UK doctors must engage with the assisted dying debate now, says The BMJ
As the UK considers new laws to permit assisted dying, The BMJ this week explores the debate around assisted dying—prescribing life ending drugs for terminally ill, mentally competent adults to administer themselves within strict legal safeguards.
The UK public has shown consistent support for legalisation, yet doctors' views on assisted dying are split, and most doctors' organisations take no position on the issue, explain editor in chief Dr. Fiona Godlee and colleagues in an editorial.
They point out that currently, fewer than 50 British citizens a year seek help to die in Switzerland, as many as 14% of UK suicides are among people with terminal or chronic illness, and some people ask loved ones or doctors to help, although those who agree risk investigation and potentially prosecution.
The British Medical Association (BMA), which opposes legalisation, is due to debate the issue at its annual meeting this month, with motions calling for it to move to a neutral stance, after a poll last year showed a split among members' views.
The BMJ has previously called for the professions' representatives to take a position of "engaged neutrality"—neither in support nor opposition—"because doctors should not obstruct a decision that is for society and parliament to make."
Neutrality is far from an abdication of responsibility, say the authors. Instead they believe that it enables organisations to facilitate and fully engage with essential yet currently lacking societal conversations about death and what it means to die well.
"No professional should be obliged to participate. But doctors who oppose assisted dying should not stand in the way of colleagues who find it ethically justifiable to assist a dying patient's death. Nor should they stand in the way of dying patients who reasonably are asking for doctors' help to end their life," they conclude.
Many will assume that faith groups are implacably opposed to assisted dying, but this is not the case, say former Archbishop of Canterbury Lord George Carey and Rabbi Jonathan Romain. They discuss their involvement in a new religious alliance in support of doctor assisted dying, and argue that nothing in the scripture directly prohibits assisting a death to end suffering.
"There is nothing holy about agony," they write. "If terminally ill people do not wish to live out their last few months in pain, for what purpose should they be forced to do so, and in whose interest is that life being prolonged?"
They acknowledge that this is difficult territory, but say it is religiously appropriate to try to navigate it. "If there is a right to die well—or at least to die as well as possible—it means having the option of assisted dying, whether or not it is taken up. That, surely, is a truly compassionate, and very religious, response."
The main arguments for legalisation are respecting self-determination and alleviating suffering, but Professor Ole Hartling questions whether self-determination is genuinely possible when choosing your own death.
As former Chairman of the Danish Council of Ethics and author of Euthanasia and the Ethics of a Doctor's Decisions—An Argument Against Assisted Dying, he describes some of the critical issues that would arise if assisted dying were legalised and argues that autonomy is largely an illusion in the case of assisted dying.
"A patient overwhelmed by suffering may be more in need of compassion, care, and love than of someone kindly offering to help end his or her life," he writes. "It is not a question of whether people have a right to say that they are unworthy. It is a question of whether they have a right to be believed when saying it."
It's more vital than ever that we have data to support the debate on assisted dying, says Jacky Davis, consultant radiologist.
A recent BMA survey showed that more UK doctors personally support law change (50%) than oppose it (39%), and the Office for National Statistics (ONS) has been asked to investigate how many dying people in the UK take their own lives and how many travel abroad to access assisted dying.
"The BMA survey results have forced people to question their long held assumptions about the status quo," says Davis. "It is to be hoped that the evidence from the ONS will do the same and that the information will be available in time for the forthcoming debate in the House of Lords."
The importance of using high quality evidence to inform legislative change is well recognised. But Katherine Sleeman and Gareth Owen argue that there are evidence gaps to fill and that we must prioritise research.
They call for a deeper understanding of public opinion to help guide any legislative change and say important questions about the effectiveness of consent as a safeguard and what exactly the role of the doctor should be remain unanswered.
"Whether or not assisted dying becomes legal in the UK, good palliative care, provided across care settings, is essential," they write. "In addition, much more needs to be understood about the perspectives of patients and carers towards assisted dying."
Disability rights activist Stephen Duckworth, says he is "deeply troubled by the persistent narrative that disabled people have something to fear from a change in the law on assisted dying."
He points out that transparent assisted dying legislation with appropriate safeguards and protections for disabled people can exist and already work effectively around the world.
"I am pleased that medical opinion in the UK is shifting," he writes. "It should not matter if we are disabled, medically qualified, both or neither, surely together we can recognise that the outright ban on assisted dying goes against an individual's right to choose?"
Two feature articles describe where UK healthcare bodies stand on legalising assisted dying, and ask will Scotland become the first part of the UK to legalise assisted dying?
Essay (Carey): www.bmj.com/content/374/bmj.n2094
Essay (Hartling): www.bmj.com/content/374/bmj.n2135
Opinion (Davis): blogs.bmj.com/bmj/2021/09/08/i … te-on-assisted-dying
Opinion (Duckworth): blogs.bmj.com/bmj/2021/09/08/i … ge-the-dying-process
Opinion (Sleeman): blogs.bmj.com/bmj/2021/09/08/a … -prioritise-research
Feature (Best): www.bmj.com/content/374/bmj.n2075
Feature (Christie): www.bmj.com/content/374/bmj.n2012