Assisted dyingBMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e4075 (Published 13 June 2012) Cite this as: BMJ 2012;344:e4075
Ann McPherson, who died a year ago, was a general practitioner and a writer who successfully championed the importance of the patient’s voice in healthcare decisions.1 But her most important legacy may turn out to be a change in the law on assisted dying. Her commitment to this cause pre-dated her own final illness. It stemmed from her experience of being powerless to help terminally ill patients suffering prolonged indignity and distress despite having received optimal palliative care and asking for help to die.2 With terrible irony, Ann’s own death from pancreatic cancer exactly mirrored this experience. As told this week by her daughter Tess McPherson, the story offers a powerful case for a change in the law.3
Helping someone to die is a crime in most parts of the world. A few countries (including Belgium, Luxembourg, the Netherlands, and Switzerland) and three American states (Oregon, Washington, and Montana) have so far legalised assisted dying. In the United Kingdom in 2006 a bill on assisted dying for terminally ill patients was defeated in the House of Lords4; and in 2010 guidance from the director of public prosecutions made it likely that doctors in England, Wales, and Northern Ireland would be prosecuted if they hastened a patient’s death or advised patients on how to do so.5 In a debate in the House of Commons in March this year, many speakers were against further legislative change, although a consensus endorsed non-prosecution in cases of compassionate assistance to die.6
Amid this official opposition to a change in the law, support for legalisation among the general public is strong, running at more than 80% in successive social attitudes surveys.7 8 Opinion among doctors is more divided, with around 65% against.9 When asked in a poll on doctors.net whether they would want the option of assisted dying for themselves, a third of the 1000 general practitioners surveyed said they would, a third said they would not, and the remainder were unsure.10
Some of the arguments for and against assisted dying have been rehearsed in the BMJ.11 12 Last month Iona Heath argued against assisted dying and this week we publish a selection of the mainly critical responses her article received.13 14 In January this year, a special commission led by Lord Falconer examined the evidence and arguments on both sides.15 It concluded that, when a terminally ill patient who is mentally competent and has received optimal palliative care requests assistance to die, the doctor should be allowed to prescribe life ending drugs within strict legal safeguards. The report has been dismissed by some because it was commissioned by the pro-legalisation group Dignity in Dying. Supporters say, however, that it was independently chaired and the sponsors had no say in its content or conclusions.
The depth of personal, professional, and religious feeling on this matter draws parallels with abortion reform in the 1960s. Then the profession’s representatives in the UK (the BMA and the Royal College of Obstetricians and Gynaecologists) resisted efforts at legalisation, fearful of a loss of clinical autonomy.16 But a series of private members bills, sponsored by campaigners and fuelled by growing public concern about the effects of botched illegal abortions, eventually garnered government support. Once a change in the law was inevitable, the BMA and the college dropped their opposition and entered negotiations with the bill’s sponsors and the government on the technical detail. Although doctors controlled the means to perform abortions, they did not control the decision to change the law.
The same is true for assisted dying: doctors hold the means but the decision rests with society and its representatives in parliament. A change in the law, with all the necessary safeguards, is an almost inevitable consequence of the societal move towards greater individual autonomy and patient choice. But it may take a while, and it may not happen until we properly value death as one of life’s central events and learn to see bad deaths in the same damning light as botched abortions.
What view if any should the profession take while this shift is under way? The campaigning group set up by Ann McPherson and others, Healthcare Professionals for Assisted Dying (HPAD), wants the BMA and royal colleges to move their position from opposition to neutrality. A new poll commissioned by Dignity in Dying found that, of 1000 general practitioners surveyed, 62% supported neutrality.17 As HPAD’s chair Raymond Tallis explains in a column this week, the aim is “studied neutrality” not indifference.18 It is intended to communicate neither support nor opposition to a change in the law, to reflect the diversity of personal and religious views among doctors and their patients, and to encourage open debate. At this year’s annual policymaking meeting the BMA will debate several motions urging neutrality. The BMJ supports this call and will continue to provide a platform for the debate.
Cite this as: BMJ 2012;344:e4075
Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.