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

Examination of Witnesses (Questions 222 - 239)



  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 Saunders.

  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 immobile—so 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 illness—depression or a psychotic illness—how 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 than resisting?

  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 GPs—I have got to say that because I am a GP—then 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 society—society 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 care—they 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 the College?

  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 very much.

  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 intolerable—for many—and, 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 test—what 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 difficult.

  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 autonomy—if 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 is—does 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.

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