This briefing article was originally published in Student BMJ, a magazine produced by the British Medical Journal for medical students. An online version can be found here.
Should terminally ill patients be allowed to end their own lives?
A bill on the right to allow terminally ill patients to end their own life under specific circumstances is due to be debated in the House of Commons on 11 September 2015. The form of assisted dying being debated would allow terminally ill patients to self administer drugs that will end their life, but only after two independent healthcare professionals have confirmed that the patient is of sound mind.
Although suicide is not a criminal act, the law in England, Wales, and Northern Ireland states that it is illegal to “encourage or assist the suicide” of a patient. Similarly, in Scotland a medical professional taking part in any form of assisted suicide can be prosecuted on the grounds of culpable homicide. Encouraging or assisting a suicide carries a maximum sentence of 14 years’ imprisonment.
Advice from the General Medical Council states that if a patient raises the issue of assisted suicide, doctors should provide “objective advice about the lawful clinical options” and explain that it is “a criminal offence to encourage or assist a person to attempt suicide.” Doctors are also reminded that “respect for a patient’s autonomy cannot justify illegal action” and should remember that this includes providing any information that may assist or influence a patient to end their life.
Although prosecutions against family members who accompany patients to countries where assisted dying is legal are rare, recent advice issued by the UK director of public prosecutions states that prosecution is more likely if the suspect is a healthcare professional who has a duty of care to the victim.
What does the bill propose?
If passed, the changes will allow mentally competent, terminally ill adult patients to be lawfully provided with assistance from healthcare professionals to end their own life. Terminal illness is defined as having a prognosis of less than six months, and the patient will also have to be deemed to possess a “clear and settled intention” to end their life. These judgments would be made by two independent medical professionals, and a High Court judge would be required to approve every case of assisted death. The bill also includes provisions that would require doctors to check that the patient is making an informed decision without coercion or duress. Only a registered medical practitioner or nurse would be authorised to assist the death, and the patient would be required to self administer the medicine. Assisting the suicide of a patient who is not terminally ill would remain a criminal offence.
What’s happened so far?
The issue of assisted dying was raised in parliament last year, when an Assisted Dying Bill was debated in the House of Lords. After rigorous debate, the bill passed its second reading, with peers unanimously agreeing that it should be given further consideration. The general election in May 2015 meant that the bill expired before it could undergo a third reading.
Campaigners hope their new bill, reported to be “essentially the same” as last year’s bill, will fare better when discussed in the House of Commons, which hasn’t debated assisted dying since 1970.
Several countries have legalised assisted suicide or euthanasia. In 2002, the Netherlands became the first country to legalise both assisted suicide and euthanasia, although assisted dying has been legal in some US states from as early as 1997. Forms of assisted suicide are currently legal in Belgium, Luxembourg, Germany, and Switzerland.
Key points in the debate
Many of those who oppose the bill have raised concerns that the law might put pressure on elderly patients to end their life prematurely. Campaigners point to statistics from Oregon, which has similar laws to those being discussed in the United Kingdom. These figures show that since 1998, 40% of patients opting to end their life have cited becoming a “burden on family, friends, and caregivers” as an “end of life concern.” In response, supporters of assisted dying argue that such risks already exist, since patients are able to reject lifesaving treatments. Similarly, they dismiss concerns regarding potential inaccuracies in the diagnosis of a terminal illness with evidence that suggests doctors are more likely to overestimate than underestimate a prognosis.
Further opposition to the bill comes from the apparent shift in medical ethics that the legislation would present. Indeed, the British Medical Association (BMA) argues that “the principal purpose of medicine is to improve patients’ quality of life, not to foreshorten it,” although this view is not shared by the entire medical community. In an editorial last year, The BMJ editor-in-chief Fiona Godlee argued that assisted dying should be legalised to respect patients’ individual choice, while the group Healthcare Professionals for Assisted Dying has been actively campaigning for a change in the law.
The BMA are also concerned that assisted dying legislation would encourage society to embark on a “slippery slope” by “undermining the safeguards” against voluntary and involuntary euthanasia. Despite campaigners insisting that the safeguards in the bill are robust, sceptics point to a study from the Netherlands that shows that around 18% of assisted suicides ended in euthanasia. These were performed by doctors who felt compelled to intervene because of complications with the procedure. Although the UK bill doesn’t mention euthanasia, it is unclear what the legal precedent for these situations would be were assisted dying to be legalised.
Many disabled rights organisations have also voiced opposition to the legislation. Speaking to Student BMJ, a spokesperson for the charity Scope commented that many disabled people are “really worried” about a change in the law, arguing that the example from the Netherlands reveals the dangers of assisted suicide, which could cause “widespread premature deaths of disabled, ill, and older people.” However, a representative of the campaign group Dignity in Dying insisted that they “only campaign for assisted dying for terminally ill, mentally competent people.” He argued that this bill was about “a right to die well, not an unfettered right to die.”
Who stands where?
The issue has divided several medical organisations and charities. The Royal College of General Practitioners, Royal College of Physicians, British Medical Association, and British Geriatrics Society all oppose a change in the law. Meanwhile, the Royal Society of Medicine, Royal College of Psychiatrists, and Royal College of Nursing pursue a neutral stance on the issue.
Some disability rights charities have also announced their position on assisted dying, with Scope and Mencap publicly opposing the suggested changes. A campaign group called Disabled Activists for Dignity in Dying represents disabled people who support assisted dying.
What might it mean for medical students?
If the bill succeeds, doctors in the future are likely to receive more requests from patients who want to end their life. Medical students will require more in-depth teaching on the subject as UK medical school curricula have little guidance on assisted dying.
The Assisted Dying Bill states that medical professionals with a “conscientious objection shall not be under any duty to participate” in assisted dying procedures. However, some doctors suggest that similar clauses have failed to protect conscientiously objecting staff in previous legislation regarding abortion and some forms of fertility treatments. Some supports of assisted dying believe that the procedures should not be performed by doctors, but should be carried out by other professionals. A survey commissioned by the Royal College of Physicians suggests that 10% of doctors fall into this category, and the BMA have proposed that in the event of legalisation there should be a “clear demarcation” between doctors who would be involved in assisted dying and those who would not.
How likely is it that the bill will become law?
Private member’s bills proposed by individual MPs face strict time constraints and Robert Marris, the MP who proposed the bill, has previously conceded that “the prospects of getting the law changed are difficult without official Government support.” Such support is unlikely to be forthcoming—speaking in the House of Commons in June, David Cameron made clear that he “didn’t support the assisted dying proposals.” However, parliament is also under pressure from the Supreme Court, who in July 2014 warned of a “real prospect” that future courts could rule that the current law is “incompatible” with human rights law.
Despite the challenges they face, supporters of the bill remain optimistic and are keen to recall that the major changes to divorce, homosexuality, and abortion laws all started from successful private members’ bills.
For many, assisted dying law represents an example of individual patient choice being restricted by a hesitant and paternal medical profession. Others argue that the individual freedoms of a minority should be limited to protect vulnerable patients. Yet as MPs prepare to tackle some of the fundamental questions of medical ethics, only one thing is certain: assisted dying will stoke passionate debate from MPs, doctors, and patients alike.