Select Committee on Assisted Dying for the Terminally Ill Bill Minutes of Evidence

Memorandum by The Royal College of General Practitioners

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 medical records

  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 requirements

  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

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