Views & Reviews Personal View

Legalising assisted dying puts vulnerable patients at risk and doctors must speak up

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f4062 (Published 26 June 2013) Cite this as: BMJ 2013;346:f4062
  1. Bill Noble, Macmillan senior lecturer in palliative medicine, University of Sheffield, Academic Unit of Supportive Care, Sheffield S11 9NE, UK
  1. bill.noble{at}sheffield.ac.uk

If proposed legislation on assisted dying involves doctors, then we must make our reservations known, says Bill Noble

Assisted dying is legal, physician assisted suicide for mentally competent adults who are terminally ill. Now that another piece of legislation has had its first reading in the UK House of Lords,1 the debate is on again. I have no religious objections, but I recoil from the vision of a society where death is a therapeutic option; the idea that there are two categories of suicidal people, those deserving and those undeserving of death; and the idea that doctors should do the sorting and the killing.

In June 2012, the BMJ carried editorials supporting the call from the Healthcare Professionals for Assisted Dying (HPAD) for medical organisations—such as the BMA and the royal colleges—to adopt “studied neutrality” on the question of legalising assisted suicide.2 3 The BMJ’s editor, Fiona Godlee, is right to argue that society and not the medical profession should determine the law. But if organisations representing doctors step back, while legislation insists on doctors’ involvement, we abrogate responsibility for our patients and the next generation of doctors.

Doctors worry about the idea that ending your life before you lose dignity will become a new cultural norm. The US state of Oregon is the new model; but why should we take a moral lead on personal rights from a country without gun control, unwilling to ensure adequate healthcare for all its citizens?

Stories such as that of HPAD founder Ann McPherson, whose distress went unrelieved, cannot be denied.4 5 Palliative care cannot remove every kind of distress. Some patients suffer to the extent that they wish to be dead, but few attempt suicide or ask that we end their lives. Much more common is the relative who wants to see an end to the suffering. Wishing for death is not a purely individual decision, uninfluenced by family and society. Nor should the retention of dignity become a social prerequisite to continued existence.

I see vulnerable patients under pressure. Older people, who are already ejected from our NHS funded and governed care, acquiesce to be nursed in commercial institutions of variable and uncertain quality. Their wish not to be a burden on family is powerful, and I have seen patients reject treatments to shorten survival to make it easier for their family. If assisted dying is legalised, I fear that our society’s neglect of older people, poverty, and the lack of home care services will drive up demand for assisted suicide.

Politicians should ask who is asking for assisted dying; and why now. It is widely assumed that baby boomers are pushing for a change. Apart from a few widely publicised exceptions, it’s not baby boomers who are dying, it’s their parents. I wonder whether the loudening call for institutionalised suicide is born of the experience of witnessing distressing deaths rather than the prospect of our own. This might explain the fact that the legislation would do nothing to meet the demands of patients too disabled to take their own dose or those with a disabling, but not terminal, condition that renders life intolerable. Even though intolerable mental illness would be a powerful motive for suicide, psychiatric patients will never be recognised among the deserving by the proposed legislation.

Most members of the BMA, Royal College of Physicians, Royal College of General Practitioners, and Association for Palliative Medicine oppose the legalisation. Their memberships are not neutral, and the public should know why. If professional organisations fail to join the argument, the debate will be poorer for it. The public has a legitimate interest in understanding what the profession has to say on the subject. Many doctors share Iona Heath’s reservations about the effectiveness of legal safeguards to prevent coercion.6

The argument that doctors should not influence legislation on this subject seems rather thin if we end up with a system in which doctors have to decide whose distress is bad enough and whose capacity is good enough to receive assistance to commit suicide. This concept of the deserving versus the undeserving suicidal patient is deeply problematic. There really are no technicalities that must be assigned to the physician other than certification of death. Armed with a set of instructions and the medical records, a lawyer or social worker could make the kind of assessments that are envisaged, before assisting suicide. A patient proposed that the ideal team would be two judges and an executioner.

Yet the wish to have the blessing of a trusted doctor seems powerful within the movement to promote assisted dying. They want and need our approval. But any society that chooses legalised assisted suicide should at least own up to the process being a social and legal intervention rather than a medical one. If society is seeking the blessing of the medical profession for a system of assisted dying, we should be clear and open about our views both individually and collectively, no matter how diverse or inconvenient for the legislators.

Notes

Cite this as: BMJ 2013;346:f4062

Footnotes

  • I thank Jim Gilbert, Tim Harlow, and Clare Sambrook for their contributions to this article.

  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: membership of the BMA, Royal College of Physicians, Royal College of General Practitioners, and Association for Palliative Medicine.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.

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