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

Examination of Witnesses (Questions 340 - 353)



  Q340  Chairman: I must say that, when I came to look at this Bill first, I had rather assumed that the attending physician would be in the nature of a general practitioner who has the care of the patient year after year, and would probably have quite a considerable relationship with the patient and would know well the patient's attitudes and so on. I assume that in the sort of cases we are discussing now of spinal injuries or a terrible accident or something it might not be the attending physician, in the definition in the Bill, applied to these circumstances, and it might not be the patient's general practitioner at all.

  Professor Sir Graeme Catto: Indeed, probably would not be. It comes back to the point that Lord Carlisle made earlier about acquired referral. It may be very much more complex in a practical sense how this might be implemented, were this to become law; but in theory it does not present any greater challenges to the General Medical Council than that. There are significant practical implications in the delivery of this, when it does become law, allowing for the conscientious objection clause.

  Q341  Chairman: I wanted to understand the relationships for the purposes of the Bill established in relation to these particular cases, where this might be an issue. Spinal injuries and the like are cases where this particular matter might be well an issue, if it was a legal—

  Professor Sir Graeme Catto: It is quite likely that in a spinal injuries case there will be a definite attending physician. There will be a consultant in charge of the case at any one time—but there will be exceptions to that, as we have just discussed.

  Q342  Chairman: The person in charge of the case would be the attending physician, and then a consultant physician is required, to whom reference has to be made to, as it were, check the decisions of the attending physician. Then I assume there would not be too much difficulty in finding that sort of person in this situation?

  Professor Sir Graeme Catto: I imagine that to be the case. These will be long-term cases, not in an acute hospital situation, I imagine.

  Q343  Chairman: I wanted to ask a bit more about the question of informed consent. You referred to that at least in passing, Dr Wilks. If this Bill became law, there would be an option in some cases for this course of action to be taken rather than palliative care. Did I understand you to say that, if that were the situation, it would be incumbent on a doctor, in seeking informed consent from the patient in relation to the course of action proposed—the option of assisted dying, under what would then be an act, would have to be brought forward?

  Dr Wilks: It is not so much specifically in terms of obtaining consent for treatment—I think that is a slightly later stage. I was referring to the discussions that necessarily need to take place between a clinician and a patient about the options for treatment. I would see that, maybe not in every case but in a large number of cases involving patients who were approaching the end of their life or had a life-threatening illness or a terminal illness, because euthanasia or assisted suicide with or without euthanasia was now part of the law of the land, that it would be incumbent on doctors to offer and inform all available treatments, to at least make the patient aware of that availability. To do otherwise would not be giving all the information that the patient deserved.

  Q344  Chairman: If that is the situation, what would be the position of an attending physician who had a conscientious objection to the law in relation to assisted suicide, and was therefore exempt under the law from having any part whatever in that sort of situation?

  Dr Wilks: Accepting the detailed concern that Lord Carlisle produced about the kind of level of speciality and difficulty of finding alternative doctors, I do not believe that would present a difficulty in terms of the doctor's duty to explain and inform and discuss options. The difficulty would present itself when it would be for the doctor to say, "I have discussed these options with you"—and we believe it would be the rare circumstances if this was an Act—and the patient would say, "I would like to discuss further the practical issues around assisted suicide". The doctor would then conscientiously have to withdraw from that discussion and refer the patient to another doctor who was prepared to not just have that discussion but to follow the discussion through to a decision.

  Q345  Chairman: Is it your view that the conscientious objection might not, or need not, or would not cover discussing at all with the patient the option of assisted suicide?

  Dr Wilks: To take an every-day example of abortion, the discussion about abortion being either a sensible option for the patient or a bad option for the patient is something that can occur in a discussion with a doctor who might have objections to it. In practical terms, patients tend to go to doctors who are supportive of abortion if they want an abortion; so I guess you might well find in certain circumstances that that shift would occur. The discussion of euthanasia would be a common discussion, an everyday discussion, in the sort of clinical environment that Baroness Finlay works in because we would be required to discuss it if it was an available option. Not to discuss it would be unprofessional.

  Q346  Chairman: That is what I had rather taken from what you said earlier. This option would be an obligatory subject of discussion for any doctor?

  Dr Wilks: With many patients in certain scenarios, of course.

  Q347  Chairman: Yes, that I understand. It would only arise as an option in the cases in which it applied?

  Dr Wilks: Yes.

  Q348  Chairman: That brings me to the question of the safeguards in this Bill, because it is not offering this option except in very closely defined circumstances. An essential part of this option being available is that the patient should be suffering unbearably?

  Dr Wilks: Yes.

  Q349  Chairman: From the point of view of the attending physician, they have to conclude, to use the words in the Bill, that the patient is suffering unbearably as a result of that terminal illness. The definition of "unbearable suffering" is that the suffering is such that the patient finds it so severe as to be unacceptable. Have you looked at that from the point of view of the attending physician?

  Dr Wilks: We have difficulty with any terminology that is too vague, but "unbearable suffering" is necessarily vague because suffering is not necessarily purely physical; it can be emotional suffering or loss of autonomy. The important point is that it is what the patient feels to be unbearable that is the issue here. When we talk to patients about their perception of their illness, it may be very different from the way the doctor might feel the illness is perceived, and it is terribly important to listen to the patient's view of the impact of their condition on their quality of life, and their perception of the value of their continued existence. One can only say in response to your question that, if on persistent questioning—not just one consultation but on persistent questioning there was a consistent belief by a patient that their condition was unbearable, one would accept that they found it unbearable. This is not that it is unbearable because they are depressed or because they have some other illness that they have some phobic view about. The rest of the Bill makes it absolutely clear that it is in the context of a diagnosis of terminal illness, so the Bill narrows down the group of patients in terms of the unbearableness, that the unbearable nature of the illness relates to the fact that it is a terminal life-threatening illness, not one that is treatable with a whole variety of other available therapies. I do not have a particular problem with the slightly vague notion of unbearable suffering or other terminology that has been used in recent court cases such as "intolerability", which I think is a very general term. What I think counts for the doctor is that there is a consistent expression by the patient in a competent, unprejudiced, unbiased way, that this for them is an unbearable situation for them to continue.

  Q350  Chairman: The attending physician would be entitled to conclude that the patient was suffering unbearably within the definition in the Act if he or she, the physician, thought that genuinely that was the patient's attitude?

  Dr Wilks: Yes.

  Q351  Chairman: So far as this option is concerned, the option would arise only in that situation?

  Dr Wilks: Yes.

  Q352  Chairman: So the matter would not require to be discussed until that happened?

  Dr Nathanson: Absolutely, and in those circumstances these are already where very sensitive discussions do take place. It is a little earlier than the time at which you have concluded that it is unbearable because it is a complex process of trying to understand what it is the patient finds unbearable, and why they find that unbearable, because it is only when you know the answer to both of those questions that you can start to think of the options for dealing with that symptom—to give it a medical name, as it were. Sometimes, the thing that is unbearable is open to quite a lot of management of change. It may not be medical treatment; it may be completely non-medical—it may be social engineering almost, as it were. That is why a lot of these conversations already take place, because it is the patient testing with the doctor, and the doctor testing with the patient, what options are available, and starting to decide the direction in which the individual needs to go. It may well start to take place well before the situation gets to that terminal phase. To some extent throughout medical treatment options become available at different times, and will be chosen or chosen against because at that time they do not offer relief from the thing that is distressing that patient most. That is one of the difficulties that doctors often face, that the treatment the doctor says scientifically may well be the best treatment may not be what the patient wants because it is not dealing with what they perceive to be the major problem. In fact, although it looks like it becomes something that you only talk about at a very late phase; our concern is that it will have to be discussed somewhat earlier because it would affect some of the other decisions that might be made by the patient.

  Q353  Chairman: From what you have told me, I take it—but I want to have this confirmed—that it would be perfectly appropriate, if this Bill became an Act, for the issue of physician-assisted death to be raised by the doctor rather than by the patient in the first instance. Although of course ultimately the patient's consent would require to be obtained, the issue could first be raised as a matter of discussion between physician and doctor by the doctor?

  Dr Wilks: Theoretically, yes, but in most circumstances the first thing that happens between a doctor and a patient, where there is clearly a terminal illness, is a discussion about how the patient is reacting to that, providing basic information about the treatment options that are available; and I would not expect necessarily euthanasia or assisted suicide to be very high on the list of options, when actually the patient requires information about the available treatment of their condition, which is much more immediate, such as pain relief or chemotherapy—all the things that we would do in those kinds of cases, for example with an untreatable cancer. Then the exploration of options would inevitably lead to patients saying, "If this is intolerable for me, if there is some point I find this intolerable or unbearable, what could we then do?" That is when it would be an absolute obligation for the doctor to discuss assisted suicide.

  Chairman: Thank you very much indeed. We are very grateful to you all for your help.

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