Role contradiction in physician-assisted suicide
Debate around the legalisation of assisted suicide (AS) and voluntary euthanasia (VE) continues unabated. This does not stop, however, some remarkably bizarre comments such as ‘when is a rational debate going to start?’ or ‘when is the British Medical Association going to address this?’. But for many I suspect there is a certain weariness as the same old arguments are rehearsed on either side: another dubiously relevant anecdote is milked for its publicity or the simple courtesies of discussion are sidelined into anti-religious ranting or accusations of promoting policies that will lead to the euthanasia practices of the Third Reich.
In this issue of Clinical Medicine, however, Randall and Downie offer a refreshing and neglected slant on the proposal for legal change (pages 323–5). They start by emphasising that in their paper they are not concerned as to the rightness or wrongness of AS or VE but rather are interested in the conceptual issue of what the role of the doctor should be. Their conclusion is irrelevant as to whether one believes that either is morally justifiable. They simply assert that it would not be medicine's business.
Doctors have featured prominently in this debate for three reasons. Firstly, they are human beings like everyone else, who have families like everyone else and are mortal like everyone else. They are also highly educated and articulate – along with many others in society. Secondly, doctors have all encountered death and in this respect they have a special experience. Many non-medical members of society reach middle age without even viewing a dead body. The doctors’ experience of death is not exclusive and other professional groups have similar experiences to offer. I would hazard a guess that clergy, for example, have a rather greater experience of dealing with the bereaved. However, it is undeniable that certain groups of doctors who specialise in the care of the dying – those in palliative care medicine – bring the lessons of a daily clinical involvement with death that are likely to inform their views on legal change. But the third reason for the prominence of doctors in this debate is surely that almost all discussion to date has assumed that it is doctors who will be directly involved in the assistance of suicide or the administration of a deadly poisonous substance with intent to terminate life.
This third reason gives doctors a special interest qualitatively different from other members of society and a reason why their views should at least be listened to while acknowledging, of course, the truism that doctors do not make the law, but that parliament does through the processes of representative democracy.
These concerns featured in the Royal College of Physicians's (RCP) 2006 consultation.1 A number of respondents believed that there was a strong case for removing AS/VE from healthcare. For example:
Currently, people are being treated worse than animals who are treated more compassionately. I think a much more proactive approach to ending life should be taken. Whether doctors or a new profession should do this is a valid debate. (373)
Regardless of quality of palliative care, some patients will express wish to die as issue one of control rather than symptom problem. However assisted dying service should not be provided by doctors… If society desires assisted suicide it should provide it outside of medical practice, much in the same way as execution is provided in the USA. (955)
Both these respondents appear to be in favour of some legal change. Both are challenging the role of doctors. Neither articulates the conceptual issue of Randall and Downie.2 Perhaps it is thought that it would be a way of sidelining or neutering medical opposition or perhaps it is consequential or conceptual or some other reason. Certainly for some, non-medical involvement is articulated in terms of consequences as much as concept or principle:
I think it's interesting to consider these proposals in the light of the College's recent report on medical professionalism. At this uncertain time, when the urgent task of rebuilding medical professionalism and protecting the public's trust in physicians seems so vital to the future of medicine, I believe these proposals would be disastrous… These proposals will undermine public confidence in doctors’ motives, remove the drive to better palliative care and put vulnerable patients at risk. (1180)
…if someone wants to have their lives ended by their own hand with help from others, or, more directly at the hands of others, those others could/should be non medical! It's a legal more than a medical issue. If doctors are seen to be involved, then they run the risk of losing the trust of those who don't feel like that! (1988)
Others, however, did comment on the concept of what being a doctor traditionally entails:
I believe that active ending of adult life has nothing to do with medicine and being a doctor. Active ending of adult life historically equates with murder, manslaughter, suicide or war, and only in the latter is it ‘legal’. Our society now seems to want to allow and permit active ending of adult life – then allow society to train, supervise and control ‘euthanasists’ – well trained in physiology, psychology, therapeutics etc, but do not call them doctors!… I might one day want to choose to end my own life legally – fair enough society seems now to say, but I would not want a doctor to do it, but a different well trained and supervised professional. (1562)
There appears to be an assumption that in assisted dying a physician needs to be the person either prescribing/administering the assistance, clearly this is against the principles to which we have held since the inception of our profession. However, the option of another person (who?/professional) to hold this role has not been considered. Should this be explored? (289)
Regardless over whether fellows thought this a consequential issue for medicine or a conceptual one, it was seen as practical to the point of black humour:
There is no requirement for physicians to be involved in killing people. It would be entirely possible to send (other named groups)… on a course to… administer a lethal dose of a killer drug to a client who wants it. (223)
In the days of hanging, the executioner was not medically trained, and I do not think one needs a medical degree in order to end life, even by a ‘humane’ method. (998)
If the public, supported by the state, wish to end their lives it is relatively easy to provide them with the means to do so and this does not need to involve doctors. (940)
As previously commented, the RCP's consultation featured a bigger concern about whether AS/VE should be carried out by doctors or someone else.1 Hospital deaths have been increasingly professionalised. Palliative care teams are now routinely involved in deaths on wards and certainly the overwhelming majority (over 90%) of UK palliative care specialists are strongly opposed to assisting death intentionally. There seems no prospect of the link between euthanasia and palliative care reported in Belgium.3 The number of people dying at home is falling and by 2030, if current trends continue, it will be less than one in 10.4 If those statements are true and if parliament wishes to change the law, pragmatics and principle should join together to exclude the involvement of doctors in the intended termination of human life.
- © 2010 Royal College of Physicians
References
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- Saunders J
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- Randall F,
- Downie R
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- Bernheim JL,
- Deschepper R,
- Distelmans W,
- et al.
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- Dobson R
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