Let doctors help terminally ill patients to die, says commission
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e64 (Published 05 January 2012) Cite this as: BMJ 2012;344:e64All rapid responses
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The BMJ states that “The campaigning group Healthcare Professionals for Assisted Dying [which lists one of the BMJ's deputy editors among healthcare professionals supporting change] called on the BMA, which refused to give evidence to the commission, and Royal Colleges of Physicians, Surgeons and Physicians to reconsider their opposition to assisted dying in light of the commission’s “thorough, scrupulous report.”
I remain unconvinced that this report by a (for all intents and purposes self-appointed) “commission” is “thorough” and “scrupulous”
I would like to point to two areas of major deficiency (there are more that could be pointed out btw…)
1. the protection of vulnerable patients. The Commission believes that vulnerable individuals can be protected with safeguards. I remain unconvinced.
Psychiatrist Dr Hicks recently summarised some of the cases of coercion in both Oregon and the Netherlands. The following is taken from Table 2 of her paper
Hicks MHH. Physician-assisted suicide: a review of the literature concerning practical and clinical implications for UK doctors; BMC Family Practice 2006, 7:39
(Link: http://www.ncbi.nlm.nih.gov/pmc/articles/pmid/16792812/?tool=pubmed )
Table 2: Cases of coercion in physician-assisted suicide [PAS] and euthanasia
Case 1, Oregon: An 85-year-old cancer patient with worsening dementia requests PAS but her psychiatrist believes that she is being pressured by family. Nevertheless, she is then approved for PAS by a psychologist and receives assisted suicide
[16] NB footnotes refer to the paper by Hicks
Case 2, Oregon: Louise, who has a degenerative neurological disease, requests PAS. As her disease progresses, those in her network who support her suicide become increasingly anxious that she will become too mentally or physically incapacitated to act on her request. This includes her doctor, her mother, a friend who will be present at her suicide, and the Oregon Compassion in Dying PAS advocate who has arranged for a New York Times reporter to fly in and cover the suicide. Louise says she is almost ready but not quite. She wants a week to relax and be with her mother. On learning indirectly that her doctor thinks she will not be able to act if she waits, she appears startled. Her mother tells her, "It's OK to be afraid." She replies: "I'm not afraid. I just feel as if everyone is ganging up on me, pressuring me. I just want some time" [15].
Case 3, The Netherlands: A wife who no longer wishes to care for her sick, elderly husband gives him a choice between euthanasia and admission to a nursing home. Afraid of being left to the mercy of strangers in an unfamiliar place, he chooses euthanasia. His doctor ends his life despite being aware that the request was coerced [14].
Case 4, The Netherlands: Cees requests euthanasia one month after being diagnosed with ALS (MND). As required, his request is assessed by the primary doctor who will carry out the euthanasia and by a consultant. During their assessments, both doctors allow Cees's apparently resentful wife to answer all the questions directed to him, even though his speech is still understandable and he can type on a computer. His ambivalence about euthanasia is expressed by repeatedly pushing the date back. It is also expressed by weeping in response to the doctor's pro forma question of whether Cees is sure he wants to go ahead with euthanasia. His wife quickly answers affirmatively for him and then tells the doctor to move away from Cees, saying it is better to let him cry alone. At no point does a doctor ask to talk with Cees alone before his euthanasia [15].
The second area is the existence of distressing clinical problems when performing assisted suicide. In my view this is an important issue that is only inadequately mentioned in the commission’s report. The real and (obviously) very distressing problems that occur not infrequently when assisted suicide is performed are being downplayed by the report.
Unintended and very distressing complications can occur when physician-assisted suicide (PAS) are carried out. For example in 18% of cases where a patient attempted physician-assisted suicide the doctor had to intervene and kill the patient, therefore performing euthanasia. The reasons for this were that the patient awoke from coma, or had difficulty taking all the oral medication, vomited after taking the first medication or fell asleep before taking all the medication. Furthermore, in nearly half of the cases which started as PAS the patient did not die quickly enough and the doctor had to terminate the patient. While it was planned for the patient to die within half an hour after taking the lethal drugs, 19% of patients took 45 minutes to seven days (!) to die. There were less problems observed in euthanasia as opposed to PAS but still 10% of patients took much longer to die, some up to seven days. In both euthanasia and physician-assisted suicide a small number of patients awoke from coma and had to be terminated.
(Groenewoud JH et al. Clinical problems with the performance of euthanasia and physician-assisted suicide in the Netherlands. New England Journal of Medicine 2000; 342: 551-6.)
I am not convinced that this is the “good death” hoped for.
Competing interests: No competing interests
Re: Let doctors help terminally ill patients to die, says commission
The BMJ continues its uncritical support of assisted dying by praising the self-selected committee on assisted suicide chaired by an advocate of assisted suicide/euthanasia, Lord Falconer.
The BMA – as its last Annual Meeting in Cardiff last year - has questioned the independence of Lord Falconers commission on Assisted Dying. The BMA refused to give evidence to it(!), and called on the BMJs Editorial team to present a balanced and unbiased coverage of the Commission.
We must wait in vain for this. (News section “Let doctors help terminally ill to die, says commission”; BMJ 2012; 344; e64.)
Ironically the BMJ is a subsidiary of the BMA.
For example, why does the BMJ report the outcome of a self-appointed and small “commission” favouring euthanasia but fail to report that the German Medical Association, the largest European Medical Association, at their annual meeting in May last year voted 3:1 against assisted suicide and for a change of the professional code of doctors in Germany accordingly? Participation in assisted dying (let alone euthanasia) is now prohibited according to the Germany professional code for Doctors. (www.bioedge.org/index.php/bioethics/bioethics_article/9615) Obviously, this is inconvenient for the views of the BMJs editors and not reported.
However, it is not just the German doctors who, probably because of their historic experiences, are concerned about euthanasia and assisted suicide.
A few days ago, Baroness Professor Hollins, the past President of the Royal College of Psychiatrists severely criticised the Falconer commissions report. She writes:
“Predictably, Lord Falconer’s privately funded Commission on Assisted Dying is proposing that the law should be changed. As their definition sweeps up any seriously ill person who might die within 12 months, they are, in reality, supporting physician-assisted suicide for those approaching the end of life. All previous proposals to change the law, including this one, have been clear that anyone qualifying for help to die must not lack mental capacity. The trouble is that there seems to be little real understanding of what mental capacity means or how to establish such an understanding."
She quotes Dr Martin Curtice, a consultant in old age psychiatry, who said that there was “a big overlap between depression and terminal illness and chronic physical disorders.” The presence of such depression “does not automatically mean you lack capacity, but it’s highly likely to influence your decision-making.” The British Psychological Society said “it’s incredibly difficult to assess people with a life-limiting illness for depression and anxiety.”
She writes: “Lord Falconer and his associates seem to believe that assessing mental capacity can be left safely in the hands of the patient’s GP and specialist.” But Prof Hollins is not so sure: She writes about the difficulty of assessing mental capacity, “…many psychiatrists – I write as one myself – [would not] be comfortable with the idea of assessing patients for suitability to receive lethal drugs.
“Seriously ill people need help to live, not help with suicide. They need compassionate care and effective pain relief – let’s campaign for those.”
(Sick people need help to live, not help to die; Telegraph, 05 January 2012; link
www.telegraph.co.uk/health/8995355/Sick-people-need-help-to-live-not-hel...)
It is ironic that, while the BMJ doesn’t appear to be able to contain their wild and uncritical enthusiasm about the Falconer report, a respected expert – Prof Hollins – who is also the President-elect of the BMA has grave reservations about this report and its implications.
Obviously, because this – and many other criticisms of the Falconer committee - do not fit into the ideology of the editorial Board of the BMJ, this is not reported.
Competing interests: No competing interests