Editor – Randall and Downie argue unconvincingly that involvement in assisted suicide (AS) is incompatible with being a doctor (Clin Med Aug 2010 pp 323–5). A clause, totally out of context, from an ancient – almost never sworn – oath is of little relevance to modern medicine. The General Medical Council (GMC) decides what is appropriate for doctors in their duties to the individual and to society. No GMC comment on AS is needed while AS is illegal but it is unlikely it will exclude doctors specifically if society decides that AS is permissible. This would be in line with its guidelines on end-of-life care and on the withdrawing/withholding of life-sustaining treatments (passive euthanasia). It would also be in line with past medical tradition as regards its use of ‘double effect’ – a use now considered misuse – so widely accepted that it was argued that law change was unnecessary as doctors already had what was needed to control symptoms if other treatments failed. AS may well have to involve a different medical team but doctors are involved already if and when dying patients wish to discuss it as a possible option or wish for an honest prognosis. In the circumstances envisaged it is not an ‘adverse outcome’ any more than switching off a ventilator when appropriate. Doctors will be crucial in ensuring that the patient really is making an informed choice – very different from being just a ‘supplier of goods’. It is questionable how far doctors need to be involved in the last stages of the AS pathway, perhaps apart from the prescription. In Oregon, doctors are rarely present at the time of ingestion. To exclude doctors specifically could be cruel: hopefully many will accept an ongoing obligation to the patient, who might even have second thoughts. Finally, by opting out on principle, we would diminish our relevance as a profession in the debate – regrettable, even though the present Royal College of Physicians stance differs from my own views as a member of Dignity in Dying.
Assisted suicide
In Dr Kenwright's letter he attributes claims to us which we did not make; (strangely) he agrees with us on our points of main substance; he totally misunderstands GMC and British Medical Association (BMA) views on withholding and withdrawing life-prolonging treatment.
Firstly, we did not say that doctors either do or ought to subscribe to the Hippocratic oath, but only that the oath is the beginning of a long tradition, developed at the present time by the GMC and BMA, which defines what it is to be a doctor or sets limits to the role of the doctor. Secondly, he makes the same point himself when he says, ‘The GMC decides what is appropriate for doctors in their duties…[and later] It is questionable how far doctors need to be involved in the last stages of the AS pathway…’. Dr Kenwright has in fact stated with approval our main points. Thirdly, the withholding or withdrawing of treatment because it is not providing an overall health benefit is permitted in law and BMA/GMC professional guidance, and death when it occurs as the outcome of the illness does not constitute an ‘adverse outcome’ of treatment; it certainly does not constitute euthanasia (the term ‘passive euthanasia’ has been dropped from professional discussions because it is misleading). As for the doctrine of ‘double effect’, it notes that most treatments have good and bad effects. The doctor must aim at the good effect (such as relieving pain) while being aware that the bad effect may (rarely) shorten life. The doctrine in no way sanctions the intent to kill.
Finally, while doctors routinely discuss diagnosis and prognosis with their patients, including those approaching the ends of their lives, we think (contrary to Dr Kenwright) that if AS were to be legalised, doctors would be ill-advised to be involved in the seeking of consent for AS. After Shipman, the media, and perhaps some families, would be all-too-ready to claim that a doctor exerted undue pressure on a patient. Whatever is to be argued for or against AS (and we were neutral on this) there is no logic in calling it a ‘health benefit’, and if doctors concern themselves with matters other than health benefits they will fall under suspicion.
Footnotes
Please submit letters for the editor's consideration within three weeks of receipt of Clinical medicine. Letters should ideally be limited to 350 words, and sent by email to: clinicalmedicine{at}rcplondon.ac.uk
- Royal College of Physicians
Footnotes
Please submit letters for the editor's consideration within three weeks of receipt of Clinical medicine. Letters should ideally be limited to 350 words, and sent by email to: clinicalmedicine{at}rcplondon.ac.uk
- Royal College of Physicians
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