What safeguards should be in place to protect General Practice (and GPs) should there be a change in the law to allow Physician Assisted Dying (PAD)?

Martyn Hewett is a retired GP and Hon Associate Professor, University of Exeter. He is Provost for RCGP Severn Faculty.*

Paquita De Zulueta is a retired GP and Honorary Senior Lecturer at Imperial College in London.*

As the Terminally Ill Adults (End of Life) Bill is progressing through Parliament the College must consider its position on the issue. This article does not assume support in principle for Physician Assisted dying (PAD), but it considers some of the changes that would need to be introduced to safeguard against the most prominent ethical difficulties arising from such a change in the law.

It is worth noting that although safeguards may be ‘robust’ they do not prevent the subtle, yet powerful effect that normalisation of a previously impermissible practice has on the the collective psyche and on professional practice. Furthermore, it is clear that this Bill will be legally challenged on discriminatory grounds by those who cannot self-administer owing to disabilities such that assisted dying may transmute to voluntary euthanasia, as has happened in other countries e.g. Canada.

There are four particular areas to be addressed:

• The risk of harming trust in the Doctor-Patient Relationship
• Issues around patient autonomy
• Health inequalities
• Protection for doctors who wish to opt out of the proposed processes

Risk of harming trust in the Doctor-Patient relationship

Patients have always trusted that doctors have their best interests at the heart of their actions. The ethos of doctors is to care always and heal when possible. Deliberately ending life, even for motives of beneficence, goes against millennia of medical ethos and culture. Medical ethics has, hitherto, sought to draw a clear non-utilitarian distinction between allowing a patient to die and actively killing them, although the required conditions for the “doctrine of double effect” can guide what is permissible, where sole purpose is to relieve suffering.

Developing trust requires several factors, including sufficient time and a willingness to engage with the patient’s lifeworld.¹ As GPs face an increasing workload and a declining workforce, time becomes constrained and the quality of interactions with their patients jeopardised. These systemic issues need to be comprehensively addressed. Patients who receive continuity of doctor care are more likely to experience a good doctor-patient relationship with their GP.²

Questions to consider:

• Can skilful palliation, when available, adequately resolve most (if not all) of most patients’ acute distress?
• How much will legalising PAD risk undermining trust in the doctor patient relationship? Studies give mixed results.³
• How effective would safeguards be at protecting this trust?

Issues around patient autonomy

Whilst PAD is most strongly advocated by those who cite intolerable symptoms such as pain and ‘unbearable suffering’, the empirical data show that most people who actually seek PAD in jurisdictions where it is available do so from fear, isolation, frailty, the threat of loss of control, and loss of meaning in their lives.⁴ Most people who seek PAD would benefit greatly from holistic palliative care, which includes psychological, social and spiritual support – but we know that palliative care services (and the primary and community care needed to deliver this) are very overstretched and underfunded.

Autonomy requires voluntariness and the absence of coercion. Indeed, the proposed legislation specifies that eligible patients must have the mental capacity to make the choice and to have expressed “a clear, settled and informed wish to end their own life”, free from coercion or pressure.

Frank coercion may be easy to detect, but subtle forms of intimidation, less so. One can imagine a dejected, but not depressed, patient believing that their family and the world would be better off without them, particularly if they require extensive care. If a trusted doctor refers to the possibility of PAD this could well be taken as a cue by a vulnerable patient to adopt the doctor’s suggestion.

Moreover, a vulnerable patient might appraise their condition and their likely need for time-consuming palliative care, see the parlous state of the NHS and decide that they have a moral responsibility to opt for an early death via PAD.⁵

Questions to consider:

• Are all such perceptions forms of “hidden coercion”, and thereby invalidate free consent?⁶
• Everyone makes decisions in the context of complex relationship networks – can we clearly define coercion?
• In the absence of palliative care being locally available, are patients being given realistic, humane alternatives to PAD?

It can be argued that the only reliable way to ensure there is no “hidden coercion” would be for PAD to be available in a setting without pressure in the health and social care system: where there is adequate funding for palliative, primary, community and social care with the necessary infrastructure to support these such that patients are not compelled by remediable fears, including fears of using precious, scarce NHS resources at other patients’ expense or unduly burdening their families.⁷

• Can PAD be safely legalised until this is the case?

Health inequalities

Arguably, articulate, well-educated, more forceful individuals will gain preferential access to PAD. They may obtain the necessary documentation from private clinicians and secure lawyers to persuade the tribunal of their ‘settled, uncoerced’ decision.

Inequity already exists and will be exacerbated for the under-privileged, marginalised and vulnerable who may be unable to access good care at the end of life. Stark examples of accessing PAD for economic reasons have been revealed, for example, in Canada.⁸

Questions to consider:

• What safeguards could be introduced that would be effective against the risk of increasing existing inequalities?
• What safeguards would be needed to ensure that the interests of the most vulnerable, including those in minority ethnic groups, those with mental illness and those living with disability and/or in poverty will be protected?

Protection for doctors who wish to opt out of the proposed processes (including conscientious objection)

The current bill states that doctors would not be under any obligation to take part in the assisted dying process. But how would this work?

There is evidence of a significant emotional impact on Healthcare Professionals involved in PAD in other countries, and there is a danger of GPs and other healthcare workers suffering from moral injury as a result of feeling coerced into some degree of involvement in the PAD process.⁹ Concerns about family dynamics (but insufficient evidence of coercion) and coping with a difficult and demanding patient (or relatives) while feeling a powerful ambivalence about PAD are possible scenarios.

Questions to consider:

• Is it realistic to believe that GPs will be able to opt out of any involvement in the PAD process? Is it inevitable that they will be drawn into discussion of this by patients and their families?
• Could opt-out safeguards be designed to ensure that declining to be involved in PAD does not lead to patient complaints or professional censure, or even to difficulties in the GP’s relationship with the patient and their family?
• It is especially important that there should be no requirement, nor expectation, that a GP should raise the possibility of PAD with a patient who may be eligible. Could this be reliably secured by legislation?
• Bearing in mind the unfortunate frequency with which medical problems have been reported to arise during the PAD process,¹⁰ who holds the duty of care in that circumstance? Ensuring that all concerned understand this clearly – especially if the GP has opted out – is essential.

Conclusions

It is clear from the many personal accounts from people who have experienced their loved ones dying in unrelieved pain and distress that the current situation is unsatisfactory and needs to be changed. The question is whether or not the legalisation of PAD is the answer.

We would urge our colleagues, regardless of their position on the broad issue of medical assistance in dying, and the Royal College Of General Practitioners to be mindful of the above issues, and to consider:

• How effective and workable safeguards will actually be.
• How stable and secure safeguards will be – the recent hasty retreat from a High Court judge reviewing all applications has not inspired confidence.
• Is it right for the College to drop its opposition to PAD?

*Authors’ note: Both authors are members of the RCGP Committee on Medical Ethics, and we are grateful to all the committee members, and especially David Misselbrook for their contributions to our discussions. However these views are our own, and not an official view either of the Ethics Committee or of the RCGP.

References

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