Cancer Patients 'Deserve Choice of Medically Assisted Dying'

Liam Davenport

November 17, 2019

GLASGOW — Patients terminally ill with cancer should have the choice to die with medical assistance to avoid an intolerable death, although the degree to which clinicians should be involved remains a matter of debate, delegates were told at the National Cancer Research Institute (NCRI) Cancer Conference 2019.

Prof Sam Ahmedzai, from the National Institute for Health Research, and Celia Manson, independent nurse advisor, Royal College of Nursing West Kent & Medway Branch, chaired a session dedicated to the topic that saw a passionate discussion over the issues raised by medically assisted dying.

Law Change

The debate comes after a survey last year by the British Medical Association, which currently opposes medically assisted dying, found that 55% of doctors agreed or strongly agreed that it should be made legal in defined circumstances.

Bobbie Farsides, professor of clinical and biomedical ethics at Brighton and Sussex Medical School, opened the discussion by asking whether medically assisted dying could be part of cancer care in Britain.

She noted that, for that to happen, there would need to be a change in the law, as it is currently illegal for any healthcare professional to offer any help to someone to end their life.

If the law were to change, she said, there is a question as to what role healthcare professionals should play in deciding that, and then what role they would play in offering support to people who want to die.

In the meantime, how should healthcare professionals respond to patients who want but cannot access a medically assisted death?

US Example

To give an example of what a change in the law could mean in practice, she turned to Oregon in the USA, where, since 1998, patients have had the right to request a prescription for lethal medications under the Death With Dignity Act.

The number of patients receiving and then using the prescriptions has increased over the intervening years.

The most recent annual report says that, in 2018, 103 physicians wrote 249 prescriptions to terminally ill patients, with 168 dying as a result of using the medications.

Prof Farsides noted that the median age of the patients was 74 years, 62.5% had cancer, and 90.5% were in hospice care at the time of death. Almost all (99.3%) had some form of health insurance.

The most common reported reason for having end-of-life concerns was loss of autonomy, in 91.7%, followed by reduced ability to participate in enjoyable life activities, in 90.5%, and loss of dignity, in 66.7%.

Challenges

If medically assisted dying were to become part of cancer care in Britain, Prof Farsides said it would be "challenging for some clinicians to make the shift from doing everything to keep their patient alive to allowing that they wish to be planning their death".

The core of that challenge will be to "respect and support their wishes whilst staying true to your own ethical and professional values".

She emphasised that a patient wishing to die with medical assistance is "not necessarily" a failure on the part of the healthcare professional or the care system, "although we must never get complacent on this issue".

Prof Farsides concluded that, "if the law were to change, you would still meet the same patients, and your interactions with them may not change dramatically, but the shape of their possible futures may".

When Prof Bill Noble, Academic Unit of Supportive Care, Sheffield Hallam University, London, took to the podium, he explained that he is part of a group of doctors who oppose a change to the law in assisted suicide.

He said that suicide "sanctioned" by oncologists equates it to a therapeutic intervention but, unlike the termination of a pregnancy, it does not need the assistance of a doctor to be carried out.

For him, there is a danger that, if doctors do assist with dying, their medical standing could "lead their patients to make choices that they would not otherwise consider".

Any changes in the law, he added, would have to be accompanied by organisations such as the General Medical Council and British Medical Association governing doctors' decisions in the face of complaints or allegations of malpractice.

Ethics

Prof Noble believes that proponents of assisted dying "fetishise" the patient autonomy argument, but there are three other ethical principles at play in terms of medical practice: beneficence, non-maleficence, and justice.

He argued that "postmodern" concerns around identity and neoliberal values have "normalised" the concept of assisted dying, with loss of dignity "a fate worse than death", in the absence of collective responsibility and social justice.

Prof Noble believes that loss of dignity in dying is instead a palliative care issue, arguing that a "pitiful amount" is spent on such care in the UK, and that "if you are dying an intolerable death in the UK today, the odds of it being a failure of palliative care are currently 1 in 14".

He suggested that, rather than clinicians being involved in assisted dying, it would be "more suited", for example, to solicitors, funeral directors and coroner's officers.

Prof Noble said that the reason is that "making suicide a medical procedure, carried out by trustworthy professionals, risks that, in time, it will become the last duty of a virtuous dignified patient, the exhibition of suffering as much to be avoided as its endurance".

Next, Lord Charles Falconer, of Gibson Dunn, the former Lord Chancellor, said he is an "enthusiastic supporter" of a change in the law in relation to assisted dying.

He explained that the change he would like to see is that someone who is terminally ill and has "6 months or less to live, and they are of a sufficient mental capacity to make the decision, they should have the option of taking their own life, assisted by a doctor to do so".

He agreed with "a lot" of what Prof Noble said, particularly that it is society at large, not the medical profession, who must decide on any change, and that it shouldn't become a medical procedure similar to a treatment, although he objected to his use of the word "fetishise" in relation to patient autonomy.

He also drew attention to the data from Oregon showing that, while a sizeable proportion of terminally ill patients requested a prescription for medications to end their life, only around half of them actually used them.

"It's not because they die before they use it but because they don't, in the end, need to use it, because they feel sufficiently in control not to do it."

For him, a change in the law in relation to medically assisted dying is about giving control to patients, offering them a dignified end, providing reassurance and ending the "mess" around the law as it currently stands.

He pointed out that, even by buying the train ticket for someone to go to Switzerland and end their life with Dignitas, "you're guilty of a crime of assisting someone to commit suicide" that is punishable by 14 years in jail.

The Director of Public Prosecutions has the power to decide not to prosecute people who assist their loved one through care and affection, which Lord Falconer called "an elaborate cheat" in terms of the law.

In addition, only people who have the means to do so can go to Switzerland to die, he said. Also, they have to go earlier than they might do otherwise in order to be sure they are capable of making the journey.

They then die in an "anonymous flat" and their loved ones are investigated by the police, even if they are, in the end, not prosecuted.

"It is appalling in our law, at the moment, that the only assistance that is allowed is amateur assistance, or doing it yourself," he said.

Lord Falconer believes that a judge should decide in cases of medically assisted suicide, albeit with medical intervention to give the prognosis and to provide the prescription, and to be there to supervise its use.

That change "would make so much difference; it would be so much more just than the current law, and it would...increase the dignity of the end of quite a small number of people but to whom it would matter hugely".

Seeing Both Sides of the Argument

Roger Wilson, Consumer Forum, NCRI, then took to the podium. He explained that he is a sarcoma patient who has survived six relapses, including regional metastases, and is tumour-free, and has worked with other patients for many years.

He said he can see the arguments on both sides of the debate, whether viewed "entirely rationally or from a religious perspective".

He continued: "The concept of dying is one I'm familiar with, personally I've come a bit closer to it than I would have liked, but have luckily escaped the full journey so far.

"I'm not scared of it. Frankly, I'm much more concerned about being diagnosed with dementia and experiencing the protracted decay that I saw both my mother and her younger sister go through."

Roger Wilson added: "I admit that I sit on the fence. As I stand here today, I might seek an assisted death and I might not, assuming I have the choice... it would all depend on the circumstances.

"To have the choice available is, for me, the single biggest argument in favour of allowing assisted dying, although I admit it may not be a strong argument on its own."

However, he noted that" no one I have ever been with has raised the issue of wanting to control the timing of their death; it has never been a discussion point".

Roger Wilson believes that there is no reason for assisted dying to be [made] "any more complicated" than any [other] medical procedure or treatment.

He added: "As patients, I don't think we would want to see an onerous process because that would make it inaccessible to some, the process itself would become fearsome. If you were able to make the decision, you would not want protracted approval.

"I can understand those who resist this idea, many doctors and clinicians amongst them," he said, adding: "Within the context of their medical training, which is focused on cure and frankly is not always sensitive to issues of patient care...their professional ethical codes may still remain dominant.

"But I would argue that the principle of 'do no harm' also needs reconsidering."

"When a patient has no hope of a longer life, no hope of quality of life, and when that patient seeks the opportunity to die with dignity, while they are still able to make that choice, I believe they should be permitted to do so."

He added that he "might argue that it is harmful to wilfully allow a patient to enter an inevitable period of decline, with perhaps increasing pain and other symptoms of advancing disease, when they will die anyway, whatever treatments are brought to bear".

Roger Wilson concluded: "My case is: Give me choice. It is a route for which I may be grateful."

No funding declared.

Prof Farsides is a member of the BMA Ethics Committee. Prof Noble is co-chair of Medical Evidence on Dying, Illness and Care. No other conflicts of interest declared.

NCRI Cancer Conference 2019: Could medically assisted dying be part of cancer care in Britain?. Presented 4th November.

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