Examination of Witnesses (Questions 340
- 353)
THURSDAY 21 OCTOBER 2004
DR MICHAEL
WILKS, DR
VIVIENNE NATHANSON,
PROFESSOR SIR
GRAEME CATTO
and MS JANE
O'BRIEN
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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