Helen Burn is a GP with a specialist interest in elderly care and frailty
The Assisted Dying Bill, a private member’s bill (the third bill debated in recent years) had its second reading in the House of Lords in October 2021. During the debate Lord Field revealed that he was terminally ill and now supported the legalisation of assisted dying, having previously voted against it. His words read out by Baroness Meacher: “I changed my mind on assisted dying when an MP friend was dying of cancer and wanted to die early before the full horror effects set in, but was denied this opportunity.” 1 The bill is currently at the committee stage.
A YouGov poll of 1758 adults published in August 2021 showed that 73% supported allowing doctor assisted suicide.2 The largest ever public poll, undertaken in 2015 by Dignity in Dying, found that 84% of the 5018 people polled supported assisted dying.3
…the BMA adopted a neutral position on assisted dying at its annual meeting in September 2021.
The British Medical Association (BMA) held a vote in February 2020 in which 150,000 members were contacted. A total of 28,986 members responded and of those 40% felt that the BMA should actively support a change in the law. 50% of respondents supported a change in the law to allow a physician to prescribe life ending drugs. 39% opposed this and 11% remained undecided. Subsequently the BMA adopted a neutral position on assisted dying at its annual meeting in September 2021.4
The Royal College of Physicians (RCP) polled its 36,000 members in 2019 on whether the RCP should support a change in the law to allow assisted dying. Of the 6,885 physicians who responded 43.4% did not want the RCP to support this. Of those remaining, 31.6% did wish the RCP to support a change in law and 25% were neutral on the issue.5 As a consequence, the RCP has adopted a position of neutrality with regard to a change in the law.
The Royal College of General Practitioners (RCGP) obtained the views of 6,674 of its members in 2020 and found 40% in support of a change in the law, 47% in opposition of a change in the law and 11% believing that the RCGP should remain neutral on the issue.6 The RCGP maintains its position in opposition of a change in the law.
The British Geriatrics Society (BGS) stated in 2015 that they would not support a change in the law. However, they accept that within society there is a growing emphasis on the rights of the individual, including the right to choose the manner and timing of one’s death. The BGS would play a constructive role in discussion with law makers if there were to be any change in the law, to ensure robust safeguards to protect the interests of older and vulnerable people.7
There are now 11 countries in which some form of assisted dying is legal, either country wide or in certain states or provinces. A review of Canada, in which medically assisted dying (MAID) became legal in 2016, shows that there were 7,595 cases of MAID in 2020, representing a 34.2% growth rate from 2019 and accounting for 2.5% of all deaths.8 The vast majority of these deaths required a physician to administer an IV drug to facilitate death. Cancer was the most common underlying condition (69.1% of cases), followed by cardiovascular conditions (13.8%), respiratory conditions (11.3%) and neurological conditions (10.2%). Of these patients, 82.8% were receiving palliative care at the time of their death. 68.1% of patients received MAID care from a family physician and a shift was noted towards receiving MAID care in the home environment, with 47.6% of patients in a private residence, 28% in hospitals and 17.2% in palliative care settings. 78% of written requests for MAID were granted, with the remaining not granted due to death before receiving MAID (12.7% of requests), ineligibility (6%) or withdrawal of request (2.5%).
All patients should receive excellent palliative care when they are given a life limiting diagnosis. It is our hope that all patients experience a good death. The government published its National Commitment For End Of Life Care in 2016 aiming to provide all patients with high quality and compassionate care, respecting the wishes of a dying patient, easing their pain and lifting their spirits.9
Patients with end stage dementia and neurological illness, and those at the end of life are often unable to express their pain, their wishes and their concerns. It falls to physicians then to ensure that patients are pain free and that their wishes are respected during this time. Relatives often feel the burden of care and of decision making during the end stages of illness, they can feel helpless and tormented at the sight of their loved ones. If we encouraged families to initiate conversations about death and dying in times of better health, and in absence of fear and depression that illness so often brings with it, then both relatives and doctors could be more confident in acting in the individual patient’s best interests.
GPs however have the opportunity to discuss end of life wishes over a longer period of time…
It is understandable that many hospital physicians may not feel comfortable with discussing assisted dying with patients who are generally admitted due to acute illness or decompensation. They will not necessarily know the patient and their family well, and understandably are focussed on trying to treat illness with the aim of discharging a patient home. GPs however have the opportunity to discuss end of life wishes over a longer period of time, raising the issue when it feels appropriate and in anticipation of decline.
It is entirely reasonable to accept that not all physicians would be willing to assist a patient in ending their life. However, this should not necessarily mean that they cannot support a change in the law, and it does not mean that they should avoid the discussion and the debate. It is relevant to remember how different our roles within the medical profession are and how this changes one’s perspective on the issue. Let us also never forget the perspective of the patient. And if we are to believe the surveys historical and current, the general public seem more concrete in their views on the issue than we do.
Many medical professionals have yet to express their views on the matter of assisted dying, as demonstrated by the small percentage of member responses to the various surveys published. The RCGP, who continue to hold a position of opposition to any change in law, received responses from just over 13% of their members in 2020.6 Given their integral role to the potential future practice of assisted dying, as demonstrated by the current practice in Canada,8 it is GPs who should be most encouraged to debate the issue without fear of judgment from within the profession. It is incredibly challenging for a physician to consider the issue in plurality; as any individual might contemplate their own death and that of a loved one, a physician must also contemplate what it would be to take responsibility for ending another person’s life, even when that is considered to be in their best interest.
Andrew Papanikitas* is deputy editor of the BJGP. He is on twitter @gentlemedic
Peter Toon is a retired GP writer and virtue ethicist
Paquita De Zulueta, is Hon. senior lecturer in medical ethics and law at Imperial College and recently retired GP. She is on twitter @PdeZ_doc
David Misselbrook is senior ethics advisor for the BJGP
John Spicer* is a South London GP, ethicist and medical educator. He is on twitter @johnspicer3
This week’s BJGP Life articles (see bottom of article for what is coming up) will have an ethical or philosophical flavour, as BJGP Life launches a new column: Ethics of the ordinary (EotO) is a regular column that explores ‘ethical and moral concerns relevant to general practice and primary care.’
There are many reasons why primary care generates ethical and philosophical issues. Patients are likely to be meaningfully autonomous -fully clothed and fully conscious, more empowered to contest medical ideas of best interests and risk.1 Primary care teams look after entire families, and generally do not discharge patients who choose not to comply with their recommendations. They can be left to look after patients deemed ‘untreatable’ by secondary care services.2 They often have a holistic understanding of patients’ backgrounds, life stories and values acquired from longer term relationships built on trust and familiarity. And there is just so much general practice happening out there that involves moral complexity. A patient attends during a full surgery, distraught over a marital breakdown – how much time should you give them? Can this teenager be in a consensual relationship with their few-years-older partner? Should we be motivated by compassion or duty? Should we delay the initial COVID-19 vaccination programme because of possible risks? The issues are as endless and everyday as general practice itself. And it is a poorly kept secret that ethics teaching in undergraduate and postgraduate medical education is often delivered by general practitioners.3
Some cases involve much discussed ‘ethical dilemmas,” such as those concerning abortion or end of life care, or arise from societal or technological changes such as assisted fertility or advances in genomic medicine. But many raise everyday and ordinary issues which are ‘unsexy‘4 from a popular or academic perspective because they are not associated with a new technology, a change in the law or a moral panic. Dramatic and technology-driven ethical issues also clearly affect community and primary care settings. Issues and conflict may also arise in the interface between teams, whether they are located in hospitals or community settings.5
The ethics of the ordinary is a reference to the of issues and decisions found in everyday practice.6,7,8 It may be that the public interest, or academic funding, or political gaze, have moved on. It may be that that undramatic instances still raise moral questions worth answering. EotO relates to all healthcare settings (not just general practice and not just those which are patient-facing).
EOTO has also been embodied as a mundane revolution in UK primary care, by groups of British GPs and allied academics in a variety of disciplines. Admiring the relative success of clinical ethics committees in hospitals and national groups9 like the Genethics Forum and the UK Clinical Ethics Network, some set up discussion groups,10 others contacted their local hospital ethics committee with their dilemmas.11 We called for a body of knowledge and community of scholars to support primary healthcare12,13 and ran a series of conferences at the Royal Society of Medicine over a decade, with support from the Institute of Medical Ethics, The University of Oxford and the RCGP.14,15 A large group of us wrote an award-winning handbook of primary care ethics,16 cited in the RCGP curriculum. The BJGP ran an A-Z of medical philosophy – explicitly inviting readers to use the ideas in reflecting on their own professional lives.17 During this period the RCGP committee on medical ethics has been a presence at the RCGP annual conference, running sessions on (inter alia): shared decision-making, part-time working, sponsorship, guidelines and conflicts of interests as well as tackling artificial intelligence and genomic medicine in primary care.18
The references below represent the range and evolution of issues raised, and a collegial community which is far from homogenous in world view and intellectual tradition. You will see familiar authors from past and present, and we invite the wider BJGP and BJGP life community to join us in this discourse. We will include both solicited and reasonably argued unsolicited work in the EotO column. EotO will not shy away from controversial or divisive topics, and collegial discussion in the comments is encouraged. Please ensure that debate is respectful, and founded on reasonable arguments and facts.
What to expect the week commencing 14th February 2022 on BJGP Life:
On Wednesday, Felicitas Selter, Kirsten Persson, and Gerald Neitzke discuss the similarities and differences in animal and human euthanasia as a source of moral distress for the practitioner.
On Thursday, Helen Burn explains that because legalised physician-assisted dying would likely involve GPs, GPs should think about their views on the issue.
On Friday, Matthew Davis and Ana Worthington argue that the arguments in favour of the recent Assisted Dying Bill at its second reading in the UK House of Lords are based on flawed evidence.
On Saturday, Koki Kato introduces us to phenomenology as an approach to understanding patient-centred care, using his own illness-experience as a worked example.
On Sunday Samar Razaq reflects on truth, medical opinion and the scholarship in the age of Twitter.
All this week’s BJGP Life articles have been recently independently submitted (none were commissioned). We hope that they generate discussion and collegial debate.
1. Brody H. The essence of primary care, p. 56-61 in The Healer’s Power. New Haven: Yale University Press. 1992
2. Pellegrino E. The healing relationship: the architronics of clinical medicine, in Shelp EA, ed. The clinical encounters: the moral fabric of the patient-physician relationship. Reidel, Dordrecht 1983
3. Misselbrook D (2012) The BJGP is open for ethics. Br J Gen Pract, DOI: https://doi.org/10.3399/bjgp12X629964
4. Butcher F (2011), The appeal of ‘unsexy’ ethics, https://wellcome755.rssing.com/chan-8434298/latest-article2.php (accessed 12/2/22)
5. Wiles K et al, Ethics in the interface between multidisciplinary teams: a narrative in stages for inter-professional education, London J Prim Care (Abingdon). 2016; 8(6): 100–104. doi: 10.1080/17571472.2016.1244892
6. Papanikitas A and Toon P, Last but not least: the ethics of the ordinary, Br J Gen Pract, 2010; 60 (580): 863-864. https://bjgp.org/content/60/580/863.full
7. Cyril et al, Ethics of the ordinary: a class response, Br J Gen Pract, 2012; 62 (595): e143-e146. DOI: https://doi.org/10.3399/bjgp12X625283
8. Gardner J et al, Emerging themes in the everyday ethics of primary care, Clinical Ethics 2011; 6 (4):211-214 doi: https://doi.org/10.1258/ce.2011.011034
9. Peile E. Supporting primary care with ethics advice and education, BMJ, 2001; 323(7303): 3–4. doi: 10.1136/bmj.323.7303.3
10. Evans Patel G, King A, and Spicer J, Healthcare ethics: learning in the workplace, Work Based Learning in Primary Care 2006; 4: 57–64 https://www.researchgate.net/publication/321318915_Healthcare_ethics_Learning_in_the_workplace accessed 12/2/22
11. Sokol D (2009), Who wants to be the flu GP? http://news.bbc.co.uk/1/hi/health/8135658.stm (accessed 12/2/22)
12. Papanikitas A, Toon P. Primary care ethics: a body of literature and a community of scholars? Journal of the Royal Society of Medicine. 2011;104(3):94-96. doi: https://doi.org/10.1258/jrsm.2010.100353
13. De Zulueta P. (2008) Welcome to the ethics section of the London Journal of Primary Care London Journal of Primary Care, doi: https://doi.org/10.1080/17571472.2008.11493183
14. Papanikitas A, et al. (2011) Ethics of the ordinary: a meeting run by the Royal Society of Medicine with the Royal College of General Practitioners. London Journal of Primary Care, doi: https://doi.org/10.1080/17571472.2011.11493331
15. Papanikitas A et al, 4th annual primary care ethics conference: ethics education and lifelong learning London J Prim Care (Abingdon). 2014; 6(6): 164–168. doi: https://doi.org/10.1080/17571472.2014.11494369
16. Jewell D, Brave new ethics, Br J Gen Pract 2019; 69 (681): 200. doi: https://doi.org/10.3399/bjgp19X702053
17. Misselbrook D (2013) An A-Z of medical philosophy. Br J Gen Pract, doi: https://doi.org/10.3399/bjgp13X660841
18. Papanikitas A. (2016) Education and debate: a manifesto for ethics and values at annual healthcare conferences. London Journal of Primary Care 8:6, pages 96-99. https://doi.org/10.1080/17571472.2016.1244152
Featured image: From the classroom to the clinic, by Andrew Papanikitas