Physician-assisted dying: the BGS, the RCP, and the law
David Oliver is the current President of the BGS, a visiting Fellow at the Kings Fund, and a consultant in geriatrics and acute general medicine at the Royal Berkshire NHS Foundation Trust.
In the wake of Lord Falconer’s Bill to legalise assisted dying for terminally ill patients in restricted circumstances, the Royal College of Physicians of London recently surveyed its members, asking them a number of questions regarding a possible change in the law.
As the biggest speciality within the college, BGS members were among those who responded. It’s the nature of our work as geriatricians that (alongside palliative care and oncology specialists) we spend a greater proportion of our working lives than most physicians dealing with planning, care and support towards the end of life, and supporting patients and their relatives through the final phase of their illness. So we have a key stake and keen interest in this question.
Geriatricians focus on the oldest old, those living with frailty, complex co-morbidities and dementia, so we're familiar with the issues around protection for our most vulnerable citizens, including those with impaired mental capacity or relying on family advocates. We are also bound to see the issues through a slightly different clinical lens than those dealing with, say, patients in mid-life with cancer or neurological conditions (but whose cognition and communication are generally intact).
The RCP poll was very shrewd in ensuring that the questions it put to its members were not specific to the Falconer Bill, which is bound to run out of time before the end of this parliament. Instead, they could apply generically to further attempts to change the law. Over 8,000 doctors responded and although there could be some response bias, it’s a big enough sample to put some confidence intervals around.
32% said they supported a change in the law to permit assisted suicide for the terminally ill, with the assistance of doctors. 37% percent, answering a more general question, said a change in the law was needed (as opposed to only 28% in the RCP 2006 poll). 21% said they would personally participate in assisted suicide if legalised.
This still leaves a majority of the respondents against a change in the law and more still against personal participation. It certainly represents no mandate to change the RCP’s current stance. Both the BMA and the RCGP remain officially opposed to a change in the law, though a number of high profile doctors are individually in favour.
Whilst I didn't express a personal view in my recent “BMJ Confidential” interview, I have thought long and hard about this issue.
As a doctor with an ethics and law degree I have taught numerous groups of professionals on these issues, attended many debates and personally spoken to some of the highest profile people on either side of the argument. At our BGS Spring Meeting in Manchester, Ray Tallis used his guest lecture to make a cogent argument in favour of a change in the law.
I know I am reducing a nuanced, complex argument to a simplistic overview, but in essence, both sides of the debate have both ethical arguments (based on principles and reasoning) and empirical ones (based on practicalities, safeguards and risks). Many doctors who are agnostic or in the “pro” camp would still not want to participate themselves, and wonder why medics have to be involved at all. I have also heard it said when people are in favour they are thinking about themselves or their loved ones and what they would want; those against are thinking more about implications for the rest of us.
Those in favour, include Tallis, Debbie Purdy, Falconer himself, Archbishop Carey and “Health Care Professionals for Assisted Dying”.
They tend to argue morally that respect for autonomy and the right to self determination over one’s own body is paramount: it is for no-one else to tell you how much suffering you choose to bear, nor whether you should choose to end your own life. Further, that it is actively harmful to cause someone to endure prolonged and avoidable suffering.
Empirically, they argue that the current law drives people to go to overseas while still able to travel and so die earlier than they would like. And that with appropriate safeguards, checks and balances there is no reason for vulnerable people to be pressurised to have assisted suicide. They will also argue that in countries and states where assisted suicide is legal, the floodgates have not opened despite warnings. As Tallis has argued: “you can go down the slippery slope with skis, or with crampons”.
Those against – including Baroness Finlay, Baroness Campbell, Dominic Lawson, Archbishop Welby and “Care Not Killing”
Morally, they argue that respect for autonomy can’t trump all other societal considerations. If, for instance, we allow severely disabled people to choose suicide, we are saying something about the moral worth of all people who are disabled. They also worry that in many occasions people don’t have absolute autonomy – compromised as it may be by cognitive impairment, fear, depression, pain, undue pressure from others, lack of information, a society that doesn’t support people to live well with disability or lack of access to adequate palliation for their symptoms.
Empirically, they also argue that no checks and balances would be adequate so that the precautionary principle is better observed. “One minute it’s a small group of mid life people with cancer or neurological disease. The next it will be older people with frailty or dementia who aren’t even terminally ill” They also tend to dispute the other side’s interpretation of the data from places like Oregon or the Netherlands.
It’s quite a polarised and polarising debate. As I did in my BMJ interview, I am still going to plead the 5th: my role as BGS President is public, collegiate and I can only speak for myself.
The question is, what do you all think? We would love to know – not via a poll, but by all means through social media and correspondence. The current official BGS position statement on this issue can be found here, and at the time we came out against. The RCP Poll has shown a moderate change of heart among their 8,000 respondents. What about us?