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EDITORIALS: Timothy E Quill Physician assisted death in vulnerable populations BMJ 2007; 335: 625-626 [Full text]

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Rapid Responses published:

There is more to vulnerability

Andrew Thorns   (1 October 2007)

Don't be fooled into accepting doctor-assisted dying

Stephen MW Hutchison   (1 October 2007)

Concerns not dispelled

Desmond O'Neill   (3 October 2007)

Mentally ill given short shrift

Madelyn H. Hicks   (10 October 2007)

Medical and nursing professions must collaborate on assisted dying

John G Hunt   (15 October 2007)

There is more to vulnerability 1 October 2007
Andrew Thorns, Consultant in Palliative Medicine Pilgrims Hospice. Margate. Kent. CT9 4AD. Send response to journal: Re: There is more to vulnerability	Quill’s editorial review of the relationship of vulnerability to physician assisted death (PAD) welcomes recent data suggesting that, in most circumstances, vulnerable groups are no more likely to receive PAD than other non-vulnerable groups (1). He reports 1 in 50 patients in Oregon discuss assisted dying with their doctor – a not surprising figure which is similar to informal surveys of my own practice. These may not be explicit requests to have PAD but clear expressions that the person felt, at that time, that they would be better off dead. The reasons: poor information and communication skills, lack of effective symptom control, misperceptions of what the last stages of life will be like, fear of being a burden and the impact on families. These were not vulnerable people as defined by research standards, but made vulnerable by their situation. Vulnerability is a state we can all find ourselves in, especially when facing the end of our lives regardless of background or status. The first step in managing an individual’s vulnerability is to improve the poor areas of practice that cause it. Andrew Thorns Consultant and Honorary Senior Lecturer in Palliative Medicine Chair of the Association for Palliative Medicine Ethics Committee. Pilgrims Hospice and East Kent NHS Trust. Margate. CT9 4AD. 1. Quill TE. Physician assisted death in vulnerable groups. BMJ 2007;335:625-6 Competing interests: None declared
Don't be fooled into accepting doctor-assisted dying 1 October 2007
Stephen MW Hutchison, Consultant Physician in Palliative Medicine Highland Hospice, Inverness, IV3 5SB Send response to journal: Re: Don't be fooled into accepting doctor-assisted dying	Quill’s editorial raises several issues that must be challenged. He cites the practice in Oregon and Holland where many patients are involved with hospice care. He says, “Oregon is amongst the nation’s leaders in other markers of good end of life care, including deaths at home, opioid prescribing, hospice enrolment, and public awareness about end of life options”. However it is important to recognise that palliative care in Oregon and Holland are far removed from the service we are privileged to have in the UK. For instance, in Oregon, most hospice care is at home, expenditure per patient is negligible compared to that in the UK, and there are only 2 in-patient units and a total of only 23 beds for the whole state! Hospice care plans are reviewed once every 2 weeks in contrast to every few hours in UK palliative care units (1). We certainly cannot look to Oregonian practice as an optimal standard of palliative care. Quill states of physician-assisted death in Oregon that “There has been no significant change in frequency over nine years”. This is wrong. In 1998 there were 5.5 physician-assisted suicide deaths per 10000 deaths, and in 2004 the figure was over 12 per 10000. In 1998 a total of 16 people died in this manner, and the figure has risen to 38 in 2005, a 42% increase (2). In Holland, the number of euthanasia deaths fell from 2.6% in 2001 to 1.7% in 2005, but the number of deaths from ‘terminal sedation’ has increased to 8.2% of all deaths (3). In Oregon, ‘deep sedation’ may be used to achieve pain control (1). Such practice is alien to UK palliative care. In my work, resorting to sedation in order to achieve symptom control is vanishingly rare. We do not need to sedate patients into oblivion in order to achieve symptom control. In any case we also seek to enable patients to interact to their maximum potential with their environment, and sedation thwarts that important aspect of care. Quill almost seems to legitimise the LAWER cases where the lives of approximately 1000 people each year are terminated without their explicit consent. Heaven forbid that we should blithely grow to see such statistics as acceptable! The figure of one in fifty deaths from covert practice of physician- assisted suicide or euthanasia prior to Oregonian legislation does not reflect UK experience, where there is no evidence of any covert physician- assisted suicide (4) and the incentive to legislate in order to prevent covert practice needs to be questioned. Finally, Quill acknowledges that the studies he quotes "do little to resolve the moral and religious questions surrounding these practices”. However, let us be very careful that these do not become relegated to the irrelevant. Matters of faith and belief will, for many doctors, legitimately guide their response to these issues, and all of us must guard against subtle erosion our moral standpoint. That does not mean the slide into an unthinking state, but on the contrary, requires that we constantly rehearse the sound moral, religious, ethical and practical reasons for our rejection of doctor-assisted dying in the UK. 1 Lessons from Oregon: the hospice perspective. Presentation by Ann Jackson, Executive Director, Oregon Hospice Association, Help the Hospices, London, June 2007. 2 Eighth Annual Report on Oregon’s Death with Dignity Act. Oregon Department of Human Services, March 2006. 3 van der Heide et al. End-of-Life practices in the Netherlands under the Euthanasia Act. New England Journal of Medicine 2007, 356: 1957-65 4 Seale. National survey of end-of-life decisions made by UK medical practitioners. Palliative Medicine 2006; 20: 3-10 Competing interests: None declared
Concerns not dispelled 3 October 2007
Desmond O'Neill, Director Centre for Ageing, Neuroscience and the Humanities, Adelaide & Meath Hospital, Dublin 24, Ireland Send response to journal: Re: Concerns not dispelled	Hyperbole and misplaced emphasis are unhelpful in ethical debate, particularly for contentious issues such as physician-assisted death (PAD). The assertion by Quill (1) that the Battin analysis (2) 'dispels many of the concerns' of the impact of PAD on vulnerable groups is an exaggeration of the security of the findings, given the nature and type of data provided. The data in the study is limited in both quantity and quality, and the time scale for Oregon - 9 years - is short. By focussing only on the over 85's as the "elderly" group misses out on older people from 65 to 84 who are not only more likely to have more frailty than other age groups, but who are also over-represented in the PAD ratios in both countries. It is also somewhat lacking in perspective to dismiss the euthanasia of 3% of those with Alzheimer's disease and advance directives as effectively unimportant in the debate, a point which fuels further concern over the inherent prejudices against disability implicit in advance directives (3). Of more concern is the narrow definition of vulnerability, and indeed the recognition that vulnerability not only carries corresponding responsibility but also that vulnerability applies to the majority of the population at any one time (4). Perhaps the most illuminating metaphor for our universal extrinsic vulnerability is captured in Sontag's Illness as Metaphor, wherein she talks of the social and philosophical context so colouring the context of healthcare that it is "impossible to take up residence unprejudiced by the lurid metaphors with which it has been landscaped". It is in this context that the leniency of the courts, and the lack of sanction from the medical profession, for involuntary euthanasia of a patient with Alzheimer's disease in the Netherlands raise serious concerns (5). The societal and professional damage and concerns arising from PAD require a broader and less polemical discussion, and may be also be aided by the insights of doctors involved with other forms of physician-assisted death should also be considered (6). 1) Quill TE. Physician assisted death in vulnerable populations. BMJ 2007;335:625-6. 2) Battin MP, van der Heide A, Ganzini L, van der Wal G, Onwuteaka- Philipsen BD. Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impact on patients in "vulnerable" groups. J Med Ethics 2007;33:591-7. 3) O'Neill D. Present, rather than, advance directives. Lancet. 2001;358:1921-2 4) Vladeck BC. How useful is 'vulnerable' as a concept? Health Aff (Millwood). 2007;26:1231-4. 5) Sheldon T. Dutch GP found guilty of murder faces no penalty. BMJ 2001;322:509. 6) Gawande A. When law and ethics collide--why physicians participate in executions. N Engl J Med. 2006;354:1221-9. Competing interests: None declared
Mentally ill given short shrift 10 October 2007
Madelyn H. Hicks, Honorary Lecturer Health Service and Population Research Dept, Institute of Psychiatry, de Crespigny Park, London, SE5 Send response to journal: Re: Mentally ill given short shrift	Quill (1) and Battin (2) misleadingly convert the lack of appropriate research on mental illness and euthanasia or physician-assisted suicide (EAS) in Oregon and the Netherlands into ‘evidence’ of no vulnerability. If a law specified ‘advanced age’ as a justification for EAS, the elderly would be recognized as vulnerable. Yet they assert that the Dutch mentally ill are not vulnerable, despite Dutch law allowing EAS for mental disorders without physical illness. They minimize rates of EAS for mental disorders, neglecting to report cases where Dutch psychiatrists are consulted by another physician who carries out EAS for a mental disorder, in addition to the 2-5 directly-assisted deaths by Dutch psychiatrists annually. EAS is allowed for mental disorders without any psychiatric assessment. Psychiatrists are consulted in only 3% of Dutch EAS requests (3). The number receiving EAS for mental disorders among the remaining 97% of patients is unknown, though Dutch GPs report performing EAS for depression (4). Finally, the studies they cite used clinicians’ impressions of whether patients were depressed, even though it is well-documented that clinicians frequently fail to diagnose depression in the terminally ill (5). The single study that used a standardized depression-screening tool found that depression increased euthanasia requests in Dutch cancer patients by a factor of four (6). Other studies using standardized tools associate depression in the terminally ill with increased requests for hastened death, including physician-assisted suicide and euthanasia (5), yet Oregon and the Netherlands have never used standardized depression screening to determine how often depressed patients request and receive EAS. Mental illness is common and undertreated in the terminally ill, a problem that crosses ethnicity, gender and age. This review shines a feeble 10-watt glow into a mine shaft; insufficient unless you don’t really want to see whether someone is at the bottom. References: 1. Quill TE. Physician assisted death in vulnerable groups. BMJ 2007;335:625-6. 2. Battin MP, van der Heide A, Ganzini L, van der Wal G, Onwuteaka- Philipsen BD. Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impact on patients in "vulnerable" groups. J Med Ethics 2007;33:591-7. 3. Groenewoud JH, van der Maas PJ, van der Wal G, Hengeveld MW, Tholen AJ, Schudel WJ, van der Heide A. Physician-assisted death in psychiatric practice in the Netherlands. NEJM 1997;336:1795-801. 4. Jansen-van der Weide MC, Onwuteaka-Philipsen BD, van der Wal G. Granted, undecided, withdrawn, and refused requests for euthanasia and physician-assisted suicide. Arch Intern Med 2005;165:1698-704. 5. Hicks MH. Physician-assisted suicide: a review of the literature concerning practical and clinical implications for UK doctors. BMC Family Practice 2006; 7 (1):39. http://www.biomedcentral.com/1471-2296/7/39. 6. van der Lee ML, van der Bom JG, Swarte NB, Heintz PM, de Graeff A, van den Bout J: Euthanasia and depression: a prospective cohort study among terminally ill cancer patients. J Clin Oncol 2005; 23:6607-12. Competing interests: None declared
Medical and nursing professions must collaborate on assisted dying 15 October 2007
John G Hunt, [Student nurse] [Student] Send response to journal: Re: Medical and nursing professions must collaborate on assisted dying	I totally concur with Prof. Quill that "the risks and benefits of controversial practices like physician assisted death or terminal sedation are more favourable when practitioners work together with patients and families in an open and accountable environment". On 1st October, sections 24-26 of the 2005 Mental Capacity Act [www.opsi.gov.uk/acts/acts2005/20050009.htm] came into force. These relate to "Advance decisions to refuse treatment", but do NOT legalise assisted dying. Just two weeks earlier, at the Green Party national conference in Liverpool, I was privileged to propose a motion to amend policy by including support for assisted dying. I am delighted to report that the motion was carried by a significant majority. In recent years other UK political parties have begun to adopt Green policies in other areas. I hope they join us on this one too. The four previous Rapid Responses all express concerns about physician-assisted death: and valid concerns should, of course, be considered and addressed. However, as Dignity in Dying, (formerly the Voluntary Euthanasia Society), has found in repeated polls that over 80% of the population are in favour of allowing the practice to be regulated, I believe it is high time for members of the medical and nursing professions to collaborate on working out how to address practical concerns, instead of perpetuating agony, suffering, and misery by continuing to stick patriarchal heads in the sand, denying patients the choice that many desperately crave. Only a small proportion of these patients are physically and financially able to go abroad to use facilities such as those of Dignitas in Zürich: and, as Dr. Anne Turner complained when she did so in January 2006 [1], she was compelled to end her life prematurely precisely because she needed to be fit enough to travel. [1] Dr Anne Turner's assisted suicide refuels UK euthanasia debate www.bmj.com/cgi/content/full/332/7536/306?ehom British Medical Journal 2006;332:306 (4 February) Obituary Competing interests: Green Party parliamentary candidate for Brentford & Isleworth; member of Dignity in Dying; proposed motion on assisted dying at Green Party national conference, 14th Sep., 2007.