Assisted suicide: a substitute for a caring doctor?
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1590 (Published 23 March 2010) Cite this as: BMJ 2010;340:c1590
All rapid responses
We all know that death is coming: we often don’t know when or how it
will come but we know it will come and we are frightened, more afraid than
we have ever been.
When the time comes, will there be a doctor who cares, a physician we
can trust, a rational doctor who will palliate, a doctor who will truly
help us achieve a gentle, natural and easy death? Many of us are afraid
because we can see those kinds of doctor fast disappearing over the
horizon. We have lost control over something that all rational people
desire.
All our GPs are obsessed with the QOF (Quality and Outcomes
Framework) and now spend their lives chasing points where points win
prizes: there are no monetary prizes to be had in palliation and caring
for the dying. Looking at it rationally, when the time comes, the real
hope in a death by suicide, assisted or otherwise, is altogether
unsurprising.
Competing interests:
None declared
Competing interests: No competing interests
Respected Sir,
Legal issues involved in assisted suicide help us to understand the
concept of death. In a few parts of the world, assisted suicide is legal and
illegal in some. It will be very interesting to compare data involving the
level and attitude towards care from these countries. In India, it is
still a debatable issue whether assisted suicide should be legalised or
not. Article 21 of Indian Constitution says that no person shall be
deprived of his life or personal liberty except according to procedure
established by law. But then, the right to die is also a question of
personal liberty of deciding the course of one’s life.
In our indoor wards, we have observed the difficulties faced by the
caregivers of frail patients with severe dementia. We never came across
any situation in which carer of any patient considered assisted suicide as
an option. May be Indian cultural concepts of ‘Matri Rina’ and ‘Pitra Rina
(mother and father debt) have a role to play in it. Despite various
personal, social and economic problems, the carers tend to look after the
patients very well despite knowing that no cure is available for the
illness and they have to care for the patients in the same manner till the
patient dies. Legal sanction to assisted death may increase the
options available to the carers.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir
Professor Livesley makes a convincing case for the need for medical
practitioners, particularly those involved in palliative care, to retain
their humanity. He is not alone in noting the apparent loss of this
throughout medical training: Weatherall (1994) described a demonstrable
narrowing of perspective and hardening of attitudes in medical students
and other studies have shown a diminution of interpersonal and
communication skills suggesting that medical education actually reduced
the students’ inherent ability for caring (Helfer 1970).
There is a growing perception of the value of the inclusion of
humanities based subjects to enable students of medicine to broaden their
understanding of the human condition and thus retain their humanity. As a
result there are a number of courses available in the ‘Medical Humanities’
including the University of Bristol intercalated BA (the example given by
Livesley), the MA in the Medical Humanities at Swansea and numerous
undergraduate SSCs. Such study is engaging, supported by anecdotal
evidence, personal experience and case reports that suggest it may make
better doctors but is not compulsory. Though the humanities have been
included in undergraduate training for some years there have been few
attempts to evaluate the effectiveness of these interventions and the
outcomes are still ambiguous. The UK medical school curriculum leaves
little space for extras so to justify the inclusion of humanities it must
be ensured that these courses are achieving what they set out to do. It
is, therefore, important that those of us involved in medical education
including humanities remain objective and make strenuous attempts to
evaluate our work.
Livesley, B. ‘Assisted Suicide: a substitute for a caring doctor’.
BMJ 2010; 340:c1590
Weatherall, D.J. ‘The inhumanity of medicine’. BMJ , 1994; 309:1671-
2
Helfer, R. E. ’An objective comparison of the pediatric interviewing
skills of freshman and senior medical students’. Pediatrics 1970; 45:623-7
Jane Moore, MA Medical Humanities, GP and GP Tutor, King’s College
Medical School, London
Competing interests:
None declared
Competing interests: No competing interests
To paraphrase an old saying.
A physician knows how to treat,
A good physician knows when to treat,
A great physician knows when to palliate.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
We read with interest the personal view by Professor Livesley (1) and
would like to share a finding of our recent studies to provide ‘evidence’
for his thoughts.
We have recently performed qualitative interviews with medical
students and Foundation Year One doctors to explore their learning about
palliative care, as well as medical and nursing staff to explore the care
given to dying patients in an acute trust. The common finding in all these
studies was the “death as a failure” culture that permeates within acute
trusts, hindering the care given to patients (and their learning).
Therefore, whilst we agree that ‘one of the key remedies lies in updating
clinical education’, it will only work if it highlights this prevailing
culture; (2) otherwise the chasm between ‘what they hear us say’, the
formal curriculum, and ‘what they see us do’, the hidden curriculum (3)
will remain.
1. Livesley B. Assisted suicide: a substitute for a caring doctor?
BMJ 2010; 340: 713
2. Gibbins J, Reid C, Chambers E J, Campbell C, McCoubrie R, Forbes
K. Changing the death taboo. BMJ 2008; 337: 1244
3. 2. Inui, T. A Flag in the Wind: Educating for professionalism in
medicine. Washington DC: Association of American Medical Colleges, 2003
Competing interests:
None declared
Competing interests: No competing interests
The importance of care
The GMC has long recognised the importance of care as well as
treatment. This is reflected in our central guidance Good Medical Practice
and in the supporting material which places as much weight on care and
respect for patients as it does on clinical skills. For example, in our
current guidance on end of life care we recognise that there is a time
when the focus of care must change from the active or curative, to
palliative. We have been reviewing this guidance and the new version, to
be published next month, will place even more emphasis on this issue.
We also ensure that medical students are trained within this
framework. As the foreword to Tomorrow’s Doctors makes clear, 'Medicine
involves personal interaction with people, as well as the application of
science and technical skills' and it identifies working with patients and
their families at the end of life - including good communication and team-
working - as one of the outcomes of the undergraduate curriculum.
The curricula for doctors in the foundation years, and many of those
for specialists, also identify the need for a range of clinical and
communication skills in providing care for patients at the end of life.
The GMC has not therefore been silent on this matter, but we
recognise there is always room to refresh and reinvigorate our approach.
In particular we are anxious to consider how we can bring to life the
principles in our guidance and make them as relevant as possible in
clinical practice. We will be attempting to do this following the
publication of our new guidance on end of life care.
Competing interests:
None declared
Competing interests: No competing interests