Assisted dying risks undermining trust between doctor and patient, warns GP

‘Coercion can be very difficult to detect, and often we have to get to know patients really well before they will trust us and open up about what is going on at home.’

Kim Leadbeater’s Bill to legalise assisted suicide risks harming and undermining the trust at the heart of the doctor and patient relationship, a member of the Royal College of GPs Council has warned.

In her address to The Tablet webinar, “Assisted Dying: A question of Faith, Ethics and Public Policy”, Dr Lily Lamb said that trust is “absolutely essential” to doctor’s work.

“Establishing trust takes time, takes effort on our part and on the patients’ part as well. There is a risk that legalising assisted dying will undermine this trust,” she said.

She referred to a palliative care consultant who had surveyed some minority ethnic groups on assisted dying.

“The people she spoke to are very cautious in their trust of doctors already, but they said that if they knew that doctors were delivering this service, they just wouldn’t go and see a doctor. They wouldn’t want to go to hospital anymore, because they would be so scared that the doctor was going to kill them. I thought that was worrying and it is not a narrative that is been heard.”

Discussing concerns over protection for doctors who wish to opt out of providing assisted dying, she noted, “There isn’t the same option for hospices, unfortunately.”

If palliative care and general practice support were reliable and available, could all suffering potentially be managed, she wondered. 

“Unfortunately, not every patient who needs it gets palliative care. There is something of a post code lottery in the UK, and while some areas have great provision, many do not.”

Dr Lamb, whose research is looking at the potential consequences of legalisation of assisted dying on the existing and future GP workforce, in particular the potential for moral injury and resultant mental health problems, highlighted how hospices are reliant on charitable funding and typically get less than a third of their funding from the NHS.

“So they are dependent on things like car boot sales to pay their staff, which makes it very hard for them to run effectively. Often they have to close beds, even though they have got the beds physically there, they haven’t got the staff to manage them.”

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Highlighting concerns over GP resources and health inequalities and the impact on areas of deprivation, she said some of the most deprived areas, in the northeast, have the worst access to palliative care and life expectancy is much lower.

“Is there a risk that more deprived populations will be more likely to seek an assisted death if they are losing their benefits, if they can’t afford to heat their home. Is that going to be seen as the only way out? There is evidence of that happening in Canada,” Dr Lamb warned.

Another concern she raised relates to the bill’s requirement that the request for assisted dying be made voluntarily and without coercion.

“Coercion can be very difficult to detect, and often we have to get to know patients really well before they will trust us and open up about what is going on at home”.

If assessments are carried out by video conferencing, “the chances of being able to detect that someone is being coerced subtly, or they are a victim of domestic abuse, strike me as being quite slim,” she said.

“We hear an awful lot about suffering and how this bill is the answer and the solution to the problems people have at the end of life. But less talked about is the pressure on the workforce who are delivering assisted death and the things that can go wrong.”

Dr Lamb highlighted how evidence from around the world suggests that 15 to 20 per cent of doctors who participate in the process of assisted dying develop significant ongoing emotional health problems.

“Moral injury is a risk, and moral injury can lead to mental health issues and attrition from careers, so it can potentially impact on the workforce.”

Another issue seen in the Netherlands is doctors being pressured into involvement in the process by patients and their families. “Is there a risk that opting out will lead to difficulties in patient relationships, complaints, reductions in practice ratings,” Dr Lamb asked.

She quoted a family physician in Canada who said in 2019, “Few Canadian doctors foresaw that going neutral would guarantee the arrival of euthanasia, or that promises of a shot in the arm for palliative care would be forgotten. Even fewer realised that they would have no option but to cooperate with providing death on demand. It has become all too easy to end patients’ lives.”

Dr Julian Hughes, a Fellow of both the Royal College of Psychiatrists and the Royal College of Physicians of Edinburgh, who was a NHS consultant for over 20 years in North Tyneside and Newcastle, told the webinar that it “is an affront to human dignity, to the intrinsic dignity of every human being, to suggest that the only sure way to maintain dignity is by assisted suicide.”

He said that allowing the Secretary of State for Health to make decisions about the use of lethal drugs is “just bad public policy” and the demand for equality “is the force that will drive the expansion of the eligibility criteria for assisted suicide”.

Allowing the Secretary of State for Health to approve the drugs, as the Leadbetter bill does, is contrary to all established practice for drug approval, and it bypasses the established safety and regulatory frameworks, Dr Hughes warned.

He highlighted that compassion means suffering with. “It means accompanying the person. It is what good healthcare has always been about – sticking with a person through thick and thin, not giving up, always providing some sort of hope.”

The principled objection against intentional killing is not merely a Christian concern, Dr Hughes, who was honorary professor of philosophy of ageing at Newcastle University and subsequently professor in old age psychiatry at the University of Bristol, said and referred to the Hippocratic Oath.

It was clear to Hippocrates and his followers, he said, that the physician should do no harm or injustice to patients. The oath, he noted states, “Neither will I administer a poison to anybody who asked me to do so, nor will I suggest such a course.”

“It will always be the case that assisted suicide is contrary to the medical art,” Dr Hughes stated. “But if the Leadbeater bill comes into force, the prevention, diagnosis and treatment of illness would now include: ‘commission voluntary assisted dying’.”

Criticising those in favour of a change in the law, he said they had “purloined the word dignity” and added “It’s now as if those against assisted suicide are against dignity.” But this he suggested, was double speak.

“Dignity and dying could refer to good quality and perfectly ethical palliative care.”

Assisted suicide, according to Dr Hughes, “is wrong as a matter of faith, as a matter of ethics and as a matter of public policy. It would flout fundamental moral principles. Would lead to a coarsening of society by the expansion of the eligibility criteria; would be unsafe; and ignores or downplays the safe, moral and inspirational alternative to assisted dying, which is good, quality, innovative specialist palliative care for all.”

Philip Booth, Director of Catholic Mission and Professor of Finance, Public Policy and Ethics at St Mary’s University, Twickenham, told the webinar that he would not refer to the issue as assisted dying but assisted suicide, “because that’s what it is”.

“What we are talking about here is a legal framework to allow doctors to deliberately help others kill themselves. I know that the proponents don’t like using that phrase. In a sense, it is a great victory for the proponents that in nearly all of the media, the phrase assisted dying is now used rather than assisted suicide.”

Professor Booth, who is Director of Policy and Research at the Catholic Bishops’ Conference of England and Wales, described the bill as “wrong in principle and flawed in practice”.

He said that in response to some of its flaws, proponents had developed complex mechanisms to deal with them “which leave the bill both incomprehensible and flawed”.

According to Professor Booth, the evidence suggests that the provision of assisted suicide in jurisdictions undermines the provision of palliative care over time.

“The bill is potentially dangerous for Catholic hospices and care homes.” He said there are several routes by which hospices and care homes might be required to cooperate with and facilitate assisted suicide.

He noted that in almost every jurisdiction in the world, except a couple of states in the US, when assisted suicide has been brought in, hospices and care homes have been required to facilitate it and cooperate it with it in some way.

Under Clause 32 of the bill, the Secretary of State can develop regulations to ensure the availability of assisted suicide. “Under that clause, he might require hospices and care homes to be involved, especially if they receive NHS or local authority funding, either directly or indirectly.”

“It’s not impossible that hospices might have to end in-patient services if they are required to facilitate or assist with assisted suicide.”

He also warned that the legalisation of assisted suicide would create huge pressure on society’s most vulnerable people.

“In Oregon, which originally was a model for this bill, although they now argue that the bill is better than the Oregon legislation nearly 50 per cent of those who underwent an assisted suicide between 1998 and 2021 cited fear of being a burden on their family, friends or caregivers as a concern motivating their request.”

Philip Booth said the most likely date for the vote on the Bill is Friday 13th June.

“We need about 30 members of parliament who supported the bill to change their mind and vote against it this time, without people moving in the other direction,” he explained.

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