BMJ 2014;349:g4311 doi: 10.1136/bmj.g4311 (Published 3 July 2014)
Page 1 of 2
Observations
OBSERVATIONS ASSISTED DYING BILL
We must not deprive dying people of the most important protection A response to Ray Tallis Rob George professor of palliative care, Cicely Saunders Institute, King’s College London, and consultant physician in palliative care, Guy’s & St Thomas’ Hospitals NHS Foundation Trust, London Legalising medical treatment intended to end life is a momentous step: it alters the very nature of medicine at a stroke. The compelling logic is that once a doctor is mandated to end a life in that person’s best interest, then anyone, as equal before the law, is entitled to make the case for a death, on the basis of notions of best interest, suffering, or a worthwhile life. In his recent article supporting Charles Falconer’s Assisted Dying Bill, Ray Tallis correctly argued that the chief areas for debate were the position of “assisted dying” in the spectrum of possible lethal interventions, the involvement of doctors, and safeguards against misuse or well intentioned error, but his conclusions were wrong.1
“Assisted dying” is meaningless
Tallis may remember from clinical practice that individual prognostication, even in diseases such as cancer, is at best an estimate. Uncertainty continues even to the last days of life.2 I well recall my dementing father, and currently my mother, being “on the brink of dying” for years. When death came, the clinical indices were no different from the countless “dry runs.”3 Complex studies of comorbidities indicate that survival relates as much to toughness as anything.4 As Tallis said, in US states such as Oregon mentally competent adults with a prognosis of less than six months to live can take prescribed, life ending drugs. But after 2005 Oregon stopped reporting how many people who delayed suicide passed the six month survival point. Indeed, annual reports from 2000 give the maximum survival among people who delayed suicide as ranging from 10 months to 2.7 years.5 We can define dying to start wherever we wish. As the House of Lords has already said, “[Assisted dying is] either over-euphemistic or inaccurate (or both) . . . we have used the term ‘assisted suicide’ to mean providing someone with the means to end his or her own life.”6 “Assisted dying” is meaningless, but it is necessary so as to medicalise “assisted suicide” and present it as circumscribed. However, the moral distinction between actions lies in the difference in intent. I see no difference ethically between
prescribing an antibiotic and administering it in an injection. What counts is the decision that the infection ought to be treated, not how. Why should it be any different in making lethal decisions? Should ending a life become legal, it is clinical common sense that there would be no arbitrary line between means of delivery. Early Dutch studies reported that doctors preferred euthanasia to assisted suicide to ensure that death was achieved effectively.7 The ratio of cases of euthanasia to those of assisted suicide rose from 141:18 in 1990 to 475:21 in 2010.8 Prescribing lethal drugs prophylactically for what Falconer’s bill proposes is necessarily on a continuum with euthanasia. Therefore, it is legitimate, if not obligatory, in examining the hazards of doctors having the legal protection to end people’s lives to scrutinise the data and experiences of every legislature that permits lethal interventions and look for risks or failures irrespective of the form the lethal act takes.
The role of doctors I agree that reasons for wanting a lethal solution go far beyond poor symptom management. Views on suffering and the value of continuing to live are moral, psychological, social, and spiritual. So what special authority does a doctor have to adjudicate? Since we agree that a person’s best interests are not solely medical, prognosis is at best an estimate,2-4 and because, as in Switzerland, providing lethal means needs only a protocol, I see no reason why a doctor should be involved at all—other than to make society feel better. The categorical separation must remain in the clear and unambiguous duty of clinicians not to end life and to mitigate suffering, through symptom management, and helping people to complete key tasks, reconcile relationships, and achieve personal resolution.
Safeguards Tallis offered no evidence to support his counterclaim that “under an assisted dying law no more people would die but
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Subscribe: http://www.bmj.com/subscribe
BMJ 2014;349:g4311 doi: 10.1136/bmj.g4311 (Published 3 July 2014)
Page 2 of 2
OBSERVATIONS
fewer people would suffer.” For example, Falconer’s bill, counter to Tallis’s claim, has no obligation for psychiatric assessment. Severe mental illnesses can coexist with mental capacity, yet the bill makes only a passing mention in relation to “possible codes of practice.”9 (Section 3(b) of the bill refers only to cognitive capacity, which is subject to the Mental Capacity Act 2005. Severe mental health, subject to the Mental Health Act, is mentioned only in relation to possible codes of practice at section 8(1)(a)(ii).) Such issues are widespread and often overlooked in Oregon, despite explicit provision in the state’s law.10 11 Societies may form laws, but laws mould society, and unintended consequences are easily overlooked. Elizabeth Butler-Sloss, former president of the High Court, said, “Laws, like nation states, are more secure when their boundaries rest on natural frontiers. The law that we have rests on just such a frontier . . . The law is there to protect us all. We tinker with it at our peril.”12
Today I see dying people treated as second class citizens in the NHS, as the recent national care of the dying audit and Julia Neuberger’s review showed.13 14 For this ostensibly inconvenient and burdensome group of patients, the most important protection enjoyed by all under the law—that they will not be subject to lethal acts—must be preserved. For me the real question is this: “Which is worse: not to kill people who want to die or to kill people who might want still to live?” In my experience it is impossible to separate those who might want to die from those who believe they ought to die and whose view is pretty well never “settled.” No one can be sure that some people not now at risk will find themselves so were the law to change.15 A full blooded expression of autonomy includes the responsibility at times to restrain oneself on behalf of another: when it comes to having our lives ended, let’s keep it that way. Once this line is crossed there is no going back.
Competing interests: I have been quoted by the group Care Not Killing and have represented it on occasion where our views coincide but am not a member of it. Provenance and peer review: Not commissioned; not peer reviewed. thebmj.com Observations: Assisted dying is not the same as euthanasia. BMJ 2014;348:g3532, doi:10.1136/bmj.g3532. 1 2 3 4 5 6 7 8
9 10 11 12 13 14 15
Tallis R. Assisted dying is not the same as euthanasia. BMJ 2014;348:g3532. Glare P, Sinclair C, Downing M, Stone P, Maltoni M, Vigano A. Predicting survival in patients with advanced disease. Eur J Cancer 2008;44:1146-56. Coventry PA, Grande GE, Richards DA, Todd CJ. Prediction of appropriate timing of palliative care for older adults with non-malignant life-threatening disease: a systematic review. Age Ageing 2005;34:218-27. Goeman JJ, Le Cessie S, Baatenburg de Jong RJ, van de Geer SJ. Predicting survival using disease history: a model combining relative survival and frailty. Statistica Neerlandica 2004;58:21-34. Oregon Health Authority. Death with Dignity Act annual reports. http://public.health.oregon. gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Pages/ar-index. aspx. House of Lords. Assisted Dying for the Terminally Ill Bill first report. 2005. www. publications.parliament.uk/pa/ld200405/ldselect/ldasdy/86/8602.htm. Groenewoud JH, van der Heide A, Onwuteaka-Philipsen BD, Willems DL, van der Maas PJ, van der Wal G. Clinical problems with the performance of euthanasia and physician-assisted suicide in the Netherlands [comment]. New Engl J Med 2000;342:551-6. Onwuteaka-Philipsen BD, Brinkman-Stoppelenburg A, Penning C, de Jong-Krul GJF, van Delden JJM, van der Heide A. Trends in end-of-life practices before and after the enactment of the euthanasia law in the Netherlands from 1990 to 2010: a repeated cross-sectional survey. Lancet 2012;380:908-15. HM Government. Assisted Dying Bill [HL] 2013-1 4. http://services.parliament.uk/bills/ 2013-14/assisteddying.html. Hendin H, Foley K. Physician-assisted suicide in Oregon: a medical perspective. Mich Law Rev 2008;106:1613-40. Ganzini L, Goy ER, Dobscha SK. Prevalence of depression and anxiety in patients requesting physicians’ aid in dying: cross sectional survey. BMJ 2008;337:a1682. Butler-Schloss E. We legalise “assisted dying” at our peril. Telegraph 14 Dec 2013. www. telegraph.co.uk/health/elderhealth/10517890/We-legalise-assisted-dying-at-our-peril.html. Royal College of Physicians. National care of the dying audit of hospitals. 2014. https:// www.rcplondon.ac.uk/resources/national-care-dying-audit-hospitals. Independent Review of the Liverpool Care Pathway. More care less pathway: a review of the Liverpool care pathway for the dying. https://www.gov.uk/government/uploads/ system/uploads/attachment_data/file/212450/Liverpool_Care_Pathway.pdf. Beckford M. Baroness Warnock: Dementia sufferers may have a “duty to die.” Telegraph 18 Sep 2008. www.telegraph.co.uk/news/uknews/2983652/Baroness-Warnock-Dementiasufferers-may-have-a-duty-to-die.html.
Cite this as: BMJ 2014;349:g4311 © BMJ Publishing Group Ltd 2014
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
Copyright of BMJ: British Medical Journal is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Page 1 of 2
Observations
OBSERVATIONS ASSISTED DYING BILL
We must not deprive dying people of the most important protection A response to Ray Tallis Rob George professor of palliative care, Cicely Saunders Institute, King’s College London, and consultant physician in palliative care, Guy’s & St Thomas’ Hospitals NHS Foundation Trust, London Legalising medical treatment intended to end life is a momentous step: it alters the very nature of medicine at a stroke. The compelling logic is that once a doctor is mandated to end a life in that person’s best interest, then anyone, as equal before the law, is entitled to make the case for a death, on the basis of notions of best interest, suffering, or a worthwhile life. In his recent article supporting Charles Falconer’s Assisted Dying Bill, Ray Tallis correctly argued that the chief areas for debate were the position of “assisted dying” in the spectrum of possible lethal interventions, the involvement of doctors, and safeguards against misuse or well intentioned error, but his conclusions were wrong.1
“Assisted dying” is meaningless
Tallis may remember from clinical practice that individual prognostication, even in diseases such as cancer, is at best an estimate. Uncertainty continues even to the last days of life.2 I well recall my dementing father, and currently my mother, being “on the brink of dying” for years. When death came, the clinical indices were no different from the countless “dry runs.”3 Complex studies of comorbidities indicate that survival relates as much to toughness as anything.4 As Tallis said, in US states such as Oregon mentally competent adults with a prognosis of less than six months to live can take prescribed, life ending drugs. But after 2005 Oregon stopped reporting how many people who delayed suicide passed the six month survival point. Indeed, annual reports from 2000 give the maximum survival among people who delayed suicide as ranging from 10 months to 2.7 years.5 We can define dying to start wherever we wish. As the House of Lords has already said, “[Assisted dying is] either over-euphemistic or inaccurate (or both) . . . we have used the term ‘assisted suicide’ to mean providing someone with the means to end his or her own life.”6 “Assisted dying” is meaningless, but it is necessary so as to medicalise “assisted suicide” and present it as circumscribed. However, the moral distinction between actions lies in the difference in intent. I see no difference ethically between
prescribing an antibiotic and administering it in an injection. What counts is the decision that the infection ought to be treated, not how. Why should it be any different in making lethal decisions? Should ending a life become legal, it is clinical common sense that there would be no arbitrary line between means of delivery. Early Dutch studies reported that doctors preferred euthanasia to assisted suicide to ensure that death was achieved effectively.7 The ratio of cases of euthanasia to those of assisted suicide rose from 141:18 in 1990 to 475:21 in 2010.8 Prescribing lethal drugs prophylactically for what Falconer’s bill proposes is necessarily on a continuum with euthanasia. Therefore, it is legitimate, if not obligatory, in examining the hazards of doctors having the legal protection to end people’s lives to scrutinise the data and experiences of every legislature that permits lethal interventions and look for risks or failures irrespective of the form the lethal act takes.
The role of doctors I agree that reasons for wanting a lethal solution go far beyond poor symptom management. Views on suffering and the value of continuing to live are moral, psychological, social, and spiritual. So what special authority does a doctor have to adjudicate? Since we agree that a person’s best interests are not solely medical, prognosis is at best an estimate,2-4 and because, as in Switzerland, providing lethal means needs only a protocol, I see no reason why a doctor should be involved at all—other than to make society feel better. The categorical separation must remain in the clear and unambiguous duty of clinicians not to end life and to mitigate suffering, through symptom management, and helping people to complete key tasks, reconcile relationships, and achieve personal resolution.
Safeguards Tallis offered no evidence to support his counterclaim that “under an assisted dying law no more people would die but
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;349:g4311 doi: 10.1136/bmj.g4311 (Published 3 July 2014)
Page 2 of 2
OBSERVATIONS
fewer people would suffer.” For example, Falconer’s bill, counter to Tallis’s claim, has no obligation for psychiatric assessment. Severe mental illnesses can coexist with mental capacity, yet the bill makes only a passing mention in relation to “possible codes of practice.”9 (Section 3(b) of the bill refers only to cognitive capacity, which is subject to the Mental Capacity Act 2005. Severe mental health, subject to the Mental Health Act, is mentioned only in relation to possible codes of practice at section 8(1)(a)(ii).) Such issues are widespread and often overlooked in Oregon, despite explicit provision in the state’s law.10 11 Societies may form laws, but laws mould society, and unintended consequences are easily overlooked. Elizabeth Butler-Sloss, former president of the High Court, said, “Laws, like nation states, are more secure when their boundaries rest on natural frontiers. The law that we have rests on just such a frontier . . . The law is there to protect us all. We tinker with it at our peril.”12
Today I see dying people treated as second class citizens in the NHS, as the recent national care of the dying audit and Julia Neuberger’s review showed.13 14 For this ostensibly inconvenient and burdensome group of patients, the most important protection enjoyed by all under the law—that they will not be subject to lethal acts—must be preserved. For me the real question is this: “Which is worse: not to kill people who want to die or to kill people who might want still to live?” In my experience it is impossible to separate those who might want to die from those who believe they ought to die and whose view is pretty well never “settled.” No one can be sure that some people not now at risk will find themselves so were the law to change.15 A full blooded expression of autonomy includes the responsibility at times to restrain oneself on behalf of another: when it comes to having our lives ended, let’s keep it that way. Once this line is crossed there is no going back.
Competing interests: I have been quoted by the group Care Not Killing and have represented it on occasion where our views coincide but am not a member of it. Provenance and peer review: Not commissioned; not peer reviewed. thebmj.com Observations: Assisted dying is not the same as euthanasia. BMJ 2014;348:g3532, doi:10.1136/bmj.g3532. 1 2 3 4 5 6 7 8
9 10 11 12 13 14 15
Tallis R. Assisted dying is not the same as euthanasia. BMJ 2014;348:g3532. Glare P, Sinclair C, Downing M, Stone P, Maltoni M, Vigano A. Predicting survival in patients with advanced disease. Eur J Cancer 2008;44:1146-56. Coventry PA, Grande GE, Richards DA, Todd CJ. Prediction of appropriate timing of palliative care for older adults with non-malignant life-threatening disease: a systematic review. Age Ageing 2005;34:218-27. Goeman JJ, Le Cessie S, Baatenburg de Jong RJ, van de Geer SJ. Predicting survival using disease history: a model combining relative survival and frailty. Statistica Neerlandica 2004;58:21-34. Oregon Health Authority. Death with Dignity Act annual reports. http://public.health.oregon. gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Pages/ar-index. aspx. House of Lords. Assisted Dying for the Terminally Ill Bill first report. 2005. www. publications.parliament.uk/pa/ld200405/ldselect/ldasdy/86/8602.htm. Groenewoud JH, van der Heide A, Onwuteaka-Philipsen BD, Willems DL, van der Maas PJ, van der Wal G. Clinical problems with the performance of euthanasia and physician-assisted suicide in the Netherlands [comment]. New Engl J Med 2000;342:551-6. Onwuteaka-Philipsen BD, Brinkman-Stoppelenburg A, Penning C, de Jong-Krul GJF, van Delden JJM, van der Heide A. Trends in end-of-life practices before and after the enactment of the euthanasia law in the Netherlands from 1990 to 2010: a repeated cross-sectional survey. Lancet 2012;380:908-15. HM Government. Assisted Dying Bill [HL] 2013-1 4. http://services.parliament.uk/bills/ 2013-14/assisteddying.html. Hendin H, Foley K. Physician-assisted suicide in Oregon: a medical perspective. Mich Law Rev 2008;106:1613-40. Ganzini L, Goy ER, Dobscha SK. Prevalence of depression and anxiety in patients requesting physicians’ aid in dying: cross sectional survey. BMJ 2008;337:a1682. Butler-Schloss E. We legalise “assisted dying” at our peril. Telegraph 14 Dec 2013. www. telegraph.co.uk/health/elderhealth/10517890/We-legalise-assisted-dying-at-our-peril.html. Royal College of Physicians. National care of the dying audit of hospitals. 2014. https:// www.rcplondon.ac.uk/resources/national-care-dying-audit-hospitals. Independent Review of the Liverpool Care Pathway. More care less pathway: a review of the Liverpool care pathway for the dying. https://www.gov.uk/government/uploads/ system/uploads/attachment_data/file/212450/Liverpool_Care_Pathway.pdf. Beckford M. Baroness Warnock: Dementia sufferers may have a “duty to die.” Telegraph 18 Sep 2008. www.telegraph.co.uk/news/uknews/2983652/Baroness-Warnock-Dementiasufferers-may-have-a-duty-to-die.html.
Cite this as: BMJ 2014;349:g4311 © BMJ Publishing Group Ltd 2014
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
Copyright of BMJ: British Medical Journal is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
