Physician-Assisted Suicide - BGS Position Statement
It is not the role of doctors or other health professionals to procure, assist or otherwise facilitate suicide. Indeed, the recent guidelines from the Director of Public Prosecutions about the situations where prosecution is more likely include any involvement from the medical profession. Geriatricians cannot meet their legal and professional obligations if they accede to patient or patient advocate requests to end life.
As the mean age at death in the UK is now over 80, members of the British Geriatrics Society (BGS) look after many dying patients, and have experienced a rising number of conversations with patients about euthanasia. Often these are phrased as “Can’t you just let me go?” Some of the public demand for euthanasia stems from the fear of a prolonged death through unwanted burdensome medical care. This can be diminished through sensitive listening to patients’ wishes, in the context of a trusting doctor-patient relationship.
While understanding that those with degenerative conditions may feel anguish and anxiety about progressive decline with loss of independence and dignity, the BGS does not accept that intentional killing is justified. On the contrary, geriatricians are skilled in comprehensively assessing people with complex and progressive disorders and planning a positive approach - which can often significantly improve an individual’s well being. Our members enjoy close collaboration with Palliative Care Medicine, which has been enormously beneficial in reducing suffering at the end of life.
If assisted suicide were to be legally sanctioned, the lives of vulnerable people would be threatened and some would feel pressure to give up their lives to reduce the burden they cause to others. Such a measure would also seriously diminish the ethical code of physicians and is incompatible with the role of doctor as healer.
Responding to a consultation by the Commission on Assisted Dying in April 2011, The BGS said:
- The BGS accepts the rights of individuals to determine the choice of treatment and care they receive. We further accept that sometimes, but very rarely, some symptoms are difficult to control and that even if they are, people may still find their life unbearable. Yet a policy which allows patients, in certain circumstances, to choose death, and to be helped to die by their physicians, is not ethically acceptable to the society.
- The BGS believes the duty of the physician to care for his/her patients is incompatible with a duty to bring about death even at the request of the patient. It is argued by proponents of euthanasia that curing disease and bringing about death are not mutually exclusive roles, the intention in both cases being the relief of suffering. It is further argued that the primary role of the physician is to care for his/her patient, which must therefore entail respecting their autonomous wish to die. However, the BGS believes that crossing the boundary between acknowledging that death is inevitable and taking active steps to bring about death changes fundamentally the role of the physician, changes the doctor patient relationship and changes the role of medicine in society. The focus would shift from providing the best palliative care i.e. easing symptoms, to providing death on demand. Such a shift will inevitably dilute the sanctity of life doctrine. Once quality of life becomes the yardstick by which the value of human life is judged, the protection offered to the most vulnerable members of society is weakened.
- In the experience of many geriatricians, the feeling of many older people that life is unbearable in its later stages is a direct result of the reaction of others to their frailty and the care and treatment they are afforded. Our concern then is that many older people, because of the care given to them by society in general and the NHS and Social Care system in particular, will perceive themselves as a burden and feel under pressure to end their lives. The BGS considers the best way of helping these vulnerable people is to maximise their independence and health, rather than acceding to their expressed wish to die.
- The BGS believes that Older People are often strongly influenced by their families and carers. Although in the majority of cases the “next of kin” of an older person will have their well being at heart, it is important to remember that not all these people necessarily will do so. Even if they do, it is noteworthy that almost all requests to end life – made either directly or indirectly to us as geriatricians - come from the patients’ families and not the older person themselves. Often such requests are then forgotten if such degrading symptoms as urinary and faecal incontinence, depression and unremitting pain are relieved.
- Whilst many older people are competent to make decisions about their wish for assisted dying, many will not be. The Mental Capacity Bill allows the appointment of a health attorney with the legal authority to take health and welfare decisions for a person in the event of his or her loss of capacity. This could mean that a decision to end an older person’s life could be made by a nominated health attorney. The complexities arising from such conditions could therefore lead to serious abuse of this power. Furthermore, such situations might interfere with the beneficial use of the Mental Capacity Bill.
- The right of any individual, whether terminally ill or not, to have their symptoms controlled is undisputed. In our opinion there is no overlap in clinical practice between symptom control and the wilful termination of life (or assisted dying). To muddle the two is to cause considerable confusion and to risk the danger that symptom control becomes an easier way to hasten death than completion of the declaration and all the safeguards therein - especially for people who are deemed incompetent.
- In the same vein, the BGS would emphasise that the right of a patient to choose or decline treatment and or intervention whatever the consequences, supersedes all other guidance and wishes. People who express their wishes regarding their future care for example, using an advance directive which is properly constituted and which is made known to their physician can be assured that such wishes will be respected. Thus people who wish to decline treatment in certain situations can ensure that their wishes are respected.
- Finally the BGS is concerned that ‘Assisted dying’, whilst it does not apply directly and solely to older people, will lead to a change in attitude to death in society and also within the medical profession. The prohibition on intentional killing is the cornerstone of society and it is worth preserving the notion that all lives are precious. The BGS accepts that this denies a very small number of persons the right to have their life ended by their physician if it is their autonomous wish. However it must be noted that every society puts some limits on respect for autonomy, which must be balanced against the greater good of society. The BGS urges improvement in the medical and social care of older people, placing them back in the centre of a society which respects their wisdom and experience. Rather than defining the conditions under which physicians may become killers, our efforts should focus on improving all aspects of palliative care, such that the debate on assisted death becomes irrelevant.