Posts Tagged ‘Assisted suicide’

Physicians don’t support assisted dying change

By Mike Broad - 27th November 2014 4:54 pm

A majority of medics do not support a change in the law on assisted dying.

The Royal College of Physicians surveyed fellows and members with 58% saying they do not want a change in the law on assisted dying.

The results broadly reflected the overarching result of the RCP’s 2006 survey, although the number taking this position has fallen.

The survey asked medics whether they “believe that with improvements in palliative care, good clinical care can be provided within existing legislation, and that patients can die with dignity. A change in legislation is not needed.” 63% of respondents agreed with the statement.

The current legal position is that assisting another person’s suicide is illegal.

The college recognised that it is a difficult and personal issue for doctors and society, and therefore the RCP Council felt it was important to consult members.

Although there is still a majority opposing a change in the law on assisted dying, there has been an 11% decrease in the percentage of members and fellows holding this view since the survey was last conducted in 2006.

Another question asked that in the event of legislation receiving royal assent, would the doctor personally be prepared to participate actively in ‘assisted dying’? Only 21% would be in favour of this.

Dr Andrew Goddard, RCP registrar and senior officer with responsibility for professional matters, said: “These results give us a basis for our position on assisted dying and for responding to proposed legislation, now and in the coming years.

“Whilst there is still a majority against a change in the law, we recognise there has been a shift in opinion over the past eight years, and will continue to engage with members and fellows on this issue.”

Assisted dying debate has been irrational

By Tom Goodfellow - 21st July 2014 10:21 am

Forty years ago, when I was a very junior houseman, a young man was admitted for surgery to remove a large malignant bowel tumour.

Post operatively he did very badly with an ileus which persisted for several weeks, dehiscence of the wound and a leaking bowel fistula. Finally, in desperation at the lack of improvement, the consultant performed a laparotomy (no CT scans in those days) and discovered that he had galloping cancer; his whole abdomen was infiltrated with tumour and faeculent fluid.

On return to the ward the consultant simply muttered, “Don’t let him wake up”. I then witnessed the surgical registrar and the senior ward sister administer a whopping dose of opiate. The young man never woke up and quietly died within twenty-four hours. That is how things were done in those days.

This was medical euthanasia, although I would maintain that it was in fact good compassionate medicine and within the law. It was accepted in those days that the administration of large doses of opiates to relieve terminal suffering was acceptable, even though it hastened the patient’s death.

I regularly witnessed similar practice when, a year or so later, I worked at one of the well-known cancer hospitals.

But things seem more complicated these days so let me relate a different case.

Several years ago the elderly father of a friend developed severe progressive dementia. He was cared for initially by his wife with family support. However increasing age and infirmity of both necessitated his admission to a care home.

After some months in the home he became unwell and, as seems to be routine practice these days, an ambulance was summoned and the old man admitted to hospital.

After a few days of IV rehydration and antibiotics he had recovered sufficiently to be discharged back to the home. However the severity of his dementia meant that he had no quality of life whatsoever and he required total care.

Over the next eighteen months this scenario was repeated five times. On the last occasion my friend was informed of the admission and managed to get there in time to discuss with the admitting team the appropriateness or otherwise of continuing active treatment. It was agreed that the old boy should simply be kept comfortable and he quietly passed away after a couple of days. The ‘old man’s friend’ had done the job.

In my view my friend was right to intervene; the treatment administered during the previous admissions was completely inappropriate given the clinical context. But it is difficult to blame the hospital doctors – in a busy emergency department such judgements are not always practical or possible. The real mistake was the 999 call summoning the ambulance.

Had the GP, in conjunction with the family and the home, made a proper care plan then the old man could have had a quieter and more dignified end in his own bed.

On Friday 18 July, their Lordships debated Lord Falconer’s assisted dying bill. I don’t want to rehearse all the various arguments other than to say that, in my opinion, to ignore the strong views of many disabled individuals and groups would seem to me to be foolishness in the extreme. I also think that the well-known adage ‘hard cases make bad law‘ is totally apposite in this case.

But the clincher, in my view, is the ’six months’ prognosis. Any sensible doctor knows that that is daft!

But it seems to me that society is confused and divided on this, and I accept that these issues are very complex. We spend ever increasing resources on investigating and treating a patient whose life is clearly coming to an end while vociferous groups are campaigning for assisted suicide and euthanasia.

These days it seems impossible for many to die without having multiple investigations, and I witness this on a daily basis as frail elderly folk or the terminally ill are wheeled in for yet another scan which will make no meaningful difference to the outcome.

This week, during a busy ultrasound list, I was asked by a junior if I would urgently scan a patient with acute kidney injury. I normally agree to such request on the grounds that it may significantly alter acute management. However the patient they wheeled in was a demented 92-year old! My report simply said, “92-year-old kidneys”!

These days it seems that every confused elderly patient brought in by ambulance will have a cranial CT scan on the rational that “we might miss something” or “please exclude a ….”, and every patient with mild SOB will have a CTPA to exclude a PE. There seems to be little joined up diagnostic thinking.

Please don’t get me wrong. Of course I fully support appropriate investigation of patients, irrespective of age and infirmity, but the emphasis is on the word “appropriate”!

There does need to be a discussion in our society around the end-of-life issues, but I am not convinced that the debate so far is rational. It seems to me that the case supporting Lord Falconer’s bill rested heavily on emotion and “hard cases” rather than rationality.

We are told that 69% of the population support assisted dying but then 60% would like to see the re-introduction of capital punishment! Should we go with the crowd or what? Those who oppose the re-introduction of the death penalty do so because they believe it is wholly wrong in principle, and those opposed to assisted suicide do so on the same basis.

Of course the assisted suicide bill is completely different from the case I described initially, but I for one would be deeply unhappy if our society chose to choose the slippery slope of assisted dying. Instead let us find a middle way of protecting the vulnerable while not striving officiously to preserve poor quality life at all costs.

“Thou shalt not kill; but needst not strive officiously to keep alive.”

Care minister Lamb backs assisted dying bill

BBC Health - 17th July 2014 6:53 pm

Care Minister Norman Lamb has said he has “changed his mind” and would now support a new law on assisted dying.

The Liberal Democrat told BBC Newsnight an individual should be able to “make their own decision about their life”.

But a cancer specialist told the programme it could create “death squads” by putting the decision in the hands of doctors.

Former Labour Lord Chancellor Lord Falconer’s assisted dying bill will be debated by peers on Friday.

The law change proposes to allow doctors to prescribe a lethal dose to terminally-ill patients judged to have less than six months to live.

Mr Lamb said he was speaking as an MP, not a minister, as the issue would be decided by a free vote in Parliament.

He said he had changed his mind after talking to “an awful lot of people” whose friends and relatives had died after “going through months of pain and distress”.

Read more at BBC Health.

“Assisted Dying Bill should become law”

By Mike Broad - 14th July 2014 11:41 am

Lord Falconer’s Assisted Dying Bill, which is expected to receive its second reading in the House of Lords this month, should become law.

That’s the view of the BMJ, which says “recognition of an individual’s right to determine his or her best interests lies at the heart of this journal’s strategy to advance the patient revolution in healthcare. It would be perverse to suspend our advocacy at the moment a person’s days were numbered”.

The BMJ argues that people should be able to exercise choice over their lives, which should include how and when they die, when death is imminent.

And the majority of the British public want the option too, they add. The 2010 British Social Attitudes survey shows that 82% of people are in favour of a change in the law on assisted dying.

Lord Falconer’s Bill would allow adults who are expected to live six months or less to be provided with assistance to end their lives, they explain.

Two doctors must be satisfied that the person is terminally ill, has the capacity to make the decision to end his or her life, and has a clear and settled intention to do so.

This decision must have been reached voluntarily, on an informed basis, and without coercion or duress.

The Bill does not cover people with disabilities who are not terminally ill, other people with non-terminal illness, people who are not mentally competent, or children, they add.

“That much mentioned victim - the elderly lady who believes she has become a burden to others and offers herself up for assisted dying - will not qualify,” the editorial says.

Those opposed to a change in the law cite the difficulties of establishing that someone has less than six months to live. Yet most studies suggest doctors consistently overestimate rather than underestimate prognosis, say the authors.

Another argument is that individual choice should be limited when it has a profound impact on others. “But we already accept people’s decision to reject life saving treatments, if they have mental capacity, regardless of any effects their subsequent deaths may have on those they leave behind,” say the authors.

They acknowledge that some doctors are unhappy about the part they would be asked to play. However, the Bill makes robust allowance for conscientious objection - a provision which has worked well for the almost 50 years of the Abortion Act.

They also point to the US state of Oregon, on which the Bill in England and Wales is closely modelled, that has allowed assisted dying since 1997. Last year, altogether “assisted deaths” accounted for 2.2 per 1,000 total deaths in the state.

Applying Oregon’s figures to England and Wales would mean that every eight to nine years one patient per general practice would take life ending medication, they explain.

Oregon’s experience also confounds claims that assisted dying legislation impedes the development of palliative care, say the authors.

Oregon is also regarded as a national leader in palliative care post-legalisation, and the Oregon Hospice Association, initially opposed to assisted dying, found “no evidence that assisted dying has undermined Oregon’s end of life care or harmed the interests of vulnerable people”.

“Ultimately, however, this is a matter for parliament, not doctors, to decide,” they write. Last month the Supreme Court president said that unless parliament satisfactorily addresses the Suicide Act 1961, which prevents doctors helping patients to end their lives, the court could force change upon them by declaring the act incompatible with the European convention on human rights.

“Let us hope that our timid law makers will rise to the challenge,” they conclude.

Read more.

Assisted suicide: the law and the role of doctors

By Andrea James - 1st October 2012 11:42 am

Patients asking their doctors for help to end their lives or travel to Dignitas is becoming more and more common. Few can also have been unaware of the Tony Nicklinson and ‘Martin’ cases which made headlines recently. The following is an analysis of the law on assisted suicide, GMC guidance on the matter and the issues raised within the Nicklinson and ‘Martin’ cases:

The law

Prior to 1961 it was a crime for a person to commit suicide. That was abolished with the Suicide Act 1961. However, it became (and remains) an offence for a person to encourage or assist the suicide or attempted suicide of another person. Such offences are punishable by up to 14 years imprisonment.

In 2009, Debbie Purdy famously pursued legal proceedings to force the Director of Public Prosecutions (‘DPP’) to publish a policy clarifying when and when not persons would be likely to face prosecution for encouraging or assisting a suicide. This resulted in the February 2010 Policy for Prosecutors in Respect of Cases of Encouraging or Assisting Suicide. Whilst nothing in that policy decriminalises encouraging or assisting suicide, or guarantees that someone will be immune from prosecution in certain circumstances, it does set out a long list of factors tending in favour of and against prosecution.

Factors tending in favour of prosecution include the victim being under 18, the victim lacking capacity, the suspect standing to gain from the death and (of particular importance from your perspective) the suspect acting in a professional capacity such as being a doctor, nurse or other healthcare professional. Factors tending against prosecution include the victim having reached a voluntary, clear, settled and informed decision to commit suicide, the suspect having acted wholly motivated by compassion and the suspect reporting the suicide to Police and fully assisting Police enquiries.

What does the GMC say about assisted suicide?

In May 2010 the GMC published its own guidance Treatment and Care Towards the End of Life: Good Practice in Decision Making. This makes clear that “an act by which the doctor’s primary intention is to bring about a patient’s death would be unlawful” and “decisions concerning treatment must start from a presumption in favour of prolonging life”.

The guidance is otherwise silent on the issue of assisted suicide, save to highlight that there is “no defence of mercy killing or euthanasia in English law”. The GMC expects doctors to act within the law at all times and therefore, when patients raise the issue of assisted suicide, to explain that they cannot discuss it in case that discussion could be construed as them committing a criminal offence. Such refusals are difficult to impart without leaving patients feeling abandoned or compromising your obligation to act with compassion. Further helpful guidance is available from the NHS National End of Life Care Programme.

The Nicklinson and ‘Martin’ cases

Few will be unaware of the story of Tony Nicklinson, who died on 22 August aged 58. Nicklinson was an athletic, outgoing man until he suffered a catastrophic stroke in 2005, which resulted in him suffering from ‘locked-in syndrome’. He pursued legal proceedings seeking either (i) a declaration that it would be lawful for his GP, or another doctor, to terminate his life or (ii) a declaration that the law on murder and/or assisted suicide as it stands contravened his right to respect for private life until Article 8 of the European Convention on Human Rights (ECHR).

Nicklinson’s legal proceedings were joined with those of ‘Martin’ (not his real name). Martin, age 47, suffered a catastrophic stroke in 2008 which left him with only slightly more functionality than Nicklinson. He sought an order that the Director of Public Prosecutions should clarify the policy on prosecutions for encouraging or assisting suicide so that persons outside Martin’s family, such as doctors or solicitors, who would be willing to assist Martin to commit suicide, would know in advance whether they would be likely to face criminal prosecution. In the alternative, if Martin failed in his claim against the Director of Public Prosecutions, he wanted a declaration that Section 2 of the Suicide Act is incompatible with Article 8 of the ECHR.

Whilst the cases attracted widespread media attention, there was little mention of the fact that the GMC was named as a Defendant to the proceedings alongside the Director of Public Prosecutions, Solicitors Regulation Authority and Ministry of Justice. In relation to the GMC, Martin specifically sought a declaration that a doctor who played a part in helping him to commit suicide should not be exposed to the risk of professional disciplinary proceedings.

Outcome

Both Nicklinson’s and Martin’s claims failed. Although the GMC defended the claim against it, unfortunately the court did not go so far as to set out or comment upon the terms of the GMC’s defence. As the court held that it would be wrong for it to depart from the long-established position that voluntary euthanasia is murder, that Article 8 of the ECHR did not afford a possible defence to murder and that the DPP was not obliged to publish any further clarification of its policy on prosecutions following suicide, it stated simply that it followed the claim against the GMC also failed.

In a statement issued following the case, the GMC clarified that, in its view, “it is not part of the GMC’s role to take a view on whether the law should be changed - that is a matter for Parliament to determine”.

Of note, the GMC also stated that it is currently working on guidance for its case examiners (the people who decide how fitness to practise complaints against doctors should be dealt with) to help them decide what action to take if a doctor is alleged to have assisted or encouraged a suicide.  The guidance is expected by late 2012.

Sadly, Tony Nicklinson died of natural causes within days of the judgment. However, Martin’s case goes on. On the day of Nicklinson’s death, his solicitors confirmed that he will appeal the judgment to the Court of Appeal.

Conclusion

As at the date of writing, (October 2012), it remains a criminal offence to encourage or assist the suicide of another person. Being a doctor or other healthcare professional makes it especially likely that you will fact prosecution if you do encourage or assist a suicide. The GMC is clear that doctors must act within the law, whatever that says about suicide, and that any doctor convicted of a serious criminal offence is likely to be erased from the medical register.

Andrea James is Head of Healthcare Regulatory at George Davies Solicitors LLP, former in-house solicitor to the General Medical Council and specialises in defending healthcare professionals. For further information click here.

‘Locked-in’ man to have right-to-die case heard

BBC Health - 12th March 2012 12:35 pm

Tony Nicklinson, who is paralysed and wants a doctor to be able to lawfully end his life, should be allowed to proceed with his “right-to-die” case, a High Court judge has ruled.

The 58-year-old from Melksham, Wiltshire, has “locked-in syndrome” following a stroke in 2005 and is unable to carry out his own suicide.

His is seeking legal protection for any doctor who helps him end his life.

Read more at BBC Health.

Assisted suicide: “Strong case for legalisation”

BBC Health - 5th January 2012 2:31 pm

There is a “strong case” for allowing assisted suicide for people who are terminally ill in England and Wales, a group of experts says.

The Commission on Assisted Dying - set up and funded by campaigners who want to see a change in the law - said the current system was “inadequate”.

It said it was possible to allow assisted dying within a strict set of rules to ensure it was not abused. But the report has had a mixed response. Critics say it is biased.

The commission was chaired by Lord Falconer, a barrister and former justice secretary, and included a wide range of experts including doctors, an ex-police commissioner and a former president of the GMC.

Read more at BBC Health.

Top surgeon offers support to right-to-die campaign

PA - 11th January 2011 9:57 pm

One of the UK’s top surgeons has backed the right-to-die campaign by insisting that he would be willing to help terminally ill patients end their lives.

Sir Terence English, who performed the UK’s first heart transplant, has offered his support to an influential steering committee that backs assisted dying.

Sir Terence told The Sunday Times: “A doctor has responsibility first to the patient and, if I knew that patient was terminally ill, was of sound mind and hadn’t been got at by friends and relatives, I would be prepared to assist him or her.”

His comments come after director of public prosecutions Keir Starmer last year clarified the legal position on assisted dying. The move was interpreted by many as a clear indication that friends and family were unlikely to face prosecution if motivated by compassion to help a relative or close friend with a “clear, settled and informed” wish to die.

Read more at Press Association.

Religious beliefs shape end-of-life decisions

By Mike Broad - 27th August 2010 12:16 pm

Atheist or agnostic doctors are almost twice as willing to take decisions that they think will hasten the end of a very sick patient’s life as doctors who are deeply religious, research reveals.

The study in the Journal of Medical Ethics also suggests that doctors with a strong faith are less likely to discuss this type of treatment with the patient concerned.

Nearly 4,000 doctors responded to the survey and they were asked about the care of their last patient who died, if relevant, including whether they had provided continuous deep sedation until death, whether they had discussed decisions judged likely to shorten life with the patient, their own religious beliefs, ethnicity, and their views on assisted dying/euthanasia.

The specialties targeted included those in which end of life decisions would be particularly likely to arise, such as neurology, elderly care, palliative care, intensive care and hospital specialties, and general practice.

Specialists in the care of the elderly were somewhat more likely to be Hindu or Muslim, while palliative care doctors were somewhat more likely than other doctors to be Christian, white, and agree that they were “religious”.

But, overall, white doctors, who comprised the largest ethnic group among the respondents, were the least likely to report strong religious beliefs.

Ethnicity was largely unrelated to rates of reporting ethically controversial decisions, although it was related to support for assisted dying/euthanasia legislation.

Specialty was strongly related to whether a doctor reported having taken decisions, expected or partly intended to, end life. Doctors in hospital specialties were almost 10 times as likely to report this as palliative care specialists.

But irrespective of specialty, doctors who described themselves as “extremely” or “very non-religious” were almost twice as likely to report having taken these kinds of decisions as those with a religious belief.

The most religious doctors were significantly less likely to have discussed end of life care decisions with their patients than other doctors.

These attitudes were reflected in support for assisted dying/euthanasia legislation, with palliative care specialists and those with a strong faith more strongly opposed to it. Asian and white doctors were less opposed to such legislation than doctors from other ethnic groups.

The author Professor Clive Seale, from Barts and The London School of Medicine and Dentistry, concludes that the relationship between doctors’ values and their clinical decision making needs to be acknowledged much more than it is at present.

He said: “One potential response to the findings about the influence of religious faith is to suggest, as other have done, that religious doctors disclose their moral objections to certain procedures to patients so that patients can choose other doctors if they wish. This assumes that religiosity is the ‘exception’ to be set against the non-religious ‘norm’. It is equally plausible to argue that non-religious doctors should confess their predilections to their patients.

“After all, the data show some religious faith is held to by almost half of the medical population and approximately two-fifths of the general population. Whether religious or non-religious, it would seem advisable that doctors become more aware of how broader sets of values, such as those associated with religiosity or a non-religious outlook, may enter into their decision-making in end-of-life care.”

Read the full study.

Doctors risk prosecution over assisted suicide

By Mike Broad - 3rd March 2010 2:13 pm

Doctors face a greater risk of prosecution for assisting a patient’s suicide following new guidance, defence body MPS has warned.

The director of public prosecutions, Keir Starmer QC, has created six mitigating factors against an individual being prosecuted for assisting the suicide of another.

However, the MPS warned doctors to be extremely cautious when providing help or advice to patients who are considering assisted suicide.

The guidance, called Policy for prosecutors in respect of cases of encouraging or assisting suicide, includes a specific reference to the suspect acting as a doctor, nurse or other health professional as a factor in favour of prosecution.

In the interim policy, a suspect providing assistance to a victim in the course of their usual job was a factor against prosecution. This has been deleted from the final copy, which is now effective.

Dr Nick Clements, head of medical services (Leeds) at MPS, welcomed the clarification into the factors that will be taken into consideration when deciding whether to prosecute cases.

But he added: “We believe that the final policy on assisted suicide places doctors in a much more risky position than before. While we recognise that the law on assisted suicide has not changed, the factors for and against prosecution send a clear signal that the actions of health professionals will be carefully scrutinised and may well set a lower threshold for bringing prosecution against them.”

The MPS is concerned that doctors could face prosecution who were involved quite indirectly in an assisted suicide.

He said: “For instance, we have been contacted by doctors whose patients have requested medical or fitness to travel reports so that they can gain access to clinics such as Dignitas.

“The patient may not have initially made it clear to their doctor why they wish to have these reports but the doctor may harbour a suspicion. A doctor who helps a patient with these requests may leave themselves open to a criminal investigation and prosecution.”

Doctors are being advised by defence bodies to not to comply with requests for medical or travel reports if they suspect the patient may be planning an assisted suicide. The MPS is calling for greater clarity around the position of doctors. 

Read the full document.