Written evidence collated by The Royal
College of Physicians of London
ON BEHALF OF THE ACADEMY OF MEDICAL ROYAL
The Royal College of Physicians of London (RCP)
has considered this Bill both in its original 2003 version, and
in the amended version of 2004. It has been considered by RCP's
Committee on Ethical Issues in Medicine, and its Council.
Throughout what has been extensive discussion,
there has been considerable sympathy for the considerations that
have informed the proposed Bill: humane concern for the possible
unnecessary suffering of patients; respect for the autonomy of
patients in this most important area of decision making; and the
need to protect doctors who may be uncertain of their duties in
an unclear legal situation or who may be driven to activities
that are currently illegal by their wish to serve what they perceive
to be the best interests of their patients.
The first version of the Bill was unanimously
rejected both within RCP's Committee on Ethical Issues in Medicine
and within our Council on a variety of grounds including the fact
that there were serious ambiguities in the formulation of the
Bill. Many concerns were also raised about the impact the Bill
would have, if enacted, on the relationship between individual
patients and their doctors, between the medical profession and
society and also upon society itself.
The College reconsidered the Bill in detail
when it was proposed in an amended form, which had addressed some
of its concerns. Moreover, the initial response elicited some
extremely useful, and in part reassuring, information on the impact
of comparable legislation in other countries on the relationship
between doctors and patients and the medical profession and society
as a whole.
When the amended Bill was considered, there
was no longer a unanimous opinion. Setting aside empirical issues
regarding the impact on society, there was a clear division of
views as to its desirability from the ethical point of view. Extensive
debate both within the Committeeincluding presentations
from the Lord Joffe and Ms Deborah Annetts (in favour of the Bill)
and Baroness Ilora Finlay and Dr Rob George (against the Bill)and
within Council did not bring agreement any closer.
One area where there was strong and overwhelming
agreement, was that the Bill was essentially a matter for society
as a whole to decide and that the College should not assume a
position for or against.
The comments in our submission are therefore
confined to areas in which the medical profession could claim
to have a special understanding and expertise. It does not signal
support for, or opposition against the Bill, but instead highlights
those issues for practising doctors which would have to be carefully
thought through both within the Bill and any subsequent Code of
Practice, if assisted dying were legalised under the terms of
the proposed legislation.
Members of the Select Committee should note
that our submission incorporates the views of the Academy of Medical
Royal Colleges (AMRC) whose members were consulted in the course
of our deliberations.
1. When a patient seeks assistance in dying,
it is important to diagnose the reasons for this before discussing
this option. In many cases unbearable suffering may be due to
remediable symptoms. These should be identified and adequately
addressed. Doing so requires considerable expertise and this expertise
is unfortunately at present not available to all dying patients.
2. Many dying patients, are, for entirely
understandable reasons, depressed. This depression may not simply
be a reflection of their medical condition and may be amenable
to treatment by antidepressant drugs or by counselling. It is
essential, therefore, that a treatable depression should have
been identified and managed. This again requires considerable
3. It has to be recognised that autopsy
studies have shown that in a small minority of cases people who
are thought to have had terminal cancer turn out to have had a
treatable non-cancerous cause of death. This places the onus on
the clinical team to make an accurate diagnosis before even considering
4. The request for assisted dying may be
the reflection of a fear of the process of dying: these fears
should be identified and in many cases may be allayed by discussion
5. Palliative care specialists have noted
that unbearable suffering prompting the request for assisted dying
is often a reflection of unresolved psychosocial issues. These
should be identified and resolution attempted.
6. Finally, it is important to ensure that
the request for assisted dying, and the decision to grant it,
is the not the result of external pressures; for example the feeling
that one is a burden to others or that one is pointlessly consuming
There should be clear documentation that all
these concerns have been identified and addressed as far as possible.
It will be evident from the foregoing that the
management of the dying patient, and, more specifically a clear
understanding of the issues surrounding the request for assisted
dying, both require a high level of competence in making the complex
diagnoses. Anyone involved in the assisted dying process should
have received rigorous training in how to discuss these issues
with patients and with their supporters; in the legal framework
of assisted dying; in the appropriate methods of assisting patients
to die; and in the context and settings in which this should take
Any facility where it is likely that patients
will be requesting assisted dying should have a team of doctors
and allied professionals, who have willingly opted to belong to
the team and who could be well trained and might even be "on
call" when their specialised decision making assistance was
required. This of course would be necessary only if the Bill were
Consideration should be given as to who would
be responsible for assisting a patient to die. Not all physicians
will wish to be involved and this is acknowledged in the "conscientious
objection" component of the Bill. This should be clearly
supported in practice as well as in theory.
It follows from this that, other attendants
than those usually overseeing the patient's care (eg hospital
consultant, general practitioner) may be involved in assisted
dying. Co-opting others to assist in dying should be the subject
of careful consideration and even more careful scrutiny. The extension
of a nurse's role to encompass this assisted dying, for example,
would be a major step. Involving others less directly concerned
with patient care, such as pharmacists, is an even greater step.
How will this be arranged and how will this be perceived? How
will those requested to assist in dying cope with the impact on
themselves? As care is increasingly delivered in multidisciplinary
teams it is imperative that there are clear lines of responsibility.
Finally, we ask that the Committee give careful
consideration to the current recommendation to have two co-signatories
to sanction an assisted dying procedure, as a number of people
have questioned whether this constitutes a sufficient safeguard
against potential abuse of the law.
Audit and documentation
Many believe that the enactment of the Bill
would be a leap into the dark. There have been widely expressed
concerns about a "slippery slope"; that assisted dying
may be extended beyond those groups envisaged in the Bill to those
who seek euthanasia voluntarily while not terminally ill; or,
more worryingly, to those whose request for assisted dying is
not truly informed or even truly voluntary. There have been additional
worries that these concerns could have an adverse impact on the
doctor patient relationship and the relationship between the profession
and society as a whole.
There should therefore be sufficiently detailed
documentation and audit of the uptake of assisted dying in order
to address purposefully, rather than merely incidentally, the
concerns expressed with respect to "slippery slopes".
Audit should include a clear examination of the availability of
palliative care services to patients who have received assisted
dying to make sure this was genuinely a comprehensive service
and was truly accessible. In addition there should be proper evaluation
of the impact of the availability of assisted dying on the attitudes
of patients who have a terminal illness and on the relatives of
those who have died with and without assistance. Finally, there
should be regular surveys of public opinion about the impact of
the Bill in the areas indicated.
We also seek clarification as to whether assisted
deaths would require notification to the coroner. Since the immediate
event resulting in death would be unnatural, we presume that notification
would be required and that each individual death would be subject
to medico-legal scrutiny.
Campaigning for palliative care services
Even those who are opposed to the Bill welcome
the acknowledgement that there are patients who have unacceptable
deaths with unalleviated, prolonged and unbearable and pointless
suffering. Irrespective of whether the Bill is or is not enacted,
it should be seen as a trigger to campaign for better care for
dying patients. This includes not only an extension of first-class
palliative care services to all patients beyond those who have
traditionally received such care, but also a more rational, human
and intelligent discussion of a wide range of end-of-life issues.
The medical profession is not alone in experiencing increasing
uncertainty as to the proper approach to decision making in this
area. Technological advances, changing values and increasing ethnic
diversity of viewpoint have left many clinicians feeling bewildered
and at times unprotected when they wish to do what they see is
their human best for their patients.
The Royal College of Physicians and the Academy
of Medical Royal Colleges very much hopes that these essentially
medical consequences of a change in law should receive at least
as much attention as the ethical debate.