A senior doctor explains that there is now widespread acceptance among all types of clinicians towards assisted dying, but the most important issue remains safeguarding.
The Terminally Ill Adults (End of Life) Bill was introduced to parliament at the end of last year to pave the way to relieve the suffering of the terminally ill. Currently at committee stage, the essential criteria are that it is voluntary, in a patient with a terminal illness, with a prognosis that they only have six months to live.
The prime responsibility of the medical and nursing professions is to relieve suffering and improve the quality of life in all patients young and old, for however short or long that life is.
Palliative care was created to relieve suffering in a humane way, with physical, psychological and pharmacological support. We all nominally uphold the Hippocratic Oath, to improve the quality of life of patients and not foreshorten it. But the modern interpretation is more akin to a “promise to uphold the art of medicine and act in a patient’s interests”.
A divisive issue
It is currently a divisive issue in society and within medical circles. The Royal College of Surgeons (RCS) has raised just concerns that: it may change the nature of our relationship with our patients. The risk of coercion and the threat of undermining palliative care has also been raised. Engagement there is crucial.
Importantly, both the British Medical Association (BMA) and the RCS are concerned that implementation would lead to the widening of the criteria of eligibility. A key point for the BMA is that there is a difference between stopping treatment and deliberately shortening life by the active prescription of drugs, though it does acknowledge that patients’ distress and suffering cannot always be alleviated by current medical management.
A recent Australian National Survey on Voluntary Assisted Death in 2023 (Go Gently Australia) showed widespread acceptance among all types of clinicians. Clearly, there is now growing acceptance of this treatment strategy. Ultimately, a patient should have a choice in their death, provided the safeguards are in place.
“In Europe, Switzerland was the earliest to allow assisted dying as far back as 1942.”
Around the world
In other countries, there is some variation in the criteria for assisted dying.
In Canada, the scope of assisted dying has been extended beyond a terminal illness and now includes unbearable suffering from an irreversible illness or disability. The method involves self-administration. Two doctors or nurse practitioners also need to be involved. It is a two-track system that includes the conventional route where natural death is foreseen, and the more recent track, where natural death is not foreseen. This will include suffering from a mental illness in March 2027.
In Australia and New Zealand, the criteria are like that proposed in the UK, where the drug can be either self-administered or given by injection. The only difference is that the projected life expectancy for neuro-degenerative disorders like motor neurone disease is up to 12 months.
In the state of Victoria, for example, the process requires two medical practitioners to agree on eligibility, and one of the doctors will write the prescription once approval is granted. In Queensland, a nurse practitioner can ensure that the prescription is administered. As with other countries, there is emphasis that medical practitioners have the relevant experience and have completed “voluntary assisted dying training”. If a patient’s usual doctor cannot assist, the patient can contact the Statewide Care Navigator Service to obtain an accredited doctor.
In Europe, Switzerland was the earliest to allow assisted dying as far back as 1942. In some European countries such as Austria, the drug must be self-administered, whereas Spain, Belgium and Holland allow physician-assisted dying.
Two declarations
In the proposed bill in England, the mechanism for such a process would involve a patient aged 18 or over, who has the mental capacity to seek to end their life due to a terminal illness, discussing this with the GP.
The patient will make “a first declaration” and submit it to either the GP who is happy to provide the assistance or another clinician.
The coordinating doctor will make a clinical assessment and then refer the case to a “second doctor” or “independent doctor” for a second assessment.
Both clinicians would discuss the diagnosis, prognosis, possible treatments, and alternative therapies such as hospice care, pain management and possible psychological support. In addition, they would offer what method of assisted dying would be used.
These doctors need to be qualified in ascertaining patient capacity. They would then make a “second declaration” and after a seven-day period of “reflection”, the case would be referred to the court for approval.
If the court approves, there is a second period of 14 days of “reflection” and then the patient makes a “second declaration”. The case can be cancelled at any stage.
If the case is to go ahead, the coordinating doctor will provide the substance directly and in person to the patient. This could either be a tablet to be self-administered or via a medical device that can be self-administered. The coordinating doctor or “authorised medical practitioner” needs to be present until death has occurred.
The Australian experience
Intrinsically, as this is a new departure in British medical practice, and there may be a reluctance to take on this type of work. The role of the coordinating doctor is pivotal as they are also involved in the final stage of medication for self-administration, although the bill allows this to be delegated to another medical practitioner.
Some judges have been critical that their role would in fact just be a “rubber stamping” exercise. More recently it has been suggested that the judicial phase could be performed at the circuit judge level. This would make more sense as it would be more local for the patient.
Despite the concerns raised, as the Australian experience has shown, once it had been implemented, there is widespread acceptance.
Patients should have the freedom to choose the manner of their death if they are suffering a terminal illness. Although a significant minority of patients don’t go through with assisted dying, they do have the choice. There is now a worldwide experience of both physician-assisted suicide and physician-assisted euthanasia. The most important issue is safeguarding that the correct process is followed and is legally sanctioned. There would be concerns that the entire process could be lengthened, increasing the period of suffering. The limiting factor is in finding medical practitioners who would be able to act as coordinating doctor or the independent doctor. As with other countries, accreditation and training are paramount for these practitioners.
Currently, the only practical strategy is via physician-assisted suicide as then the patient can take it at home. Long-term, closer cooperation with hospices should be sought.
