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


Examination of Witnesses (Questions 320 - 339)

THURSDAY 21 OCTOBER 2004

DR MICHAEL WILKS, DR VIVIENNE NATHANSON, PROFESSOR SIR GRAEME CATTO and MS JANE O'BRIEN

  Q320  Baroness Finlay of Llandaff: Sir Graeme, can you tell us how many of the new registrants with the GMC are UK graduates from UK medical schools, and how many are graduates from schools elsewhere?

  Professor Sir Graeme Catto: I think it still remains around 50 per cent. It is about 6-7,000 that are UK graduates and about an equivalent number coming from overseas.

  Q321  Baroness Finlay of Llandaff: Of those coming from overseas, do we know how comprehensive their training is in palliative care and in communication skills?

  Professor Sir Graeme Catto: We have no direct evidence. We no longer inspect overseas medical schools in the way that we did, but there is an assessment, an exam, before those doctors can work here, so we do assess their competence at the point of entry before they work within the United Kingdom system.

  Q322  Baroness Finlay of Llandaff: Does that exam include a section on palliative care?

  Professor Sir Graeme Catto: It includes all aspects of the care that they may be expected to provide in this country, so there are questions relating to palliative care included in the assessment, yes.

  Q323  Baroness Finlay of Llandaff: Dr Nathanson, from your experience of teaching students, even graduates from this country who have had some exposure, do you feel that they feel competent to have some of the complex discussions and take the decisions on their own? or do they feel they need input from other professionals, such as the nurses who are closely involved in the care of the patients?

  Dr Nathanson: I think that you are absolutely right that, particularly after a little experience of clinical medicine, doctors are very aware that the key issue here is about team-working, about different members of the team with different skills and different experience, giving the patient different levels of information in different ways; and that the best palliative care is offered in that team sense. Nurses can give assurances and reassurances that are different from those that are wanted from doctors. With experience, I think all doctors would say the same thing: many patients who raise questions about the end of life and euthanasia or suicide, sometimes in very heavily coded ways and sometimes more explicitly, are very often asking quite simply, "what services will be available to me if I develop symptoms that I cannot accept, that are intolerable to me?" It is not always pain; it is very important to recognise that symptoms that people are most worried about are very varied. They want reassurance. I remember well one patient saying to me, very explicitly: "What I want to know is that I will not be abandoned; there will not be a stage at which people say, `there is nothing more we can do for you'"—they can just go away quietly, into a corner almost. That is a very important reassurance to give, to say that we do not abandon people; that we will always look for what else we can do; and that sometimes those solutions are high technology but very often they are low technology and are about reassurance. That is one of the key issues that these discussions, whether they have in them the possibility of physician-assisted suicide or not, are all about reassurance; that you are valued as an individual and treated as an individual and will not be abandoned.

  Q324  Baroness Finlay of Llandaff: Given that we are looking at this Bill, which focuses in large part on the patient being able to take whatever medications are prescribed themselves and therefore physician-assisted suicide, but accepting that there will be some who, for reasons of physical disability, need the medication administered to them, and therefore that is euthanasia, do you feel from the response coming from your membership that a separate independent service to deliver such lethal medication would answer society's request and the small number of patients who say that they want to be killed. It would mean that the doctor was not the vector and was not therefore intending to kill the patient within the terms of euthanasia? What is your response to that?

  Dr Nathanson: That has been raised several times in the debates we have had on these issues because, although it is still a minority, there are more doctors who are comfortable with the concept that they might prescribe drugs which the patient could self-administer; but there are very, very few who say that they would ever be prepared to then administer those drugs themselves. There have been discussions as to whether there should be a separate service. What doctors find it impossible to consider is who would want to provide that service. They find it almost impossible to conceive of the person who would want to spend their life administering lethal injections. Whether such a service could ever be set up, and who would be the people who took part in it, raises very serious questions.

  Q325  Baroness Finlay of Llandaff: Sir Graeme, Lord Taverne has spoken about the figures suggesting that there are a lot of doctors who are killing their patients covertly; and this Bill is talking about it becoming overt. I just wondered what the GMC is doing about the numbers that we have seen in the papers at times which state that there are several thousand doctors in the country who are covertly killing their patients.

  Professor Sir Graeme Catto: We have no evidence that that is the case, and we have had a discussion this morning about the anecdotal nature of some of these reports. No doubt there is some truth behind them, but we have no objective evidence of which I am aware that this exists. I wonder if I might pick up the point about the teams of doctors who might go around administering this service. From the General Medical Council's point of view, our interest would be to ensure that the patients had given properly-informed consent to that. As I indicated before, my personal experience of dealing with patients on dialysis is that it was frequently a topic about withdrawing treatment, to which they would return but not frequently make use of. I think society would want to be absolutely sure that patients who did consider this had a long-term relationship with the doctor, and that these considerations were fully understood before an irrevocable decision was made.

  Dr Wilks: I would be very uncomfortable with that kind of service, I have to say. Obviously, if one says, "we would not be in favour of euthanasia", then we are in some people's minds abrogating responsibility for looking after patients who want to die in that way. I do think that the establishment of a separate service is a kind of signal that there is a different group of patients who do not deserve the same kind of overall assessment and communication and discussion about options, and that they can go off to the euthanasia service instead. I would be very concerned that that process could be so easy for patients to take advantage of it if it is there. Part of our concern would be that a lot of the evidence we have had about patients' desire for euthanasia is based on their perception that they are a burden to their families, to the Health Service; and that would be reinforcement of that feeling—"ok, if you feel a burden, you know where to go". I think that would be a very worrying development.

  Q326  Lord Joffe: I have a couple of statistical questions of Dr Nathanson, and then to Dr Wilks, arising out of a couple of responses to the questions from Baroness Jay about studied neutrality and weight of opinions. Is it correct that in 1992, at the annual conference, 54 per cent voted against euthanasia, assisted dying, and 46 per cent in favour? For some reason it is on both sides of that in the submission, but not that particular statistic.

  Dr Nathanson: I do not have that statistic with me. We will look it up in the records. There has always been a majority voting against, and that majority has varied slightly from year to year. I do not have any information on that particular vote. We have quoted all those that we thought we had records of, but we will certainly look it up.[1]


  Q327  Lord Joffe: You could write to me?

  Dr Nathanson: Absolutely.

  Q328  Lord Joffe: Dr Wilks, does the BMA accept that there are some terminally ill patients who ask for assistance to die for whom palliative care is unable to address their unbearable suffering?

  Dr Wilks: Yes.

  Q329  Lord Joffe: What does the BMA suggest should be done about these patients who are suffering unbearably?

  Dr Wilks: That they should be offered the best care that we can provide. I think that, having said that, we accept that there are such patients. Obviously, one is too many, but the numbers are not very great. I think that very often further exploration with the patients about what kind of tolerability they have, whether it is physical pain or whether it is other types of distress, can improve their care. One of the issues here is that we do know that there are a small number of patients who may request euthanasia who will suffer as a result of not having euthanasia. This gets back to the balance of harm and benefit in legislation, as in the case of medical treatment. The harm that the BMA believes will accrue from providing to that sort of patient the facility to die at their request and at the time of their request, is counterbalanced by the potential harm of creating a bill in which the sort of regulatory problems we have already rehearsed here would be very real. It is a tough call to say that some people might have to suffer as a result of protecting vulnerable people, but it is the kind of honest judgment that professional bodies such as the BMA should make.

  Q330  Lord Joffe: If one looks at a patient like Dianne Pretty—and the facts are well known—she should just be left to suffer!

  Dr Wilks: No, absolutely not. Dianne Pretty was someone who requested the ability to choose the time of her death, but behind your question is something that we talked a bit about before here today, which is that there is an assumption that not providing assisted death for a patient is synonymous with abandoning them. It may be inadequate in the eyes of someone in Dianne Pretty's situation, but it is simply not good enough in medicine to say, "we will look after you the best we can but we won't kill you". It is not right, I think—and it is getting into common parlance—that medicine will say, "once we cannot do anything for you, we have nothing to offer". Our guidance and the GMC's guidance on the withdrawing and withholding of treatment makes it absolutely clear that the obligation of the doctor to the patient continues well beyond the withdrawing and withholding, or no further treatment, in the context of basic care—warmth, palliative care, pain relief and food, and all the things that will make that patient comfortable and preserve their dignity. We could not offer all the things that Dianne Pretty wanted, but we also could offer a lot.

  Q331  Lord Joffe: This Bill contains an array of safeguards. What safeguards are there in place in  other end-of-life decision-making such as withdrawing or withholding treatment, or terminal situations?

  Dr Wilks: A number, and they are enshrined in the BMA's guidance on withdrawing and withholding life support and medical treatment and in the GMC's guidance on the same topic. Both contain a fair degree of commonality in the area that you are asking. The first is that a careful clinical judgment is made about the benefits and harms of continuing treatment, of alternative treatments, including no treatment at all. That is the medical part of it, and what doctors do best—making that kind of balance of judgment. As I said before, that is not good enough. You then have to go on and see that clinical decision or those clinical options through the eyes of the patient and, when you have got a competent patient, obviously that is achievable, depending on good communication. Where you have patients that are incompetent or children, you have other ways. Our guidance on withdrawing and withholding artificial nutrition and hydration requires a further assessment by an independent doctor. It requires that, if there is disagreement between patients and their families, the case goes to court and is arbitrated by a court—which we have recent experience of, as you will be aware. And, of course, from the General Medical Council's point of view, doctors who have strayed outside those rules—and we have one example of that where they had their licence threatened by the GMC. There are safeguards built in.

  Q332  Lord Joffe: If there is no legislative safeguard it is left solely to the BMA and the GMC, why is there such insistence and concern by the BMA about the legislative safeguards that are incorporated in this Bill, when, after all, one would hope that the BMA and the GMC in principle would draft similar guidelines to those excellent guidelines you have at the moment?

  Professor Sir Graeme Catto: Were this Bill to become law, it would present no insurmountable problems for the GMC. There would be challenges we would be required to meet, but there is nothing that would cause us at the present time insurmountable problems.

  Q333  Lord Joffe: In relation to this Bill?

  Professor Sir Graeme Catto: In relation to this Bill.

  Dr Wilks: There are two things. If the Bill were to become law, the duty of the BMA would be to draft guidance to doctors on how to operate within the new legislation; but our job in representing our members' view is to come here today and look at the practical difficulties around the legislation being enacted in the first place, and I hope that is what we are doing.

  Q334  Earl of Arran: Dr Wilks, you have said the ground has shifted—your words—in relation to opposition to this Bill. Would you accept, as the arguments sway backwards and forwards, that probably assisted suicide is inevitable?

  Dr Wilks: I have a personal feeling—and I would like to stress, a very personal view—that some form of assisted death legislation in this country is inevitable at some stage. That is a very general statement, but I say that because partly it comes from the discussions Baroness Hayman initiated. People do have difficulty with the difference between the legal right to refuse treatment, even if it results in your death, and requesting that death a little bit sooner. When you look at society's views, as far as one can test them and judge them, we in medicine talk very clearly and quite passionately about people's autonomous rights to make a decision for themselves. That is something that the BMA's ethics department is constantly saying is a very powerful right, and it can only be compromised when it comes up against someone else's autonomy in a very distinct way. The autonomous right to refuse treatment, even if you will die as a consequence, and the autonomous right to ask for death, are in many people's minds much closer together than the law currently declares that to be. My personal belief is that that process will develop momentum, which will take us towards Oregon type legislation at some point. I think it is absolutely right that we flag up, on behalf of our members, the problems that we see that producing now. I would like to say one more thing, which I hope is not inappropriate. We have talked a bit about trust here today. Trust in doctors is very high, and we know this; but trust is quite a fragile thing. There are peripheral issues around this debate that are important to just mention. One is trust in doctors generally following certain problems, like Shipman, Alder Hey and Bristol. There is the need to maintain trust, that doctors will always be doing something that is primarily in the interests of the patient, where there is no hidden agenda and it is focused entirely on the patient's wishes and best interests. That is something that needs to be preserved at all costs at the moment. I have a concern that re-defining the role of the doctor in the way that this Bill would do might pose some threat to that trust. That is a very general statement, but it is one that bothers our members quite a lot, as they feel rather beleaguered at the moment.

  Q335  Baroness Hayman: I think you have just said that patient trust depended on believing that what a doctor will do will be entirely in the best interests of the patient?

  Dr Wilks: Yes.

  Q336  Baroness Hayman: But in reply to an earlier question of mine, you accepted that for a small number of people, their definition of their own best interests, properly arrived at, was something that had to be sacrificed in the interests of society as a whole: therefore is there not a disparity between those two things?

  Dr Wilks: There is a general statement in there, and there is a specific point at which we have to draw some lines. I do not think that the two are in opposition to each other. I make the general point about trust, but we have accepted, from the BMA's perspective, that we cannot help all patients as much as they would wish to be helped in palliative care; but it is a very small group. I would hate to use the word that you have used—"sacrificing" those patients for the good of society as a whole and not creating vulnerable groups that might be considerably larger than the patients who are disadvantaged by not having euthanasia legislation, but that is a balance that we feel is appropriate at the moment.

  Q337  Baroness Hayman: I suggest to you that that should engender trust that doctors would always behave to the highest professional standards of what they believe to be in the interests of society as a whole, but it does not quite fit the bill of how you described it a couple of sentences earlier. What is better in the overall is something that is obviously not a simple answer, which we are all debating and expressing our different views on.

  Dr Wilks: Indeed, I would accept that. There are many, many doctors—and I still think it is a minority—who would see that provision of assisted death, whether it was assisted suicide or to a lesser extent euthanasia, as an extension of the normal medical professional obligations of a doctor to a patient in respecting their autonomy. There are many doctors who feel that very strongly, that you cannot draw a line with autonomy just because it causes you difficulties. You are either autonomous or you are not, and autonomy extends to the point of also being able to decide the time and method of your death. You can decide the method of your death by refusing life-prolonging medical treatment, and rather callously, you can choose your time of death by committing suicide; but many doctors feel that those are thoroughly unsatisfactory situations, which should be dealt with by the autonomy also extending to being able to receive euthanasia. We are flagging up difficulties with that in terms of the practicalities of the relationship between doctors and patients generally and the sheer practical difficulty of providing a legal framework in which that can occur safely.

  Q338  Bishop of St Albans: Can I have some clarification from Sir Graeme about his statement, because I seemed to hear you say that, should this proposal become law, the GMC would have no problems with it whatsoever? Is that the GMC itself or you personally, or did I misunderstand that statement?

  Professor Sir Graeme Catto: I think what I said was that, were this Bill to become law, it presented no insurmountable problems for the General Medical Council, and that in a technical sense is what I meant. It does present challenges, many of which we have discussed round the table, but there is nothing inherently present in the Bill that causes problems for the General Medical Council as it exists.

  Q339  Chairman: You referred earlier to the areas in which a patient is treated by a team, as for example with spinal injuries or something of that kind. This Bill draws a distinction between the attending physician, who is the person primarily responsible for the patient's care, and the consultant physician, who has other responsibilities. Are there any practical difficulties that any of you can see in relation to a team situation in determining who would be the attending physician and who would be the consulting physician? Sir Graeme, that is probably primarily something that the GMC would like to talk about.

  Professor Sir Graeme Catto: Yes, and it may be that Jane O'Brien will wish to correct me on this. Working in teams and working in partnership is very much part of our guidance at the present time. That does not mean that it should not be clear at any one time who has responsibility for patient care, and indeed our guidance indicates very strongly that at any given time the patient should be very well aware of who has prime responsibility for his or her care.

  Ms O'Brien: That is absolutely right. We would see a normal situation as being one person who is designated as having the overall lead. We do understand that that is not universally the case. In some areas of medicine it is more practical to have slightly different arrangements, and that is something that we are talking to a number of the Royal Colleges about at the moment, about looking at team-working and responsibility within those teams.


1   Note by witness; The issue of euthanasia or assisted suicide was not, in fact raised during the BMA,s 1992 annual meeting. It was raised in 1997but, prior to the use of electronic voting, no permanent record was available of the voting numbers, once it had been verified that a clear majority opposed both euthanasia and physician assisted suicide. Back


 
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