Dr Matthew Davis is a retired General Practitioner at the NHS Leicestershire County and Rutland
Ana Worthington is Postgraduate Student at the University of Oxford
The Assisted Dying Bill, a Private Members’ Bill introduced to the House of Lords by Baroness Meacher, received its second reading on 22nd October, 2021. Such legislation will have profound consequences on medical practice and thus it is important to scrutinise some of the arguments proposed in favour of the Bill based on available evidence and clinical experience.
Such legislation will have profound consequences on medical practice…
In her opening speech, Baroness Meacher asserted that recent changes in doctor opinion have been “extraordinary”. She then referred to the British Medical Association (BMA) and the Royal College of Physicians (RCP) which she claimed “have ended their opposition to assisted dying”. These assertions distort the stance of professional medical organisations in the UK; none actively support “assisted dying” in any form. In 2020, the RCP clarified that the organisation “does not support a change in the law to permit assisted dying”.1 The motion that the recent BMA Annual Representative Meeting passed, by 149 to 145 votes, was “in order to represent the diversity of opinion demonstrated in the survey of its membership”.2 Given that the BMA was “neutral” as recently as 2006, this is not an “extraordinary” change. According to the 2020 BMA survey, few doctors (34%) would be prepared to be actively involved in any such process.3
Baroness Meacher also stated in her opening remarks that the, “..sole aim of the Bill is to reduce unnecessary and unbearable suffering,” as “…there are forms of suffering that even the best palliative care cannot alleviate..” such as intractable “…nausea and vomiting [due to] an allergy to antiemetics” and “…fungating wounds”. As palliative care has advanced, however, untreatable physical suffering has greatly diminished. The management of nausea is a core component of basic palliative care and it is exceedingly rare for a patient to be intolerant, let alone allergic, to every antiemetic. Fungating wounds are rare and, again, their management has changed radically in recent years through specialist dressings, antibiotics, pain control, psychological support and appropriate privacy. If the sole aim of the Bill is to reduce suffering, we would expect palliative care consultants, who deal with the most severe of patient symptoms at the end of life, would be overwhelmingly in favour of “assisted dying”. Yet, only 7% voted in favour of legalisation in the most recent BMA poll.3
Baroness Meacher claimed that this is a “…modest Bill based on tried and tested laws from overseas”. In truth, the results of testing assisted dying laws overseas are deeply concerning. In the Netherlands, there are large-scale unexplained geographical variations in the incidence of euthanasia which researchers conclude may represent overuse or misuse of euthanasia.4 In Belgium, it is estimated only 50% of euthanasia cases are actually reported to the Federal Euthanasia Control and Evaluation Committee.5 In Canada, there are calls to extend the right to die to the mentally unwell, patients who are unable to consent, and children6 and physicians report that “MAiD” complicates patient care, threatens the doctor-patient relationship, and makes patients fearful to enrol in hospice services.7 The eligibility criterion within the Assisted Dying Bill supposedly protects vulnerable patients from abuse or coercion. One requirement is that patients must be within six months of the end of life. Studies show, however, that prognostication in terminal illness is extremely inaccurate and it is impossible to verify that patients are in fact in the last months of life.8 The bill’s definition of terminal illness is also problematic. According to Oregon’s Death With Dignity Act,9 which Meacher’s Bill is based on, anyone with a chronic illness who is likely to die within six months if they choose to stop treatment is eligible for assisted dying. This means eligible patients could include insulin-dependent diabetics, who have an illness which is inevitably progressive and whose treatment will never reverse the condition.
But how can any doctor know what happens behind closed doors…
During the debate, Baroness Mallalieu stated that she believes “…two separate doctors and experienced High Court judges” will be able to detect “pressure, either internal or external” on vulnerable patients. But how can any doctor know what happens behind closed doors—whether that is perceived burdensomeness, persuasion, abuse, neglect or coercion? It is also unlikely that the second medical opinion will be truly “independent.” In busy clinical settings where challenging another’s opinion is difficult and often personally costly, we think the second medical opinion will, in time, become a rubber-stamping exercise. In Oregon, patients can approach numerous doctors until they find one willing to prescribe assisted suicide drugs and in 2020 one doctor wrote as many as 31 lethal prescriptions.10
While it is clear that proponents of the Bill seek to improve end of life care options, the above arguments made in support of such legislation do not stand up to scrutiny in light of international evidence and clinical expertise.
1. Royal College of Physicians. The RCP clarifies its position on assisted dying. Royal College of Physicians 2020. https://www.rcplondon.ac.uk/news/rcp-clarifies-its-position-assisted-dying
2. Chisholm, J. BMA adopts neutral position on physician-assisted dying. BMA News and Opinion 2021. https://www.bma.org.uk/news-and-opinion/bma-adopts-neutral-position-on-physician-assisted-dying
3. Chisholm, J. BMA physician-assisted dying survey results published. BMA News and Opinion 2020. https://www.bma.org.uk/news-and-opinion/bma-physician-assisted-dying-survey-results-published
4. Groenwoud AS, Femke A, Arvin M, et al. A. Euthanasia in the Netherlands: a claims data cross-sectional study of geographical variation. BMJ Supportive & Palliative Care 2021. doi: 10.1136/bmjspcare-2020-002573
5. Smets T, Bilsen J, Cohen J, et al. Reporting of euthanasia in medical practices in Flanders, Belgium: cross sectional analysis of reported and unreported cases. BMJ 2010; 341:c5174 https://doi.org/10.1136/bmj.c5174
6. Steger M. Update on medical assistance in dying in Canada. British Columbia Law Institute 2021. https://www.bcli.org/update-on-medical-assistance-in-dying-in-canada/
7. Mathews JJ, Hausner D, Avery J, et al. Impact of Medical Assistance in Dying on palliative care: A qualitative study. Palliative Medicine 2021; 35(2): 447-454. doi:10.1177/0269216320968517
9. Stahle F. Oregon healthy authority reveals hidden problems with the Oregon assisted suicide model. Euthanasia Prevention Coalition 2018.
10. Oregon Death with Dignity Act 2020 Data Summary. Oregon Health Authority Public Health Division, Center for Health Statistics 2021. https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year23.pdf