Assisted dying

MOST of us tend to assume that the British Medical Journal acts as a mouthpiece for the policies of the British Medical Association. It is after all a wholly owned subsidiary. Yet recently the Chair of the BMA was at pains to point out that the BMJ “quite rightly has editorial independence”.

The reason behind this statement was a clash of opinion over the divisive issue of assisted dying.

In July of this year the Assisted Dying Bill – sponsored by Lord Falconer of Thornton – had its second reading in the House of Lords. The bill would allow terminally ill patients to seek medical assistance to end their lives. In an editorial published in advance of the debate, BMJ UK editor Tony Delamothe along with patient editor Rosamond Snow and editor-in-chief Fiona Godlee expressed their hopes that the bill eventually becomes law.

This prompted a statement from Dr Mark Porter, Chair of BMA Council, who said: “There are strongly held views within the medical profession on both sides of this complex and emotive issue. The BMA remains firmly opposed to legalising assisted dying. This issue has been regularly debated at the BMA’s policy forming annual conference and recent calls for a change in the law have persistently been rejected.

“Its [the BMJ’s] position on assisted dying is an editorial decision and does not reflect the views of the BMA or the medical profession. Our focus must be on making sure every patient can access the very best of palliative care, which empowers patients to make decisions over their care.”

Lord Falconer’s bill would apply only to patients aged 18 years or older who are expected to die within six months. The process would require a “clear and settled intention” and would be dependent upon a request being made by the person concerned and no one else, including doctor, family or partner.

Only patients resident in England and Wales for at least one year would be eligible under the bill: no one would be allowed to travel to these countries for assisted death. A patient would be required to sign a declaration in the presence of an independent witness and this would need to be countersigned by two physicians – one being an “attending doctor,” usually the patient’s GP or consultant, and the other being an “independent doctor” from a different practice or clinical team.

Both doctors would need to examine the patient and agree on the prognosis as well as their capacity to make a decision to end their own life. The doctors would also need to judge that the decision was voluntary and fully informed. Only then would the attending doctor write a prescription for the necessary medication to be supplied after a 14-day “cooling off” period (or six days if the patient is expected to die within the month).

The patient would have to self-administer the medication (a crucial difference between assisted dying and voluntary euthanasia), either orally or by a syringe driver or other delivery mechanism. An assisting healthcare professional could lawfully put the medication in the syringe but the patient would need to take the final act in ending their life.

The BMA’s policy on assisted dying is published on its website. Among the key reasons it opposes the proposed law is the worry that legalising assisted dying would weaken society’s prohibition on killing and undermine the safeguards against nonvoluntary euthanasia. “Society could embark on a ‘slippery slope’ with undesirable consequences.”

The policy also reflects concerns that assisted dying could put vulnerable people at risk of harm through coercion by relatives or even by the medical establishment in an overstretched NHS. Even more fundamentally the BMA feels that such a change would be contrary to the ethics of clinical practice which is to improve quality of life and “not to foreshorten it”. It believes that effective and high-quality palliative care can alleviate distressing symptoms associated with the dying process and allay most patients’ fears.

But to the BMJ editors it is primarily a question of patient autonomy. In their editorial they write: “People should be able to exercise choice over their lives, which should include how and when they die, when death is imminent. In recent decades, respect for autonomy has emerged as the cardinal principle in medical ethics and underpins developments in informed consent, patient confidentiality, and advance directives.”

Countering claims that such a policy might make assisted dying routine, they point to experience from US state Oregon where a similar law has operated for the last 17 years. Assisted deaths accounted for 2.2 per 1,000 of total deaths in the state last year. Extrapolating that data to England and Wales they estimate that a general practice of 9,300 patients would issue one prescription for life-ending medication every five or six years, with only one patient actually taking such medication every eight to nine years.

They believe that Lord Falconer’s bill offers sufficient safeguards to protect against coercion or abuse and the difficulties in assessing capacity. But their views are in the minority among the medical establishment. In addition to the BMA, other institutions opposed to a change in the law include the Royal College of General Practitioners, the Royal College of Surgeons and the Royal College of Physicians.

The bill has a long way to go until it reaches a vote in the House of Commons and that will not likely occur until after the next general election. But it is certainly an issue to watch.

Jim Killgore is an associate editor of GPST