains. "Patients and their medical records are independently assessed by two doctors to check whether they meet the eligibility criteria. The patient must be informed of all available palliative care options, and, if either doctor has any doubts about the person's capacity, referral to a psychiatrist is mandated."

An additional step introduced when the bill passed through the House of Lords is that the request would then go to a High Court judge of the Family Division, who "would again check whether the patient met the eligibility criteria and that he or she had a voluntary, clear, settled, and informed wish to end his or her life," she explains.

"The introduction of this court model adds to the already considerable protections offered, including the recording and reporting to parliament of all assisted deaths," she comments.

"The many safeguards, including judicial oversight, in the proposed legislation — along with the body of evidence of safe practice from jurisdictions where assisted dying is legal — should reassure opponents," she concludes.

But in the opposing "contra" piece, Dr Finlay picks holes in the proposal. She points out that estimating prognosis is a judgment call, and that many of the criteria in the proposed bill lie outside clinical practice. "How, for example, would a doctor decide whether a request for assisted suicide reflected a 'settled wish' or whether unseen personal or family pressures had influenced the request?"

"In today's world...we often know very little of our patients' lives beyond the consulting room. Yet doctors would be required to satisfy themselves that all of the designated criteria — social as well as clinical — were met," she points out.

"If doctors would find it hard to satisfy themselves that applicants for assisted suicide met all of the designated criteria, would the court be any better placed?" Dr Finlay asks rhetorically, but suggests that it would not. The proposed bill does not require the court to undertake any investigations or inquiries of its own, and the "role envisaged for the court is little more than that of a rubber stamp."

Dr Finlay points out that the Association for Palliative Medicine in the United Kingdom considers this division of responsibility between doctors and the court unsafe, and quotes it as saying that the proposal "has the potential to produce situations in which each party to an assisted suicide decision takes spurious comfort from the involvement of the other and no one is fully accountable for the outcome."

The court already deals with issues involving life or death decisions — for example, withdrawing artificial nutrition and hydration or life support treatments, she points out, so the court may also be the most appropriate vehicle for reaching independent judgments on assisted suicide cases. In such a scenario, doctors would be called on to provide expert advice and opinion, but the decision would be made by the court.

"Advocates of legalization often say that this is a matter for society rather than for the medical profession," Dr Finlay writes. "If that is so, let society make the decisions through the courts, which are accustomed to balancing the rights of individuals against those of the wider community."

"And let doctors concentrate on clinical care," she concludes.

BMJ. Published online August 19, 2015. Abstract

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