Fear of assisted dying: could it lead to euthanasia on demand or worsen access to palliative care?BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l852 (Published 26 February 2019) Cite this as: BMJ 2019;364:l852
All rapid responses
At this time, I do not wish to contribute to the ethical and ideological debate of assisted dying except this:
Of the 32 rapid responses contributing to the discussion of various features on the topic, only 3 have declared conflict of interests or COIs (2 responses by one author)
I am quite amazed at the potential number of commentators who may have religious beliefs affecting their opinion, professional work in certain areas of medicine which is traditionally antagonist to assisted dying (and the legalisation of assisted dying potentially deleterious to their livelihoods, whether they are aware of it or not) and self identification or actual membership/participants in organisations involved in lobbying for or against assisted dying...... and yet only 2 declared any such COI.
Perhaps some believe that their published opinion is independent of their personal affiliation.
Regardless, for so many comments to have no COIs, this must be the time when (to paraphrase Don Henley of the Eagles) hell freezes over if it was true
Competing interests: I have previously commented on this issues, calling out misinformation and lack of openess in declared affiliations by those involved in discussion.
The recent feature article in the BMJ exploring nuances in ‘help to die’ laws in the Netherlands and Oregon opens up an important issue to debate against the backdrop of the decision by the Royal College of Physicians of the UK to poll its members on their views towards Physician Assisted Dying.
We believe that the fundamental issue at stake here isn’t so much whether Physician Assisted Dying should be legalised or not, but rather, should Physician Assisted Dying in fact be considered a part of professional medical practice in the first place. That is, should helping a patient commit suicide be accepted as a medical procedure or not? The answer to this question cannot rely on legal prescriptions; the answer must come from physicians.
The goals of medicine must be determined ‘internally’, that is, by those who practice medicine; they cannot be imposed on the profession externally. Europe as a Union is determined by Europeans, Football as a game is determined by FIFA, Medicine as a profession is determined by doctors. This is important because the goal of any human activity affects the very character of those involved in that activity. Choosing to protect life or choosing to delete life necessarily affects a person’s character. The choice of becoming a physician is a free decision to identify oneself with what it means to practice medicine – for good or for bad.
The Royal College of Physicians has defined Physician Assisted Dying as: “The supply by a doctor of a lethal dose of drugs to a patient who is terminally ill, meets certain criteria that will be defined by law, and requests those drugs in order that they might be used by the person concerned to end their life.” If this becomes accepted medical practice, the definition of medicine will change radically. Physicians will no longer be identified with being the absolute guardians of life. Physicians will become persons willing to put an end to the life of their patients. The fine print that this will only happen under certain controlled circumstances does not alter the fundamental fact.
The cultural anthropologist Margaret Mead rightly observed that with the advent of the Hippocratic Oath, modern medicine finally came into its own. In the cultural milieu of Ancient Greece, the demarcation between medical doctor and witch-doctor was still very fuzzy. It was only with allegiance to the Hippocratic Oath taken by those who professed to heal that, “For the first time in our tradition there was a complete separation between killing and curing. Throughout the primitive world, the doctor and the sorcerer tended to be the same person. He with the power to kill had power to cure [...]. With the Greeks the distinction was made clear. One profession [...] [was] to be dedicated completely to life under all circumstances, regardless of rank, age or intellect — the life of a slave, the life of the Emperor, the life of a foreign man, the life of a defective child.”
The Hippocratic Oath did not commit physicians to changing the law of Ancient Greece. In fact, the philosophers, the law, and the society at the time condoned Physician Assisted Dying. The Oath committed physicians to a higher ethical calling – the respect for a patient’s integrity in all its dimensions: confidentiality, sexuality, and life. Since then, this has been the professional ethos of the medical profession. Patients know this. That is why they are willing to place themselves in the hands of the physician who in turn is committed to protecting that life received in trust. Physician Assisted Dying will erode this hard-won confidence as an unhappy experience in Canada already shows.
The physician-patient relationship must be guided by principles safeguarding the patient’s good. This is why a physician’s deep respect for life must be above patient autonomy precisely to protect patients from the power of medicine. In the same breath, this respect for life must be above physician beneficence-cum-compassion as a safeguard against the physician’s own ideologies, human frailty, and weakness. The decision that a particular human life is no longer worth living is a value judgment, not a medical judgment. Likewise, Physician Assisted Dying is the use of the medical profession to carry out a personal value judgment.
The goals of medicine have traditionally been the restoration of health and the relief of suffering. These noble ideals have been the altruistic driving force behind medical research and have led to the discovery of previously unheralded therapeutic options for patients. It would indeed be tragic if at the beginning of the 21st century, physicians were to abandon the search for an effective form of relief for patients with existential suffering and instead resorted to helping them commit suicide.
Existential suffering is a debilitating state that warrants all the compassionate care that medicine can offer. And yet existential suffering is neither a disease nor a pathological process. It is a symptom of a patient unable to find meaning in their suffering, unable to find hope in their life, unable to discover a transcendent aspect to their existence. The desire to die is in essence a cry for help to restore meaning and hope in life. Before the medical profession throws in the towel, other promising options such as meaning-centred therapy, hope-centred therapy, dignity therapy, and supportive-expressive therapy should be fully explored.[6-9]
We believe that the closing remarks of a commentary on euthanasia published some years back in the Journal of the American Medical Association serve equally well for the current debate: “We call on fellow physicians to say that we will not deliberately kill. We must say also to each of our fellow physicians that we will not tolerate killing of patients and that we shall take disciplinary action against doctors who kill. And we must say to the broader community that if it insists on tolerating or legalizing active euthanasia, it will have to find nonphysicians to do its killing.”
1. Albaladejo A. Fear of assisted dying: could it lead to euthanasia on demand or worsen access to palliative care?. BMJ. 2019;364:l852.
2. Pellegrino ED. The Internal Morality of Clinical Medicine: A Paradigm for the Ethics of the Helping and Healing Professions. J Med Philos. 2001;26:559-79.
3. https://www.rcplondon.ac.uk/projects/outputs/assisted-dying-survey-2019. Accessed 9.3.2019.
4. Levine M. Psychiatry & Ethics. Braziller, 1972:324–325. (Quoted by Levine as a personal communication from Mead).
5. https://www.cbc.ca/news/canada/newfoundland-labrador/doctor-suggested-as.... Accessed 18.3.2019.
6. Rosenfeld B, Cham H, Pessin H, et al. Why is meaning-centered group psychotherapy (MCGP) effective? Enhanced sense of meaning as the mechanism of change for advanced cancer patients. Psychooncology. 2018;27:654–60.
7. Duggleby WD, Degner L, Williams A, et al. Living with hope: initial evaluation of a psychosocial hope intervention for older palliative home care patients. J Pain Symptom Manage. 2007;33:247–57.
8. Chochinov HM, Kristjanson LJ, Breitbart W, et al. The effect of dignity therapy on distress and end-of-life experience in terminally ill patients: a randomised controlled trial. Lancet Oncol. 2011;12:753–62.
9. Kissane DW, Grabsch B, Clarke DM, et al. Supportive-expressive group therapy for women with metastatic breast cancer: survival and psychosocial outcome from a randomized controlled trial. Psychooncology. 2007;16:277–86.
10. Gaylin W, Kass LR, Pellegrino ED, Siegler M. 'Doctors must not kill'. JAMA. 1988;259:2139-40.
Competing interests: No competing interests
A recent article commissioned by the BMJ was presumably an attempt by the journal to present a balanced view of the assisted dying debate.(1) If that was the intention it reflects poorly on the journal. The article is liberally sprinkled with references to news articles, while the selection of facts is incoherent and patchy.
For example the author points out a slowing of Dutch euthanasia numbers in the first nine months of last year, ignoring the 311% increase in the last decade,(2) the 320% increase in Oregon over the same period (3) or the 24% increase in just six months in Canada in 2017.(4) The author claims that in the US cost savings of assisted dying would be ‘very low’ but the paper she quotes suggests savings of 627 million US dollars back in 1995,(5) which is the equivalent of 1036 million US dollars in today’s values. A more recent evaluation in Canada estimates that assisted dying would reduce annual health care spending by between 34.7 and 138.8 million Canadian Dollars. No government or health economist is going to ignore such savings.
The author mentions the current controversy in the Netherlands over patients with advanced dementia and psychiatric conditions, quoting the 2017 report stating there were only 3 patients with advanced dementia and 83 with psychiatric conditions.(2) What she does not mention is that the same report includes 166 cases of early stage dementia, 293 with ‘multiple geriatric syndromes’ which includes ‘cognitive deterioration’, 782 cases which had a combination of conditions that included dementia and psychiatric conditions, or the 13 cases of 18-40 years old individuals with a psychiatric disorder. The author also ignores data in the same report that 62% of the notifications involving a psychiatric disorder came from the end of life clinic (SLK) and that in 2017 the SLK clinic accounted for 33% of dementia cases and 37% of ‘multiple geriatric syndromes’. This is a clinic who themselves acknowledge that they will accept cases refused by other doctors.(6)
The article is not the cohesive, structured, referenced and factual contribution that is expected in the BMJ. The strangest element is the title of the article which has no relevance to the content. At what point was a misleading title added and for what purpose? This does not reflect well on the journal.
1)Albaladejo A. Fear of assisted dying: could it lead to euthanasia on demand or worsen access to palliative care? BMJ 2019;364:l852 doi: 10.1136/bmj.l852
2) Regional Euthanasia Review Committees (RTE). Annual Report 2017. Rotterdam: RTE, 2017. https://english.euthanasiecommissie.nl/the-committees/documents/publicat... (Checked 28Feb2019)
3) Oregon Health Authority. Oregon Death with Dignity Act 2018 Data Summary. Oregon: Public Health Division, Centre for Health Statistics, 2019. www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHW... (Checked 28Feb2019)
4) Health Canada. Third Interim Report on Medical Assistance in Dying in Canada. Ottowa: Health Canada, 2018. https://www.canada.ca/en/health-canada/services/publications/health-syst... (Checked 28Feb2019)
5) Ezechiel J, Batiin MP. What are the potential cost savings from legalizing physician assisted suicide. NEJM. 339: 167-72, 1998. https://www.nejm.org/doi/full/10.1056/NEJM199807163390306 (Checked 28Feb2019)
6) Levenseindeklinic (End of Life Clinic) TV documentary. Pieter van Huystee Film and NTR, 15 Feb 2016. https://www.npo.nl/2doc/15-02-2016/VPWON_1248719 (Checked 28Feb2019)
Competing interests: No competing interests