Why the Assisted Dying Bill should become law in England and Wales

As a retired GP with many years experience of caring for patients with terminal care, I support the Assisted Dying bill and applaud the editorial in this BMJ.
I am very disappointed that my professional organisation, the BMA is not supporting , or remaining neutral on the bill. Most of my medical friends and acquaintances support a change in the law, or at least neutrality.
All of us want to be able to help people and relieve suffering as best we can, and all of us believe in the principle of autonomy for the patients. We do not want to "act as gods" by denying people the relief they wish for, but rather to facilitate what is an inevitable transition in the most merciful way possible.

So the BMJ supports the assisted dying bill, and as such is being reported online in the Guardian, Telegraph and others.

Let's be clear, what we have is the view of 3 individuals who happen to be editors of the journal. The officical position of the BMA, is opposition to all forms of assisted dying.

The editorial builds its case on personal autonomy, as if this trumps other considerations. Why then limit this with less than 6 months to live? Why not those with other problems, who have a settled view that their lives are futile? If this would be a possibility, when the bill is passed, is this a direction we want to take?

"Most people want it" is the other strapline on the aticle. Is there a possibility that the general public has been unduly influenced by the difficult but rare cases that make the news? It seems that those closest to the issue (palliative care doctors, GPs with an interest in end of life care), generally oppose assisted dying.

Finally, as one of those GPs, this just doesn't feel right at all, a major dislocation in the way we practise medicine.

Delamothe, Snow, and Godlee present a strong position statement in this editorial; indeed their title makes clear that their view is the right one (whether or not people want it). As a Palliative Medicine doctor who disagrees with their position, I present a response to their main points.

Delamothe and Godlee propose that autonomy has become the “cardinal principle in medical ethics”, it underpins best patient care, and to go against this principle, is wrong and in opposition to good practice. Yet, intentionally assisting a patient to end their life goes against the foundational principle of medicine: to act for the good of the patient [1]. Of course, proponents of this Bill argue that physician-assisted suicide helps the patient, allowing them to be autonomous individuals. However, it has also been argued that the “beneficence brought about by killing to relieve suffering is highly illusory” [1]. Furthermore, later in the editorial Delamothe, Snow and Godlee go on to critique those who highlight “hypothetical victims”. They ‘reassure’ us, that those without terminal conditions simply “will not qualify”. Why do they disregard the autonomous choices of those who are not terminally ill? Yet, my concern is for patients who currently do not qualify. Consider what has happened in Switzerland where physician assisted suicide is now legal, not simply for terminally ill patients, but those with chronic diseases and mental health conditions as well. Surely this example alone is enough to cause concern about a potential slippery slope, putting vulnerable people at risk.

Delamothe, Snow and Godlee put aside concerns about difficulty in forecasting the end of life, by citing a study which found that doctors often overestimate prognosis. Yet they fail to highlight that this study only looked at prognosis in those with advanced cancer, and didn’t include those with incurable chronic illness. Numerous studies show how difficult forecasting end of life is [2 3] – establishing a six month prognosis is fraught with error.

What exactly is the capacity to decide to end ones own life? When doctors assess capacity, it is with a view to protecting patients from harm, not facilitating their suicide. Proper assessment of capacity is complex. It can fluctuate rapidly and is frequently impaired in the seriously ill. What is a ‘clear and settled intention’? I have seen many patients change their minds about care preferences as they approach the end of life. And how can a doctor be sure a patient has not been influenced or coerced? In today’s economic climate, patients already worry about being a burden [4], and most doctors know little about the presence of coercion in patients’ personal lives.

Doctors will be expected to provide assisted suicide. Yet most doctors don’t want to have anything to do with it. Despite the clause on conscientious objection, it will be impossible for doctors to be free of involvement. While I can see why Lord Falconer wants to embed his ideas in the highly respected and trusted profession of medicine, there is a serious question over whether assisting patients' suicides is a proper part of clinical practice. It goes against why most of us became doctors.

I urge readers to examine this Bill. If passed, it will have widespread and harmful consequences for the most vulnerable in society, and their relationship with those whom they trust to care for them.

References:
1. Pellegrino ED. Some Things Ought Never Be Done: Moral Absolutes in Clinical Ethics. Theoretical Medicine & Bioethics 2005;26:469-86
2. Christakis NA, Lamont, E.B., Smith, J.L., Parkes, C.M. Extent and determinants of error in doctors' prognoses in terminally ill patients: prospective cohort study commentary: why do doctors overestimate? Commentary: prognoses should be based on proved indices not intuition. BMJ 2000;320:469-73
3. Coventry PA, Grande, G.E., Richards, D.A., Todd, C.J. Prediction of appropriate timing of palliative care for older adults with non-malignant life-threatening disease: a systematic review. Age and ageing 2005;34(3):218-27
4. Bausewein C, Calanzani, N., Daveson, B.A., Simon, S.T., Ferreira, P.L., Higginson, I.J., Bechinger-English, D., Deliens, L. et al. 'Burden to others' as a public concern in advanced cancer: a comparative survey in seven European countries. BMC Cancer 2013;13:105

We’re no longer in an era where ‘doctor knows best’. I therefore strongly support the call here for Parliament to rise to the challenge and follow the lead of the public – who are overwhelmingly in favour of assisted dying. Of course, strong safeguards are necessary – stronger and safer than the government currently applies to the tobacco and food industries.

But I hope that the Assisted Dying Bill will also promote discussion around death and so weaken current taboos against talking about and planning for a good death. In his recent Guardian interview, John Ashton spoke movingly about 'midwives' for death. His wide-ranging comments also touched on sex education. Death is just as universal as sex – but there is very little education for it at any age, despite only getting one chance to get it right. Why can’t there be ‘death education’ – as an opportunity to think about what we might want to happen? It might even promote another of Dr Ashton’s ideas: the four-day week. After all, no-one on their deathbed regrets not spending enough time in the office!

Assisted dying is, of course, not for everyone – either as a patient or a doctor. But I regret that, despite his exemplary hospice care, my father had to wait to die from his metastatic cancer after he had made it clear that he wanted to be dead. I have MS and while I am well now, I also fear that, without a change in the law, I may be driven to organising my own death before I really want this, in a foreign country.
Let’s hope that Parliament makes a better and more democratic job of it than the RCGP did.