This resource is under development and will change regularly over coming weeks. Please take the opportunity to register for updates if you wish
Please note that our immediate priority is to inform members whose Colleges are polling their members on their views about medical involvement in actively and intentionally ending life.
The APM’s Position Statement is here
Letter to Trainees is here
Whilst Palliative Medicine and the APM have consultants who are members or Fellows of the RCGP, RCA & RCPsych, the APM is a Society of the Royal College of Physicians (RCP) and so this resource currently addresses the RCP Poll that has begun.
This Poll is not about the rights and wrongs of assisted suicide, but whether it should become a new duty for doctors
We urge Members and Fellows to register their vote and opinion, as the RCP’s position will have a direct bearing on how Parliament reacts to proposed Bills that come before them
Suggestions for additional evidence and material is welcome. Please email Compleat Secretariat
This subject is core to any clinician practicing in Supportive, Palliative and End of Life Care
Over time, resources will be added on relevant theory and ethics to inform your thinking
Suggestions for additional evidence and material are welcome. Email Compleat Secretariat.
The RCP 2019 and 2019 polls. The 2019 is not a direct re-run of the 2014 poll.
The poll is now open
“The supply by a doctor of a lethal dose of drugs to a patient who is terminally ill, meets certain criteria that will be defined by law, and requests those drugs in order that they might be used by the person concerned to end their life.”
From this definition it is clear that the RCP are referring solely to the involvement of doctors who will be involved explicitly in the assessment, decision making and implementation in bringing about the premature death of an individual
What does neutrality mean?
Arguments for neutrality
Arguments against neutrality
As the regulator that ‘polices’ doctors, it cannot have a view or position
No position on Assisted dying
Royal college of Psychiatrists
Royal College of Anaesthetists
Royal College of Obstetricians and Gynaecologists
Royal College of Paediatrics and Child Health
Royal College of Physicians of Edinburgh
Royal Society of Medicine
Royal College of Nursing
Royal College of Nursing Scotland
Knowing people’s view in principle can be helpful and should be based on an even-handed presentation of principles. However, questions and responses are necessarily broad and open to all sorts of interpretation when one looks at precise meanings.
The APM made a decision at the end of 2014 to survey against specific Bills for the very reason that
The results of our 2014/5 survey are here
A view of the rights and wrongs of assisted suicide is not the same as a view on a doctor’s direct involvement enabling assisted suicide or administering lethal drug. As in Switzerland doctors do not need to be involved for assisted suicide to be available.
For the purposes of the 2019 Royal College of Physicians poll, the RCP defines ‘assisted dying’ as:
The supply by a doctor of a lethal dose of drugs to a patient who is terminally ill, meets certain criteria that will be defined by law, and requests those drugs in order that they might be used by the person concerned to end their life.
The RCP is referring solely to the involvement of doctors in bringing about the premature death of an individual and is distinct from palliative care.
Canada: Medically Aid in Dying (MAID)
MAID includes clinician assisted suicide and physician administered euthanasia
This involved doctors, nurses and others such as pharmacists. It is defined by eligibility criteria that are listed as:
Oregon: Death With Dignity Act (DWDA)
This also involves doctors and has eligibilities, but is confined to physician assisted suicide
Their definitions are very clear
‘Euthanasia is performed by the attending physician administering a fatal dose of a suitable drug to the patient on his or her express request. The relevant Dutch legislation also covers physician-assisted suicide (where the physician supplies the drug but the patient administers it). Palliative sedation is not a form of euthanasia: the patient is simply rendered unconscious with pain reducing drugs and eventually dies from natural causes.’
Belgium has now extended their law to apply to mature minors
Some people welcomed it, underlining the “pioneering” role Belgium played in establishing a legal framework for euthanasia, which was presented as the ultimate “humanitarian act” of which any patient, major or minor, should be able to take advantage. In contrast, others in Parliament and in civil society opposed the extension of the law. Among these were nearly two hundred paediatricians and paediatric palliative care specialists.
When a doctor treats a bacterial infection with an antibiotic, the difference between prescribing it and administering it is practical and not moral
The same reasoning applies to ending a person’s life: the way in which a doctor does it is practical and not moral
Physician assisted suicide involves prescribing lethal drugs intended explicitly to end a life.
Physician administered euthanasia is the administration of a lethal cocktail of drugs intended explicitly to end a life
In Jurisdictions such as Canada, the Netherlands and Belgium, where both physician assisted suicide and physician assisted euthanasia are permitted. The overwhelming number of deaths are brought about by physician administered euthanasia
Note the in language and definitions of physician assisted suicide and euthanasia across jurisdictions. They are summarised here
These have remained broadly the same over time, Here they are.
2011 on assisted suicide and disability here
2015 on whether judicial consent for assisted dying will protect vulnerable people here
2017 on how Dutch safeguards are failing individuals with intellectual disability and/or autism here
2019 A sobering article by a Dutch Journalist entitled Death on demand, has euthanasia gone too far? Summarises the situation there:
His Jan 2019 Guardian article describes what happens when assisted dying becomes accepted practice. The increasing numbers and expanding criteria in the Netherlands are viewed by some as progress, but voices of alarm are growing. Concerns over the lack of adequate safeguards and the lack of conformity over decision-making are causing concern. The author comments: Without consensus on these basic motivations, euthanasia won’t be an occasion for empathy, ethics or compassion, but a bludgeon swinging through people’s lives, whose handiwork cannot be undone.
The question for any country contemplating physician assisted dying is whether the practice must inevitably expand. The author comments: The more I learned about it, the more it seemed that euthanasia, while assigning commendable value
Based on these arguments and facts, The APM does not support a change in the law.
Suggested safeguards from supporters of physician assisted suicide cannot be clearly defined in law. Should the RCP outcome favour physician assisted suicide, safety will be a major concern.
Close scrutiny of legal proposals and issues can be found here
As a summary:
In Oregon concerns have been raised about inadequate protection for patients with depression and anxiety.
Can a doctor conscientiously object to involvement in assisting suicide if it becomes legal?
Both supporters and opponents of legal change appeal to it, yet conscientious objection in medicine is under fundamental challenge.
One argument used to reassure clinicians who object to physician assisted suicide is its similarity to termination of pregnancy where a doctor with a conscientious objection has a right in law
There is no actual ‘doing’ in Physician Assisted Suicide, just facilitating or assisting.
A Bill, Conscientious Objection (Medical Activities) Bill HL 2017-19 that is still at the House of Lords level, seeks to broaden conscientious objection once again. it is unknown how successful this will be.
The APM does not believe in the long-term that conscientious objection will afford protection to doctors if Physicians Assisted Suicide is made legal.
Trust is a very difficult thing to pin down, but we all know when we have it and when it’s lost.
Most can be learned from examples from practice.
Katherine Mannix’s tells a story about a man, Ujal, living in the Netherlands who is desperate to come to the UK to die (Pp 179-195). He says:
“They didn’t mean to frighten me. I think they thought it was a comfort. But it was every day, every ward round, they told me that if I want to, I can choose to die……”
Mannix goes on to explain that
‘His only criticism is that there was a subtle, entirely unintended nuance in every consultation once his cancer had spread. In the end this nuance was too frightening to tolerate … Ujal ran away from that certain, controlled dying to live with the hope of uncertainty … Ujal lived with us [at the hospice] for two months … before dying very quietly while Tabitha [his daughter] was running and laughing in the garden outside his room.
Once the euthanasia genie is out of the bottle, you must be careful what you wish for.’
A recent Guardian article gives further reinforcement to this concern and extends it to tensions between doctors in a tragic cameo.
‘For all the safeguards that have been put in place against the manipulation of applicants for euthanasia, in cases where patients do include relatives in their
decision-making, it can never be entirely foreclosed, as I discovered in a GP’s
surgery in Wallonia, the French-speaking part of Belgium.
‘The GP in question – we’ll call her Marie-Louise – is a self-confessed idealist who sees it as her mission to “care, care, care”. In 2017, one of her patients, a man in late middle-age, was diagnosed with dementia and signed a directive asking for
euthanasia when his condition worsened. As his mind faltered, however, so did his
resolve – which did not please his wife, who became an evangelist for her husband’s death. “He must have changed his mind 20 times,” Marie-Louise said. “I saw the pressure she was applying.”
‘In order to illustrate one of the woman’s outbursts, Marie-Louise rose from her desk, walked over to the filing cabinet and, adopting the persona of the infuriated wife, slammed down her fist, exclaiming, “If only he had the courage! Coward!” Most medical ethicists would approve of Marie-Louise’s refusal to euthanise a patient who had been pressured. By the time she went away on holiday last summer, she believed she had won from her patient an undertaking not to press for euthanasia. But she had not reckoned with her own colleague in the practice, a doctor who takes a favourable line towards euthanasia, and when Marie-Louise returned from holidays she found out that this colleague had euthanised her patient.
‘When I visited Marie-Louise several months after the event, she remained bewildered by what had happened. As with Marc, guilt was a factor; if she hadn’t gone away, would her patient still be alive? Now she was making plans to leave the
practice, but hadn’t yet made an announcement for fear of unsettling her other patients. “How can I stay here?” she said. “I am a doctor and yet I can’t guarantee the safety of my most vulnerable patients.”
Having physician assisted suicide in medicine makes it a treatment subject to the economic pressures of the NHS
Here is a sobering podcast from an American Physician.
In Canada an economic analysis concludes with these words:
“Providing medical assistance in dying in Canada should not result in any excess financial burden to the health care system and could result in substantial savings.”
Reports on the ground from Canada to the APM from programme directors and clinical leaders in palliative care show that the promised investments in palliative care that were to accompany the introduction of ‘Medical Assistance In ending Life’ (MAID) have not materialised, that is some areas investment in palliative care has fallen, and heat maps of the areas in which MAID is most common are where palliative care is least available.
The APM considers that the economic factors that are relevant in deciding between treatments of any kind will extend quickly and inevitably to physician assisted suicide or euthanasia were they made legal in the UK.
Wanting assistance to suicide or die may be triggered by something clinical, but Oregon’s data show that the majority of reasons people seek assisted suicide are social and not medical. They relate to concerns about the inability to enjoy previous activities, fears about the future, worry about being a burden in needing support with care and losing autonomy.
We all have our limits. Because of our caring and compassionate relationships with our patients, we are not always best placed to judge objectively the social factors affecting a ‘settled’ wish to die such as the coercive psychological, relational and cultural pressures that may be in play.
The impact of one person’s actions always affects others and may go beyond friends, family and carers. Patients’, carers’ and society’s attitudes to doctors and their expectations of us, and probably their attitudes to the dying generally, will change if deliberately ending life early is seen as part of medicine and illness
Autonomy is not simply an isolated expression of control. The impact of one person’s action to end his or her life affects friends, family and carers, as well as society’s attitudes to the dying generally. Physician-assisted dying creates expectations that deliberately ending life early is one of a physician’s responsibilities.
A discussion of autonomy and its relationship to assisted suicide is available here
Many young doctors are feeling increasing pressure and worry about their own and colleagues’ mental health and burnout. The literature on the personal impact on them of being involved directly in assisting suicide and euthanasia reports significant psychological morbidity. Given existing challenges in our workforce this could well be a concern for the future.
Other views include
A shift away from the fundamental values of medicine to heal and promote human wholeness can have significant effects on many participating physicians. Doctors describe being
There is evidence of
One of the difficulties of commenting on the impact of legislation here, in comparison with elsewhere, is that Specialist Palliative and Hospice Care in the UK is that we rank as the best in the world. It is highly developed and what we define as hospice care will have little or no resemblance to that elsewhere. Consequently, claims from the countries with legislation around physician assisted suicide or euthanasia that palliative care has been unaffected or may have improved may be true for them. That does not make it true for us. The recent experience in Canada, which has pockets of very high quality palliative and hospice care that we would recognise as comparable to the UK, bears this out.
The APM continues in direct conversation with clinicians in Canada from both sides of the divide to try and understand the implications for us. One major proponent MAID (medical assistance in dying, that includes euthanasia) came from palliative care and is zealous in his perspective. He has presented to a lobbying Parliamentary Group in Westminster recently. Others have many concerns.
Apart from the authors above along with Harvey Chochinov and Mike Harlos. Others have expressing worries that are widespread and many would rather remain anonymous because of the impact speaking out may have on them personally. Below is a distillation of some anonymised comments we have on record.
Focus on how to support the ongoing provision of palliative care services regardless of whether MAID is also being considered by the patient.
The broad philosophy of palliative care (as described by the WHO or the recently-revised IAHPC definition) can be challenging to implement within the constraints imposed by the realities of health care service provision. This was highlighted early on when MAID became available – many palliative care practitioners expressed strong philosophical opposition – that assisted death represents the antithesis of the philosophy of palliative care.
I recall a Medical Director colleague from another city saying that he will never allow MAID to occur on “his unit”. The reality is that he was powerless to prevent it; his only option would be to resign as director. Although I could never see myself providing MAID, I felt that it was important for me to support our palliative care team in approaching this new development in health care.
Even if the palliative care community maintains that there should be no connection between palliative care and MAID,
In my experience, the following issues/challenges stand out as having been significant for our palliative care team:
Health care providers wishing to avoid involvement in MAID (conscientious objection)
For the most part there is support for clinicians who oppose involvement for religious or moral/ethical reasons. However, the framework for addressing conscientious objection is a combination of legal requirements outlined in the legislation as well as the statements/guidelines of the practitioner’s regulatory body (medicine, nursing, pharmacy, social work).
We have had many of our team members express opposition to any connection MAID; unfortunately, it seems rare that these same clinicians will take the time to inform themselves about the issue, such as reading the legislation, the requirements of their own regulatory body, and literature regarding ethical considerations around conscientious objection.
Faith based facilities, as you would imagine, have also had their own unique struggles.
Palliative Care programs will need to develop an approach to meeting patients’ needs and ensuring compliance with legal and regulatory requirements around MAID, while still supporting clinicians who object.
Ongoing education and support is needed for the team about these complex ethical and moral issues.
Palliative Care clinicians feeling they have failed in addressing a patient’s suffering if the patient chooses MAID
This is a very real challenge. The data locally indicates that
Palliative Care team members feeling upset when they were unaware that the patient was pursuing MAID (they sometimes find out after the fact).
We have had situations where the patient does not feel comfortable sharing their intentions to receive MAID. This may be concern
We have worked with the MAID providers to
Clinicians uncertain how to respond to comments from the patient about a desire for death.
Prior to MAID, palliative care clinicians were generally comfortable and skilled at exploring comments such as “I just wish this was all over”, or “I wish that I could go to sleep and not wake up again”, or “Why can’t you just give me something to end this – we treat animals better than this”.
It can also be difficult to know if the patient is actually asking about MAID, or simply expressing an exasperation with existence.
In our jurisdiction we have challenges related to faith-based facilities being exempt from the provision of MAID. This has had significant implications for patients who are in designated palliative care beds within those facilities.
The routinisation of MAID
If there have been any surprises for me, it is how quickly this has become so normal and even routine. Locally
That said, the fact that it has so quickly become part of mainstream medicine is not something I had not anticipated, nor feel particularly comfortable with. As a psychiatrist, I understand the importance of presence and how powerful that can be in supporting patients and their families. It is hard for me to reconcile that approach with a stance that would see me having to participate in hastening the patient’s death.
Criteria seem uncontrollable & safeguards ineffective
In Canada the main MAID criterion is ‘death being reasonably foreseeable’.
But opening the door on MAID has also meant that there are proponents who continue to push for expanding the criteria (you may find the report regarding advance directives, mature minors and psychiatric justification alone of interest);
I hear of virtually no one contemplating restricting the criteria as they currently stand. My sense is that public support for MAID is broad, and like the observation in have seen in medicine, is perceived to now be quite routine; I’ve even seen quite a number of obituaries that openly acknowledge and thank the MAID team for their involvement in the persons death. While I remember observing this outlook of ‘normalcy and routine’ when I visited The Netherlands, I never imagine that Canada would so quickly follow in suit.
I remember one physician in Holland saying that PAS was not a medical issue but a societal issue; and another American physician describe it as ‘an act of love’. Either way, I think both were saying that fall outside of usual medical practice. I understand that for some people, this will be a compelling choice no matter what palliative interventions are offered or available.
As a society, we need to determine if this is a choice they should be entitled to; here in Canada, the decision to provide Canadians that choice came about as a result of a Supreme Court decision, followed by federal legislation passed by Parliament in February 2016.
A very separate choice is who should be responsible for providing PAS/MAID. Like you, I too argued that it is best situated outside of medicine with judicial oversight. The role of medicine, as you point out should include diagnosis, prognosis – but let us not forget our duty to address suffering (the article by Dr Harlos makes that point well). And if medicine must take this on, it should only be by those who are specifically licensed to do so, with appropriate oversight and adherence to the Vulnerability Standards.
Physician-assisted suicide occurs when a physician facilitates a patient’s death by providing the necessary means and/or information to enable the patient to perform the life-ending act (e.g., the physician provides sleeping pills and information about the lethal dose, while aware that the patient may commit suicide).
It is understandable, though tragic, that some patients in extreme duress—such as those suffering from a terminal, painful, debilitating illness—may come to decide that death is preferable to life. However, permitting physicians to engage in assisted suicide would ultimately cause more harm than good.
Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.
Please click here to read full article
On 28 February 2014 a law was enacted “amending the Act of 28 May 2002 on euthanasia in order to extend it to minors”1. Belgium thus became the first and only country to authorise euthanasia of minors without specifying that any conditions with respect to their age should be met.
Some people welcomed it, underlining the “pioneering”2 role Belgium played in establishing a legal framework for euthanasia, which was presented as the ultimate “humanitarian act” of which any patient,major or minor, should be able to take advantage. In contrast, others in Parliament and in civil society3 opposed the extension of the law. Among these were nearly two hundred paediatricians and paediatric palliative care specialists4.