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Editorial

No more physician in physicianassisted suicide Tim Harlow Physician-assisted suicide (PAS) is an important subject internationally and receives much attention. Some jurisdictions including the Netherlands, Belgium, Luxembourg, Switzerland and four American States (Oregon, Montana, Vermont and Washington), have legalised PAS. In the UK, Euthanasia and Assisted Suicide are both illegal, but debate about whether this should change is very much alive. Legislation for PAS has been proposed in Scotland under its devolved powers,1 and most recently by Lord Falconer’s Assisted Dying bill in England and Wales.2 This latest bill ran out of Parliamentary time, but is likely to be the basis for future attempts to change the law on PAS. In its April 2015 election manifesto, The Green Party has included a commitment to ‘Provide the right to an assisted death’, confirming that this is a mainstream issue.3 Opinion polls in the UK show public support for a change in the law to allow PAS, most recently 82% either somewhat or strongly in favour of Assisted Dying.4 PAS and its interaction with palliative care is a hot topic in Europe, with calls for doctors in palliative care to be clear in their views and to communicate these views. There are questions about how clearly the diversity of opinion in the European Association for Palliative Care has been represented.5 There have been calls for UK doctors to make their concerns about PAS very clear.6 The clear opinions of UK doctors seem very different to those of the general public reported above. The British Medical Association (BMA) has been opposed to a change in the

Correspondence to Dr Tim Harlow, Hospiscare, Dryden Road, Exeter EX2 5JJ, UK; [email protected]

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law to allow PAS since 2006 and this year reaffirmed this policy.7 In 2013, The Royal College of General Practitioners surveyed its members and found 77% against a change in the law to allow PAS.8 Last year, the Royal College of Physicians of London survey showed only 32% in favour of changing the law.9 The Association for Palliative Medicine (APM) represents over 1000 doctors working in palliative medicine in the UK and Ireland: it has long been opposed to PAS. With the bills in Westminster and Edinburgh making a change in the law a real possibility, it was important for the APM to know its members’ views. In December 2014, a survey was sent to all 996 members for whom there were up to date contact details. Members had four weeks to return this survey, which yielded a 39% completion rate. The Executive Committee decided to focus on three clear aspects. First, did members support the proposal in Lord Falconer’s bill to allow PAS to those with a prognosis of less than 6 months? Second, did members think that Assisted Suicide should be part of routine medical practice or should it be outside medicine completely, perhaps in the court? Third, if such a bill allowing PAS became law, how many members would be prepared to actually participate in its implementation? Until now, there has been little real consideration as to what extent doctors should be involved in PAS; their involvement appears to have largely been implicit or assumed. Thus the survey was not a purely theoretical exercise examining an intellectual idea, it was asking concrete questions about a real proposal. It was also important to understand if members’ views changed with

seniority or the length of time in the specialty, so basic data about this were gathered and showed no such variation. This was essentially a survey of opinion, but the survey included space for free text comments as well. The results were clear as well as fascinating. The views are relevant to the wider debate on changing the law to allow PAS, certainly in the UK but perhaps elsewhere, and also, specifically, to what extent doctors either should or would be involved if the law did change.10 A clear majority (82%) of APM members were against a change in the law to allow PAS. The same proportion (82%) thought that if Assisted Suicide was legalised it should be wholly outside the province of medicine, perhaps with the family courts. Only 4% were prepared to be involved personally in assisting suicide. Changes to the law in the UK are a matter for Parliaments and it has been argued that doctors should simply keep out of the debate as we are nothing but a self-interested party.11 I disagree: our justification is our concerns, as experts in the care of the dying, for our patients’ interests. As doctors in palliative care, we have two good reasons to contribute legitimately to this debate. First, doctors in palliative care spend their working lives with precisely the patients for whom PAS is suggested—those with a limited prognosis (whatever the limitations of that statement). This means that we understand the pressures that this group feels and we sense the distress and pain of various sorts that they live through. So ours is neither a detached, nor an uninformed view. We witness daily the real pressures that we are concerned may influence people’s decisions to seek PAS, and the fluctuating nature of their lives as they try to live until they die. We are worried about the very real potential for normalising something that is not, and should not be considered, normal and should not be a part of routine medical practice. Legalisation of PAS by the recent bill

Harlow T. BMJ Supportive & Palliative Care 2015;5:122–123. doi:10.1136/bmjspcare-2015-000915

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Editorial before Parliament was intended to allow a very small minority—around 1100 deaths out of 500 000 per year in the UK—suggested by the Oregon experience on which this bill was modelled.12 We have even greater concerns about the paucity of safeguards. There are eligibility criteria in Lord Falconer’s Bill, but even the many amendments would have offered no convincing protection from coercion (at an individual or at a societal level) or reversible cause for the wish for PAS. All human constructs are fallible, and so we should not be surprised that really good safeguards should be so difficult, perhaps illusory. Even Oregon psychiatrists have little faith in their own ability to spot psychiatric influences on PAS requests.13 Second, doctors have a right, indeed a responsibility, to say whether they would or would not be prepared to be involved in implementing PAS. Having doctors involved provides no real safeguards, but might offer to society a comforting illusion of security.6 Yet of those very doctors who should see the case for PAS most clearly and are most closely involved with the dying, only 4% would be prepared actually to implement PAS.

Doctors should not be prepared to accept having the responsibility for something that makes others feel more comfortable and which we profoundly distrust and disagree with foisted on us by legislation. If society really does wish to legalise Assisted Suicide, against the better judgement of the medical profession, then society must carry the responsibility. Our skill and duty is in healing. It must be a matter for the courts and not for doctors to decide who is to be assisted to take their own life and to implement that decision. Acknowledgements These are my opinions but I thank Idris Baker, Rachel Bullock, Paul Clark, Craig Gannon, Rob George, Guy Schofield and Derek Willis for their contributions. Competing interests TH is a member of the BMA, member of Association for Palliative Medicine and chairs its ethics committee. Provenance and peer review Not commissioned; internally peer reviewed.

To cite Harlow T. BMJ Supportive & Palliative Care

REFERENCES 1 http://www.scottish.parliament.uk/ parliamentarybusiness/Bills/69604.aspx 2 http://services.parliament.uk/bills/201314/assisteddying.html 3 https://www.greenparty.org.uk/we-standfor/2015-manifesto.html 4 http://www.populus.co.uk/Poll/Dignityin-Dying/ 5 Materstvedt LJ. Palliative care and euthanasia: what is the view of the EAPC? BMJ Support Palliat Care 2014;4:124–5. 6 Noble B. Republished: legalising assisted dying puts vulnerable patients at risk and doctors must speak up. BMJ Support Palliat Care 2013;3:298–9. 7 http://bma.org.uk/practical-support-atwork/ethics/bma-policy-assisted-dying 8 http://www.rcgp.org.uk/news/2014/ february/rcgp-remains-opposed-to-anychange-in-the-law-on-assisted-dying. aspx 9 https://www.rcplondon.ac.uk/pressreleases/rcp-reaffirms-position-againstassisted-dying 10 apmonline.org 11 Joffe L. Letters to the editor. The Times 6 April 2015. 12 Oregon Public Health Division Report, Death with Dignity Act year 17. 13 Ganzini L, Fenn DS, Lee MA, et al. Attitudes of Oregon psychiatrists toward physician-assisted suicide. Am J Psychiatry 1996;153:1469–75.

2015;5:122–123. Received 30 April 2015 Accepted 1 May 2015

Harlow T. BMJ Supportive & Palliative Care 2015;5:122–123. doi:10.1136/bmjspcare-2015-000915

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No more physician in physician-assisted suicide Tim Harlow BMJ Support Palliat Care 2015 5: 122-123

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