Examination of Witnesses (Questions 222
THURSDAY 14 OCTOBER 2004
and DR IVAN
Q222 Chairman: Thank you very much
indeed for coming. In the first session we expect to have the
colleges, the Royal College of Physicians and the Royal College
of General Practitioners, for about an hour, we thought; and then
the Royal College of Nursing at 3.30. The precise time is not
absolutely definite. I am sure the physicians and the general
practitioners know that the nurses need to be well heard, so we
will not unduly encroach on their time. I should explain that
the evidence that witnesses give is recorded, and the witnesses
will have an opportunity of checking the record, not in order
to improve their evidence, but in order to check that the record
of it was accurate. If you would like now to proceed, we would
invite you each to make a short opening statement, if you wish,
and then the Members of the Committee would like to ask questions;
and we are aiming at 3.30 for completion of this particular session.
Who would like to start?
Professor Tallis: Thank you. May I start? My
name is Raymond Tallis and I am Chair of the Committee on Ethical
Issues in Medicine at the Royal College of Physicians; and I have
come with Professor John Saunders, who is the Secretary of the
same committee. I am going to make a statement on behalf of the
Royal College of physicians and Dr Cox is going to make a statement
on behalf of the Royal College of General Practitioners. Professor
Saunders and I are very grateful to be invited to give oral evidence
to the Select Committee on behalf of the Royal College of Physicians.
As I have indicated, we are respectively the Secretary and the
Chair of the Committee on Ethical Issues in Medicine. This committee
reports to the Council, which is the decision-making body of the
Royal College of Physicians. What I want to do is very briefly
summarise the position of the college as has been established
in council, though, of course, I will not reiterate everything
that is in our written submission. We want to, first of all, emphasise
that throughout our extensive discussions there has been much
sympathy for the considerations motivating the Bill: a humane
concern for the suffering of patients, which may in some instances
be unbearable, unrelievable and, given the expected outcome, pointless;
respect for patients' autonomy as the cornerstone of medical care;
and also the need to protect doctors, who may be uncertain of
their duty in an unclear legal situation or who may be driven
by their wish to serve what they perceive to be the best interests
of their patients, to actions which are currently illegal.
Q223 Chairman: I wonder if perhaps
you could speak slightly more slowly, Professor Tallis, because
the young lady is taking it down and it is a bit of a challenge.
Professor Tallis: Yes, of course. The second
point is that our response to the later version of Lord Joffe's
Bill was different from our response to the earlier version. Whereas
there was a unanimous rejection of the first version of the Bill,
attitudes to the second version among members of the committee
were not unanimous. For example, some, such as myself, are in
favour of the Bill and others, such as Professor Saunders, are
opposed. Nevertheless, there is unanimity in the college as reflected
in the Committee and in Council on two things. Firstly, it feels
strongly that the Bill is essentially a matter for society as
a whole to decide; and, secondly, that the particular contribution
of the medical profession as represented by the college, which
does not assume the position for or against the Bill, is to highlight
those areas in which the profession could justly claim to have
special authority. We have therefore focused on those issues for
practising doctors which, we believe, would have to be carefully
thought through in formulating the Bill and in developing any
code of practice or guidelines if the Bill became law. Our position,
therefore, is neutral as regards the desirability of the Bill,
but we do welcome the opportunity to highlight the clinical and,
more widely, the practical issues associated with assisted dying.
In particular, we have been concerned about the safeguards necessary
to protect vulnerable patients, and in our submission you will
see that we have identified issues that need to be addressed in
several areas: accuracy of the diagnosis of the reasons for assisted
dying; the need for specific training of any individuals who may
be involved in assisted dying; certain aspects of the practicalities
associated with assisted dying, the need for audit and documentation
of the actual use of the legislation if the Bill is made law;
and the question; of the parallel development of palliative care
services. Each of these is more complex than may appear at first
sight. I know that Dr Cox, who will be speaking on behalf of the
Royal College of General Practitioners, will address these in
his opening remarks and some of them in more detail. For the present
I want to focus on just two areas: diagnosis and palliative care
services. Diagnosis goes beyond simply determining the nature
of the patient's illness and the physical cause of the symptoms
from which she or he is seeking relief. While acceding to a patient's
request for assistance in dying demands well-founded confidence
in the nature of the underlying disease and the specific cause
of the symptoms, much more is required. For example, it must be
clear that the symptoms cannot be resolved by any other means.
Depressive illness must be identified and treated. Fears about
the actual process of dying, which may be unfounded, must be elicited
and discussed and allayed where possible; and this may go a long
way towards relieving the patient's suffering and may indeed obviate
the need for assisted dying. Unresolved psychosocial issues which
may contribute to suffering must also have been identified, as
they may be resolved through discussion. Finally, and most importantly,
clinicians should be alert to the possibility that the request
for hastening death may be in response to real or perceived explicit
or implicit external pressures which may be internalised as the
desire to not be a burden to others. This implies a high level
of appropriate training in all aspects of end of life care as
well as in the specific skills required for assisted dying; and
it follows from this that careful consideration should be paid
as to who will be involved in receiving and implementing any request
for such help. Let me say something very briefly about palliative
care services. Clinicians working with dying patients are acutely
aware of the shortfall in such services in the UK at present,
especially for patients dying from non-cancer deaths outside of
hospital. Both those who are in favour of and those who are against
the Bill are united in their concern that assisted dying should
not be seen as a substitute for optimum palliative care, and,
what is more, that the availability of assisted dying should not
diminish the pressure to develop universal, high quality palliative
care service or reduce the sense of urgency to ensure that they
are available to all patients wherever they die and whatever their
cause of death. One final preliminary remark: we felt it important
that the Committee had both perspectives on the clinical consequence
of the Bill being enacted, both the pros and cons, in order that
we should uphold the college position and of what we might call
"ethical equilibrium". For this reason, we would like
to beg your permission for both of us, John and myself, to respond
if necessary to your questions, particularly if one of us feels
that the other is making too light of or overemphasising the difficulties.
This in other words is intended as a means of preventing ourselves
from drifting into advocacy of one or other position with respect
to the Bill, because, I cannot emphasise too strongly, the position
of the college is that of neutrality.
Q224 Chairman: Thank you. Professor
Professor Saunders: Thank you, Lord Mackay.
I do not wish to add to that. Professor Tallis has spoken on behalf
of both of us and I would like to lead on to my colleague.
Dr Cox: Thank you, Chairman. My name is Ivan
Cox. I am a GP of 30 years standing from the City of Birmingham,
previously an officer of the Royal College of GPs, with particular
interest in palliative care for the last 12 to 15 years, working
with London Cancer Relief on developing projects for GPs in palliative
care. Thank you very much for inviting our colleagues to submit
evidence. I will try not to repeat the stuff that was in the original
written evidence, although I may do so deliberately in order to
emphasise its importance. Our college was unfortunate in that
it received the Bill, was not able to discuss it in council and
in depth but, nevertheless, the Bill went to over 30 members of
our college who gave their opinions on it and went to several
committees, including our Ethical Committee, who also made comments
about it. We too as a college want to take a similar stance to
the Royal College of Physicians, and that is a studied neutrality.
I am not going to go into detail now about the reasons for that,
and perhaps you might like to question us later on this particular
issue. Our college became more concerned about the practicalities
associated with the enactment of a Bill like this, probably at
two levels. The first level really is related to issues that might
need to be considered before proper drafting of the Bill to do
with definitions and wordings; and, secondly, issues that are
related to its implementation which may or may not actually be
better considered when considering regulations or codes of practice.
Nevertheless, I think they should be considered at this stage.
Professor Tallis has already mentioned issues to do with definitions
and with regard to diagnosis, so I will not repeat that, but members
of our college also have difficulties with proper definitions
of what we might call terminal care, or terminality, as it is
sometimes described. A doctor deciding that a patient has reached
a terminal state is very difficult. In some of the work that I
personally have done with doctors on this we have recognised that
doctors make arbitrary decisions about when a patient has reached
a terminal stage. This can be when the patient is discharged from
specialist care, when the patient moves from a curative state
to a palliative state; some actually just use the position when
what is known as the DS1500 form is actually prescribed, or some
just use the point where patients have become bed-ridden or immobileso
it is not easy. The other issue is related to the definition of
"unreasonable suffering" which is in the Bill. Most
people recognise that anybody who has a disease or any illness
actually is suffering, and where "unreasonable" comes
into this is sometimes a matter of opinion. It is not an objective
state. We wonder whether Lord Joffe might not mean "unbearable"
or "unrelievable". There are also questions about competence
and how one arrives at a state, an understanding of whether a
patient is competent to make such a decision. For instance, if
someone had a long history of psychiatric illnessdepression
or a psychotic illnesshow would one then decide that the
decision that their life-threatening disease would make them competent?
If at times they had been depressed and they were depressed because
of the illness, would a psychiatrist not say they are not competent
because they are depressed and they had been depressed previously?
Then there are issues to do with the implementation and the regulation
of the Bill, and I think probably one of the crucial things that
we GPs are concerned about is what is meant by "the attending
physician" and "the consulting physician"? Certainly
some of the papers that I have read and others of my colleagues
have read about this Bill and about the doctors concerned seem
to make the assumption that the attending physician could well
be the general practitioner and that the consulting physician
may well be perhaps a specialist, like a specialist in pain care
and pain management, although, again, it is not clear. The implications
of this are that, if it is to be GPs, then we need to be very
clear about that, because there are a number of GPs who would
opt out, as they opt out of providing services through the Adoption
Bill. We need to be very clear as to how those GPs would handle
patients who had requested assisted dying, because some may well
feel that the request coming from the patient would mean that
they could not make a choice because, if they passed them on to
a doctor who did support assisted dying, that would compromise
their ethical stance. So it is important to be absolutely clear
which doctors would be providing the service. A lot of discussion
has been about the erosion of trust (and we may well come back
to that a bit later) and the changing doctor/patient relationship,
but I think several of my colleagues feel that there would be
significant erosion of trust in the doctor/patient relationship,
although others feel that this is a dynamic and may not change
as much as people expect. There is also concern about the regulatory
framework and the implications of enactment of this Bill. Dare
I mention it, but there is a post-Shipman effect, and I have to
be very careful about using that term in a context like this.
No-one can actually quite measure what the Shipman effect has
been, but there are certainly anecdotal stories amongst the public
and amongst doctors that patients now are fearful that general
practitioners coming along with morphine may well actually want
to put them to death and those sorts of things. We do need to
consider the implications of a Bill like this on what I have described
as the Shipman effect. Finally, Chairman, I just want to reiterate
what my colleagues have already said about palliative care. A
lot of what this Bill seems to say is predicated on the provision
of adequate, if not very good, palliative care before the patient
reaches the point of making a decision that they want to die.
Unfortunately, there are not adequate palliative care services
in this country at the moment. Most GPs would consider this a
part of their core service, but in a number of places where what
you might describe as basic palliative care could be provided,
there is not specialist palliative care to add to that. I am sure
they would actually reiterate that. Thank you, my Lord Chairman.
That is my introduction.
Chairman: Thank you very much indeed.
Q225 Lord Taverne: The first thing
I would like to explore is a lot of the points which have been
raised by the fears which patients have, and also the question
about how far patients are competent to make decisions. These
points have been raised, which are obviously of very great importance.
Does that not really mean that it is extremely important that
the doctor should be in a position to discuss matters with the
patient? And is it not really rather an important fact that all
the evidence suggests that in The Netherlands, where they have
now had seven years experience of euthanasia, doctors are far
more ready to discuss matters with patients and patients are far
more ready to discuss matters with doctors, than they are elsewhere?
Just quoting the figures, a study of medical decisions across
six European countries found that in 92 per cent of the cases
in The Netherlands doctors discussed end of life decisions for
competent patients, 78 per cent in Switzerland, 67 per cent in
Denmark, and then it declines into the other countries down to
38 per cent in Sweden, where one does not discuss this at all
because there is very strong opposition to euthanasia. Is not
this ability to discuss also reflected in the fact that the Dutch
doctors are the most trusted of any doctors in Europe? Is not
this therefore an argument in favour of changing the law rather
Professor Tallis: John, would you like to lead
on that one on behalf of the Royal College of Physicians?
Professor Saunders: Yes. The first assumption
there is of cause and effect. You could, of course, be right that
having a law of this sort opens up and makes discussion more likely,
and on balance I would have thought that that probably is true.
I would certainly take the view, and I think the College would
take the view, that the more discussion there is between doctor
and patient about these issues the better. I think we would also
agree, and I think it is probably a College view too, that there
is very good evidence that even in the UK practice there is more
discussion about end of life issues of all sorts with patients
than there was, for example, 10 years ago. The specific documentation,
of course, comes with a separate issue, the discussions that are
based around non-resuscitation or attempted resuscitation orders.
We know that these things are better discussed than they ever
were 10, 20 years ago; so we are improving, in an improving position.
There is, of course, great difficulty in international comparisons,
which I would simply flag up. There are different systems of healthcare
in place across Europe; there are different cultures, subtly different
cultures in some cases, and I suppose you might suggest that Northern
Europeans might have a more common outlook than perhaps others.
Certainly there are differences and I would not wish to draw too
firm a conclusion from the suggestions you make, but I think it
is plausible that enactment of this Bill will improve discussion,
and that at least might be one of good effect. Can I just add
one foot-note to that. The foot-note I would like to make is that,
in order to assess a patient fully, there are great advantages
in a long knowledge of the patient. I think we all acknowledge
that that is good practice, that patients you have known for five,
10, 15 or 20 years are far easier to assess, far easier to evaluate
their critical interests as opposed to their momentary experiential
interests, and that, of course, is difficult in this Bill with
the role of the consulting physician in particular.
Professor Tallis: May I reinforce that last
point? It has implications for those who will be involved in the
actual implementation of assisted dying. John and I have a different
reading, in a sense, of the data that reflects perhaps our different
positions. I have been very impressed by the international comparisons
and, in particular, by the level of trust of Dutch doctors, the
way they are viewed by the population as a whole and by their
patients. Having said that, we all know that measuring trust is
not an easy thing and there will always be methodological problems.
So, whereas I am impressed by the data, it may well be the case
that we need more information in that area. I know Ivan has some
views about the complexity of measuring trust.
Dr Cox: There are two things I would like to
say. One is to reinforce what John was saying earlier about interpreting
the data in the sense that there may not be cause and effect.
We have done some work within our College in training doctors,
training general practitioners particularly, in palliative care,
and we have recognised that training in palliative care has encouraged
doctors to discuss issues relating to the dying of their patients.
The whole issue of learning about breaking bad news has helped
doctors actually approach the subject with their patients. But,
again, the issue in relation to trust between doctor and patient
and the development of a doctor/patient relationship is always
a dynamic; it cannot ever be seen as something static. There have
been a whole series of events in healthcare in this country which
have supposedly shifted the relationship between doctor and patients:
new contracts, the Shipman affair, the Bristol affair, and whatever,
would seemingly have undermined the public's trust in their doctors.
But actually, if you do straight surveys of patients and what
they think of their doctors, particularly their GPsI have
got to say that because I am a GPthen you discover that
well over 90 per cent actually still respect their GPs considerably.
So you do have to take the information a little carefully. As
I have said, the issue of trust is a dynamic. There are all sorts
of different things going on at any one time, and it is like societysociety
evolves. So one thing may provide a negative influence on the
doctor/patient relationship, but then equally in relation to the
evidence that you are producing would suggest that in The Netherlands
things have improved, doctors do discuss it much more efficiently
and effectively, and I am quite sure the same thing will happen
in this country.
Q226 Lord McColl of Dulwich: Very
briefly on this one question, the idea of a long knowledge of
a patient being an advantage, would there be something to be said
for having a patient who wishes assisted suicide being admitted
to a hospice for a week, where you would get a very good assessment
and you would also see the effect of treatment?
Professor Saunders: I think the one word answer
to that is, "Yes", if that was possible. Unfortunately,
as a practical issue, I suspect it would not be possible, and
it is one which I think will have to be considered as a practical
issue if this Bill becomes law. But I entirely agree with you,
Lord McColl I think that the assessment by the attending
physician is all too easily going to be a superficial issue. One
can use the words "rigorous", "thorough",
"detailed", and all the rest of it, but I think we all
know how people do rigorous, detailed and thorough examinations
of bodies before bodies are cremated. We know that those words
become rather meaningless in practice, and this is the point at
which, if enacted, this Bill may be assisted by a code of practice
to outline what we actually mean by a thorough or detailed assessment
by that attending clinician. It seems to me that to come to see
somebody and assess them over a 15-minute or 20-minute or half-hour
period may be grossly inadequate, that there may be conflicts
that it would be foolish to pretend you would uncover in that
time, and the patients' interests would accordingly be misinterpreted.
These patients, after all, we can all agree, are particularly
vulnerable, and the second opinion is going to be a key person
in it. I think one also has to say that there is a danger in that
second opinion, unless there is some sort of code of practice
in place, as a purely practical issue, that the same person would
be providing the second opinion, because there are going to be
a limited number of such patients, I suspect, and when a second
opinion is asked for it is always going to correspond with the
first opinion by virtue of the choice of second opinion who is
approached; and I do see that as an important practical issue.
Professor Tallis: I think that relates to a
key issue about the context in which this takes place, and I am
very interested in the Oregon experience, that a very high proportion
of people who have assisted in death actually do so in the context
of palliative carethey will have either received palliative
care or do so in the context of palliative care, and it seems
to me that this illustrates perhaps the non-conflict between palliative
care and supporting someone through assisted dying.
Q227 Bishop of St Albans: I am absolutely
intrigued about the notion of studied neutrality. I think you
were inviting us to raise a question or two about that. Professor
Tallis, you talked about respect for personal autonomy as being
the cornerstone of medical care, so presumably the College has
a common mind on that. If it can have a common mind on that, why
does it find it so difficult to have a common mind about this
particular issue? Is it that actually having a common mind is
not important, or what? I am just intrigued by the kind of tensions
that lie within the kind of statement that you have made.
Professor Tallis: I think the big problem is
the question of whether autonomy is, as it were, the sovereign
bio-ethical principle, and I think there is not an agreement on
that. There is no doubt about it; autonomy is the cornerstone
of general medical practice, it is in a patient's actual care
and so on, but there are certain issues where there may appear
to be conflict between the value of autonomy and other values,
and that is where the College, I think, have recognised that there
will be no consensus on that particular area of conflict. Therefore
the role of the College is to give good clinical advice if the
Bill were enacted.
Q228 Bishop of St Albans: So does
that mean that the College is abdicating its sense of responsibility
to think through bio-ethical issues of this magnitude?
Professor Tallis: Individual fellows and members
of the College will have their views and will express them. The
corporate body, as it were, so far anyway, has not reached a consensus
on that particular issue, and for that reason we act both as private
citizens, as it were, and also as representatives of the College,
and I think the college has a particular concern about training
and quality of medical care. That is its central role and that
must be the focus of the intervention that it offers in the debate.
Q229 Bishop of St Albans: I recognise
that. Because you invited us to ask why you were neutral, I am
just trying to find out why you are. Does this mean, therefore,
that I think I am right in saying in the Patient
Assisted Dying Bill 2003 the College said there would be difficulties
over the issue of personal autonomy when there are individuals
suffering learning difficulties, or communication problems, or,
indeed, issues of psychiatric concern? Have you changed collectively
your view on those difficulties now? Or are we to take it that
the views are still certainly those of individuals and not of
Professor Tallis: I think there was an effect
of the cumulative impact of several changes in the Bill, including
the definition of the kind of patients who will be appropriate,
who may be related to assisted dying. There seem to be more safeguards
built into the Bill. This is a quite significant change in the
Bill, and that is why it was felt that the College should revisit
the Bill, and that is when, if you like, the balance of opinion,
or the range of opinions, became more balanced than in the case
of the original Bill, when there was fairly uniform rejection
of the Bill.
Q230 Bishop of St Albans: Thank you
Dr Cox: I am sorry Bishop, if I may come in
too to reinforce much of what Professor Tallis has said, and to
add the fact that within the College, our college, the Royal College
of GPs, our studied neutrality has come through in some circumstances
an examination of the experiences of Oregon and of The Netherlands
and to some extent the Euthanasia Laws Bill in Australia and attempts
in New Zealand to change things. We see ourselves as an academic
college, not a democratic institution, I think is a better way
of putting it, in the sense that we try to achieve decisions by
consensus. When it is quite clear that there is a significant
division, almost 50:50, as it would be in our College now, we
do not feel we can make definitive statements, and that is where
we come from.
Professor Saunders: One further foot-note on
that, if I may, Chairman, and that is to say that we do agree
that autonomy is the key cornerstone of medical practice, but
within the committee of ethical issues in medicine over the years
there has inevitably been debate as to actually what we mean by
that concept. I do think that word is very easily traded about
as though it has a rather obvious meaning. We have debated over
the years the definitions and nature of autonomy as to whether
we understand it simply in the terms of personal liberty, as I
suppose most memorably described by John Stuart Mill, or whether
we actually think of it as having a tension between autonomy which
we may construe as some sort of atomistic individualist consumerism
(or something of that sort) verses autonomy in society, in which
there is inevitably a social animal, a social human being, exercising
choice but within the perspective of community responsibility
and some sense of solidarity; and as a College we have debated
that over the years. Certainly it does seem to us that this word
"autonomy" is not capable of some simple off-the-shelf
understanding in the way that it is often construed.
Q231 Lord Carlile of Berriew: I do
not know if Dr Cox's 50:50 was a scientific estimate or a guesstimate,
but let us suppose that it is a reliable guesstimate. In an academic
institution that seeks to make change by consensus, would Dr Cox
agree that a 50:50 division shows such a huge absence of consensus
that it would be extremely difficult to deliver ethical rules
which commanded anything like the consensus that is necessary
for such rules?
Dr Cox: Lord Carlile, I am not sure I can answer
that, in the sense that what we have tried to do in getting information
about this Bill is to ask a number of general practitioners, senior
general practitioners within the profession. They have responded
with a wide range of responses. As we have not had the opportunity
to discuss this fully in council, it has been decided that at
this stage we would not feel able to make a definitive statement
about the ethics and morality about this. We would, if we had
the opportunity, have gone to council and had a full debate on
this. There was a debate on this some years back at which time
the council decided that it would not support a Bill of this particular
nature, but, as we have not had the opportunity to discuss it
in detail at this stage in full council, this is one of the reasons
we have decided to retain a neutral position.
Q232 Lord Carlile of Berriew: May
ask one other question. I understood Professor Tallis to be saying
that he would prefer the test of "unbearable suffering"
to be replaced by a test of "unrelievable suffering".
Does he agree that to do that would completely change the character
of the Bill? The definition of "unbearable suffering"
is plainly subjective; "unrelievable suffering" would
plainly be objective and, therefore, surely would place on a doctor
the intolerablefor manyand, in my view, ethically
incorrect responsibility of making a judgment as to whether a
person should be killed irrespective of that person's wishes?
Professor Tallis: I am not aware that I made
that point explicitly.
Q233 Lord Carlile of Berriew: I took
a note of what you said. You did actually say that.
Professor Tallis: I said "unrelievable
suffering" in my summary.
Q234 Lord Carlile of Berriew: Yes?
Professor Tallis: Fine. It seems to me that
my choice of adjectives--
Q235 Lord Carlile of Berriew: You
can change your mind if you want to, but we need to be clear?
Professor Tallis: I did not change that. Perhaps
I should have done. The principle behind your question is a very
serious point, which is that of how do you evaluate suffering
and what is the point from which you can most safely evaluate
it? Should it be based on objective criteria or on subjective
criteria? I think you have put your finger on what is one of the
central difficulties of pretty well all of medicine; it is not
unique to this particular issue. In other words, when you are
deciding what the patient's interests are, what you should do
for the patient, do you, as it were, adopt the subjective viewpoint
of the patient? Or do you try and determine, on the basis of objective
pathology or whatever, what you expect they should be suffering?
It seems the whole trend of medicine, I think, over the last few
years, which has become much less paternalistic, much more patient-centred,
is to respect the subjectivity of patients, which is really, in
a way, to rely on a patient's testimony above all as to what counts
as "unbearable", "unrelievable", or whatever,
and I think that is the position from which I am coming. I do
not know whether John may wish to develop that.
Professor Saunders: I think the interpretation
of experience for all of us is filtered through our role as members
of society and responding to the language and mores of society
around us. That is why autonomy is such a very difficult concept.
Let me give a rather trivial example to illustrate what I mean;
may be it is not so trivial. I can remember many years ago somebody
telling me how they had been brutalised by a British soldier at
a check-point in Northern Ireland. When I asked them what had
actually happened, it appeared that they had been searched rather
like I was today on entry into this House. But, of course, it
was the language of the time that what British soldiers did to
Irish subjects was brutal so, by definition, this person had been
brutalised. Language of that sort rapidly acquires the meaning
of the context in which it is occurring and it reflects the social
mores of time, and the word "unbearable" is a word that
is going to have that sort of meaning put upon it. I hope I have
made that point clearly. It does seem to me there is an inevitable
subjectivity about defining "unbearable" which we sort
of understand in practice but which in trying to put into so many
words and trying to litigate for is fraught with enormous difficulties.
I have great difficulties of a practical kind in saying if we
have the power to put into people's hands to authorise killing
on these grounds, what is the testwhat is the test by which
they can defend themselves in the event of having killed that
patient, and what is the test that would stand in law? What also
is the test that stands ethically, and I think that is exceedingly
Dr Cox: Could I respond to Lord Carlile's comment
in a sense, because I also mentioned the difficulties in this
definition of "unreasonable". Our view would be that,
yes, it does place a considerable burden on the doctors in helping
the patient to make decisions. Using the terms "unrelievable"
or "unbearable" seem to us to be terms that are more
measurable. One of the things that we doctors often want to do
is to have guidelines and to have tools that we can use to measure
certain aspects. Using the term "unreasonable" is, as
you say, a subjective one which does not have within it abilities
to actually measure it effectively, but using "unrelievable"
you can define issues relating to the patient that you could measure
and you could give scores to. You can actually use pain scores,
for instance, which are used quite often in palliative care, so
there is a possibility of using these terms instead of the "unreasonable".
Q236 Baroness Jay of Paddington:
I wonder if I could just ask you a brief factual question to start
with. The written evidence we have is on behalf of the Academy
of Medical Royal Colleges as well as the Royal College of Physicians,
so that simply includes the Royal College of General Practitioners?
Or are you in a sense representing others as well?
Professor Tallis: The Academy is an umbrella
organisation and the document we presented from the Royal College
of Physicians was submitted to the Academy by our President, Professor
Black, and she invited them, as it were, to adopt it collectively.
Some suggestions for modification were included, but it did not
preclude in any way separate submissions. You will be aware, for
example, that the Royal College of Anaesthetists have made a separate
submission in which they take quite a different view from that
of studied neutrality.
Q237 Baroness Jay of Paddington:
This is, as it were, a general umbrella?
Professor Tallis: It is an umbrella organisation
basically to coordinate responses to inquiries and documents and
so on. Because we have a multiplicity of something like twenty
plus colleges, it is a way in which there can be a single voice,
if you like, within the medical profession on issues which are
of common interest.
Q238 Baroness Jay of Paddington:
I wonder if we could just return to this difficult question about
autonomy, and I must ask forgiveness from my fellow members of
the committee for quoting again from one of our senior moral philosophers
who has submitted evidence to the committee and, I think to me
at least, helpfully tried to identify its relevance in this document,
and I would be very grateful for comments from you all on it.
It says, "I do not believe an individual autonomy is the
highest moral value. It should often be postponed to another higher
value, such as consideration for common good if these are in conflict.
However, in the case of a patient who is and knows that she is
terminally ill and who would quite deliberately end her own life
if she had the means or physical confidence to do so, then it
seems to me there are no seriously conflicting values."
Professor Saunders: I have volunteered to take
that question. I do not agree with the premise, and that, of course,
is not my position representing the college, though there has
to be a personal response in that I do believe that the main ethical
doctrine today's Western Society, I think, is probably best articulated
through Kant's concept of respect for persons, though Kant, of
course, is respecting a much longer old tradition in the West
we are all aware of that. But I do think that the common good
verses autonomyif the two are in opposition, I think autonomy
would win. I think I would have to add that my understanding of
a Kantian perspective, to which you would get a far better answer
from Lady O'Neill in your own House, would of course be that the
Kantian view is that autonomy must be principled, and to be principled
there must be some concept of a general moral law that can come
from the use of that autonomy. I would acknowledge that in the
implementation of this Bill, or indeed in the opposition to this
Bill, there is inevitably a tension, if the Bill is not enacted,
between some people, and proportionality is all-important, I think,
which is an empirical issue. There is a proportionality issue
between thwarting the freely expressed wishes of some people against
the common good, and I think the proportional issue is morally
extremely important. From my perspective, of course, I think it
is not of such a scale as to pass the Bill but others will take
a different view, and on that the College can have no view.
Q239 Baroness Jay of Paddington:
Quite, and I wonder if Professor Tallis would like to add to that.
Professor Tallis: I cannot dissent from anything
that John says, and we have had a lot of discussions on autonomy.
For example, the fact remains that autonomy is always compromised,
is always contextualised and so on, and so there is never absolute
autonomy, but indeed it has to be principled, exactly as John
has said. The question isdoes this deliver us a decision
about this particular issue? Does the relationship of autonomy
to other values such as the common good give us a way of deciding
on this particular issue? I think on balance, in our discussion
within the Committee on Ethical Issues in Medicine, on which we
have theologians, ethicists, people like John, and so on, this
was probably unresolvable and that is why we have taken the stance
of studied neutrality and said that our role is to contribute
as individuals in the debate while, as a college, our special
authority comes not from resolving these meta-ethical questions
but from giving advice on the clinical implications and consequences.