Memorandum by The Royal College of General
1. The Royal College of General Practitioners
welcomes the opportunity to submit written evidence to the Select
Committee on the Assisted Dying for the Terminally Ill Bill (HL).
2. The Royal College of General Practitioners
is the largest membership organisation in the United Kingdom solely
for GPs. It aims to encourage and maintain the highest standards
of general medical practice and to act as the "voice"
of GPs on issues concerned with education; training; research;
and clinical standards. Founded in 1952, the RCGP has over 21,500
members who are committed to improving patient care, developing
their own skills and promoting general practice as a discipline.
3. The College stance on the desirability of
the Bill is one of "neutrality", recognising that it
is a matter for society to judge the ethical and moral issues
surrounding this important subject. The comments we set out below
are, therefore, focussed on practical issues arising from the
Bill in which medical professionals are likely to have a special
understanding and expertise. Our comments are not to imply either
support or opposition to the Bill but we hope the issues we raise
are given serious consideration by the Committee in its deliberations.
Clause 1: Authorisation of assisted dying
4. It is genuinely difficult for doctors
to estimate death in the medium term (definition of "terminal
illness" in line 27 of page 2 of the Bill refers). It is
possible to give reasonably accurate prognoses of death within
minutes, hours or a few days. When this stretches to months then
the scope for error can extend into years. It is only in the case
of death over the medium term that the Bill is of any help to
patients. If the patient's life is within hours or a few days
of its end, then the proposals in the Bill would not greatly assist.
Clause 2: Qualifying conditions
5. Key difficulties for physicians will
be in assessing whether or not a patient is suffering unbearably
as a result of a terminal illness, and in establishing that a
request for assisted dying is genuinely voluntary.
6. With reference to the latter point, we
note that in his book "A Good Death: conversations with East
Londoners", Michael Young writes about the huge fear of becoming
a burden which he finds to be felt keenly by those who are dying:
7. "The peace of mind which is both
so desirable and so difficult to achieve for a person so ill would
be more fraught if the patients were all the time wondering whether,
for the sake of their carers, they should seek an earlier death
than nature unaided will grant them. The right to die could become
a duty to die. It could nag continuously, so much so as to make
the last phase of life a torment on that score alone."
8. Perhaps it would be useful to include
in Clause 2 a section to the effect that physicians have a duty
to avoid advising the patient on their decision to make the declaration
or not. Their role should be to inform as best they can, and while
it may be impossible to avoid some personal preference for any
particular outcome, they should strive to let the patient make
up their own mind. Often when decisions are particularly hard,
patients resort to asking their doctor what they should do, but
it is just such decisions that are most important for the patient
to make an informed, as opposed to advised, choice.
9. Consideration also needs to be given
as to how this process of meeting the qualifying conditions is
to be met. Clause 2 (2) says that "The attending physician
shall have been informed by the patient that the patient wishes
to be assisted to die". How does the patient know that this
is an option? Does the physician inform the patient? If so, could
that be construed by the patient as a suggestion, or even a recommendation?
One practical solution to this could be to provide terminally
ill patients with a nationally produced leaflet of options for
their care, covering a wide variety of aspects, such as allowances
and benefits, prescription charges, hospice and palliative care,
NHS and non-NHS nursing services, and a section on assisted dying.
Clause 4: Declaration made in advance
10. This clause provides for a written declaration.
We believe that consideration should be given to a patient, who
is unable to sign a form, to be able to make a verbal declaration
(recorded as necessary) countersigned by a solicitor and another
witness in accordance with Clause 4. Without such a provision,
patients dying of paralysing diseases such as Motor Neurone Disease
may be unfairly excluded.
11. With regard to sub-clause (4) dealing
with witnesses other than a solicitor, consideration should be
given to including a requirement that no person is allowed to
act as a witness or signatory if they have a financial or similar
interest in the patient's death. It is true to say that a beneficiary
need not be a relative. Consideration should also be given to
making it a criminal offence to fail to disclose such an interest.
Clause 5: Further duties of attending physician
12. Here we consider the question of the
qualifications or expertise of the doctor who assists the patient
to die. Clause 5 implies this will be the attending physician,
defined in Part 1 as "the physician who has the primary responsibility
for the care of the patient and the treatment of the patient's
illness." As patients with terminal illness are, for the
majority of their remaining time, cared for by their GP, then
the responsibility for assisting the patient to die will fall
to the GP. However few GPs will feel they have sufficient knowledge
or skill to assist, so there would clearly be an important training
issue. Furthermore, it is likely that only a minority of GPs would
take up such training, so it will be necessary for the attending
physician to refer to a colleague who does have appropriate skill
for reasons other than conscientious objection. GPs who have undertaken
such training would be one option, but alternatives include Consultant
Anaesthetists, Palliative Care Specialists, or Oncologists.
Clause 6: Revocation of declaration
13. We question whether it is possible,
legally, to destroy any entry in a patient's records or if this
provision in the Bill will set a precedent in this matter.
Clause 13: Requirements as to documentation in
14. Sub-clause (2) requires the attending
physician to send a full copy of the file to the relevant monitoring
commission within seven days of the assisted death or attempted
assisted death: would it not be worth consideration to require
each event to be medically and legally assessed before the assisted
dying takes place?
Clause 14: Monitoring commission and reporting
15. The College takes the view that the
third, lay, commission member should not be restricted to someone
"having first hand knowledge or experience in caring for
a person with a terminal illness" because there is no such
restriction on the other two commission members (the registered
general practitioner and the legal practitioner).
Schedule: Form of Declaration
16. We suggest that "control of all
symptoms" should be added to the reference to (successful,
not just attempted) palliative care.
3 September 2004