03 September 2015, The Tablet

Life or death: the doctor’s dilemma

by Phil McCarthy

The chief aim of doctors is to preserve life but if next week’s bill becomes law it would be legal to end life. Here a GP warns that this would cause the medical profession profound ethical dilemmas and advocates an alternative measure to enshrine a commitment to palliative care

Euthanasia and physician-assisted suicide have been legal in the Netherlands under certain circumstances since 2002. Both have become widely accepted by the population, and increasing numbers of Dutch people end their lives voluntarily. Yet the Royal Dutch Medical Association highlights that, “For a physician, a request for euthanasia or assisted suicide is one of the single most drastic demands a patient can make.”

The Assisted Dying (No 2) Bill will be debated in Parliament next Friday. If approved it would permit doctors in England and Wales to help people believed to be terminally ill to end their lives. The bill would legalise assisted suicide, not assisted dying: someone only needs medication to end their life if he or she is not dying at the time but wishes to do so. The bill requires that the person be assessed by a doctor as having less than six months to live. He or she must make the request freely, be aware of other options, such as palliative care, and have the mental capacity to make the decision. There would be a “cooling off” period and the final decision would be taken by a family court judge.

So how would healthcare professionals respond? As Dutch doctors know, ending someone’s life is a drastic demand, particularly for GPs who may have known the person for years. The British Medical Association and the medical Royal Colleges oppose legalisation. One reason is the risk that vulnerable people would be put under pressure and might end their lives prematurely. Another is that for doctors to deliberately end their patients’ lives would fundamentally alter the ethos of medical care. The aims of medicine include improving patients’ quality of life, health and welfare and minimising suffering.

The president of the Association of Palliative Medicine, Dr David Brooks, comments: “Those who care for terminally ill people, day-in day-out, believe society should be supporting people at this time in their lives, not putting them at risk. They also make clear that if society does want to legalise assisting suicide, this should not be part of medical practice. People need to be confident that the doctor is there to care for them whatever happens, not to kill them.”

There are a wide range of views within the profession. As elsewhere, if assisted suicide were legalised in England and Wales, some doctors would be prepared to carry it out. The Assisted Dying Bill includes a conscience clause, so healthcare professionals who objected to ending life would not be forced to do so. However, as with abortion, if assisted suicide became an accepted option it might become difficult to opt out.

Assisted dying would create new dilemmas at the end of life. Doctors would be concerned about the certainty of the diagnosis. For example, I recall an elderly man who was confidently diagnosed by a specialist team as having inoperable pancreatic cancer and given weeks to live. He would have met the Assisted Dying Bill criteria, but years later he is still playing golf; the diagnosis was wrong. Doctors would be concerned about assessing people’s mental capacity to take such an irrevocable decision. The standard tests assess a person’s ability to take a decision, not whether the decision itself is reasonable or based on realistic assumptions. Doctors would be concerned that a person might be pressurised in subtle or concealed ways.

In the Netherlands the law requires that the doctor believes that the person faces unbearable and hopeless suffering and that there are no reasonable alternatives. There is no such requirement in the Assisted Dying Bill. A doctor might be asked to end the life of a person who, although believed to be terminally ill, was not suffering and where palliative care would be expected to alleviate future suffering. Even doctors who find assisted suicide morally acceptable would find ending the life of such a person difficult.

The Bill would legalise physician-assisted suicide but not euthanasia. The deliberate killing of a person with the intention of avoiding suffering would remain illegal. A health professional could assist someone to self-administer the medicine but the final act must be taken by the person herself. Consider the position of a nurse attending a home to carry out an assisted suicide. The patient cannot swallow the medication so she sets up a syringe driver. The patient is too weak to press the button and requests that the nurse does it. But if the nurse presses the syringe driver button, that would be euthanasia, therefore illegal, and would expose her to the risk of an accusation of murder. The line between assisted suicide and euthanasia can be a fine one.

The vast majority of doctors have their patient’s best interest at heart. But doctors take clinical and ethical decisions in a complex environment, subject to many pressures and constraints. Over the past few years, GPs have experienced a relentless rise in demand for their services at the same time as static NHS funding, falling personal incomes and a recruitment crisis.

GP practices are required to be members of clinical commissioning groups that commission services for the population they serve from a fixed budget. Since 2008 the growth of NHS spending has been more constrained and this is planned to continue. Assisted suicide would alleviate workload pressure on GP practices and financial pressure on the NHS. At present there is, quite rightly, a high level of trust in GPs. This would be eroded if patients suspected that their GP’s advice at the end of life was influenced by their own interests or by NHS funding constraints.

Parliament may legalise assisted suicide, but if we are to trust our doctors with our lives, the medical profession should have no part in it. Baroness Ilora Finlay’s Access to Palliative Care Bill would place a legal duty on the NHS to ensure equitable access to specialist palliative care services for all terminally ill patients. Rather than eliminating the sufferer, we should aim to alleviate suffering through improved care.

Dr Phil McCarthy is a GP in Bristol.

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