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

Examination of Witnesses (Questions 2020 - 2039)



  Q2020  Lord Joffe: But there are doctors here who support this Bill and who would be prepared to implement it.

  Dr Randall: I would assume that there are. What I am saying to you is that it becomes complicated if the doctor that is the patient's attending physician wants to conscientiously object and then the patient has to be passed to another doctor who then becomes the attending physician, so the patient's care by the definition of the Bill then has to be passed to another doctor and then you have to find a consultant physician in the right speciality who is happy to do it. It could become rather an onerous process. My main concern about the Bill is the effect of the doctor/patient relationship and the position it puts doctors in, which I think is unnecessary if society in the end decides that it is in the interests of the majority of its members to legalise these processes.

  Dr Gilbert: Could I add one further reason why it seems to me that many doctors at and arguably those doctors most closely up against these clinical scenarios particularly do not want to be involved in this process and it is this. Agreeing with a patient that it would be best for them to end their lives has been referred to as a psychological push from the bridge. I recognise not all doctors see it that way, but I think that is a useful concept. The mixture of roles and the moral judgment that is expected of doctors perhaps gives that push from the bridge psychologically greater force than were it to be a technician in such a role, clearly defined as purely doing that and making no moral judgment about whether it was the right thing for the patient.

  Q2021  Lord Joffe: There were doctors who appeared before us this morning who actually said that in their view many doctors would see it as important to remain involved with their patient's right to the end and not to abandon them.

  Dr Gilbert: I was impressed by the question asked by Lord McColl about on what grounds a doctor might object to being excluded from the actual process of administering medication and I did not hear an answer to that.

  Q2022  Lord Joffe: Are you taking a different view from Dr Randall who does not want doctors involved at all?

  Dr Gilbert: No.

  Q2023  Chairman: Not involved in the actual process of assisting the suicide or the dying.

  Dr Gilbert: Indeed. I am taking precisely the same view. I do not know where the misunderstanding has arisen.

  Q2024  Lord Joffe: Let us get it clear. Do you accept that the doctor could give the prescription for the drugs?

  Dr Gilbert: Certainly the doctor could, although I think that would be wrong as well. I think in doing so it entails a moral judgment that agrees with the patient that their life is no longer worth living. I think that may be one of the reasons why we see this disparity between those people who profess that they wish their lives to be ended and the very few people who actively take steps to commit suicide despite the availability of medication. I think they need that psychological "push from the bridge" and that moral judgment, which is often expected of doctors, to agree with them that the best thing overall would be for them to end their lives. We could achieve clarity about that by excluding doctors from the process.

  Q2025  Lord Joffe: I think there is a misunderstanding as to the role of the doctor. The role of the doctor is to ensure that the various safeguards in the Bill have been complied with. It is not to form a judgment on whether it is a wise decision or an unwise decision of the patient.

  Dr Gilbert: If you will forgive me, that seems to run counter to me to much of the evidence this morning which seemed to include doctors looking after patients towards the end of life as the final thing that they could do for the patient. I think that was positively described. What are they doing there? Simply a legalistic assessment of whether the safeguards have been met.

  Q2026  Chairman: It is perfectly plain that what the Bill envisages is not only that the doctor will see that the safeguards are in place but also, assuming the safeguards are in place, he or she will either, as in the case figured in the preamble, actually do the necessary procedure to end a patient's life or will provide the necessary medication for the patient to end his or her life.

  Dr Gilbert: Yes. It seems to me there could not be a clearer enactment of agreement that that would be the best thing for that patient than co-operating in that process.

  Q2027  Chairman: That might not be so because if a doctor says to me that I should have a life prolonging treatment and I do not want to have it and I say no, the doctor is then precluded from giving me the treatment, although he or she does not believe that my decision is the right one and thinks I should have accepted their advice. The mere fact is that the doctor who does carry out the patient's wishes in this particular case would not necessarily imply that the doctor agrees with the patient's view of the matter. He or she would be simply complying with the patient's request made in accordance with the rules and so on.

  Dr Gilbert: But actively doing so.

  Q2028  Chairman: Yes, actively agreeing or actively accepting the patient's request. You may say that no doctor would want to do that unless he or she agreed and the doctor cannot be obliged to do it, the doctor may have objections to doing it. I think you are saying that for the doctor to do it would imply in your judgment that the doctor had agreed that it was the best course open to the patient in the circumstances. All I am saying to you is that it does not necessarily follow, although it might be a difficult position for the doctor to be in if he was injecting somebody to end their lives at a time when he thought it was not a good thing to do.

  Dr Gilbert: Indeed.

  Dr Randall: There is a parallel distinction here in other parts of health care. A patient can always refuse treatment if the patient does not want it. I know there is legal argument about it at the moment, but currently patients cannot require a doctor to perform a treatment that the doctor really feels is going to result in overwhelming harm and not benefit. So the parallel is with, say, a patient requesting a surgeon to do an operation where the surgeon says the risks of it far outweigh any possible benefits. The surgeon has the power to refuse and the responsibility to refuse.

  Q2029  Chairman: He would not incur the responsibility of carrying out the operation unless he thought in the circumstances it was the right thing for him to do.

  Dr Randall: Yes. What this Bill is about is doctors being asked to do something at the request of the patient. It is not being asked for doctors to stand away and refrain from treating the patient, it is asking the doctors to do something. So it is about the patient having a positive right to require that from the health care profession who then have a duty. If the patient has a right to physician assisted suicide or euthanasia some part of society has a duty to provide it and this Bill gives the duty to doctors.

  Q2030  Chairman: I think I am right in understanding Dr Gilbert to say that he would assume that a doctor would not carry out one of these procedures unless the doctor agreed that it was appropriate in the circumstance.

  Dr Gilbert: That is exactly my position. Otherwise, while providing a patient with a lethal prescription or indeed administering that lethal prescription, he would be at one and the same time saying, "This is something that I think is wrong. I still value your life; I think you should still value your life."

  Q2031  Chairman: If the doctor has made a conscientious objection it would not be happening in any case with that doctor. But the case that you are figuring is the case of a doctor who has not got a conscientious objection against doing it at all but who in the particular circumstances of the case thought it was not an appropriate request from the patient for various reasons. Although the legal background and the legal safeguards had been fulfilled, the doctor still thought that it was not an appropriate course to take in that situation. You say that if he then carries it out it is to be assumed that he agrees that it is the appropriate course in the circumstance. Is that right?

  Dr Gilbert: That is right.

  Professor Finnis: It might help to inject the concept which is right through the Mental Capacity Bill and through the medical law which underlies that. When a doctor does anything it has to be in the patient's best interest. Rather than the word "appropriate", wrong or right, I think what Jim Gilbert is saying is that by doing something the doctor is ratifying that as "in my judgment it is in the patient's best interest".

  Q2032  Chairman: There is nothing in this Bill about the patient's best interest.

  Dr Gilbert: I accept that. I think that is what he is saying.

  Q2033  Chairman: I think it is possible to put it more generally, as Dr Gilbert has done, and say that if a doctor is doing something on account of the patient asking the doctor, he thinks it is at least a reasonable thing to do in the circumstances and if he disagrees with a patient's assessment of the situation he ought not to do it. I think that is what you were saying.

  Dr Gilbert: That is right. Can I just come back once more from the perspective of the patient in this because it may well be that the patient is still uncertain and is still in some sense testing out whether this is right, this jumble of views, one of which is that I am being a burden, one of which is that I am suffering and so on. If a doctor is prepared to enforce or ratify that view then that is what is perhaps clumsily referred to as the psychological push from the bridge. If it comes from a doctor it carries a different weight in my estimation, particularly a doctor with long association, than it would if it came from a technician.

  Q2034  Chairman: Ms Wates, I think you wanted to add something. You have been extremely patient in listening to others. You must have a chance to give your point of view on these matters.

  Ms Wates: It seems to me there are several places in the Bill where it really is very subjective from the way that the Bill is worded what is meant, and there is the whole question of whether the patient's judgment is impaired. The doctor must make a decision about that because if he considers it is wrong then he should bring in a psychiatric opinion.

  Q2035  Chairman: The assumption of the Bill is that it only applies in the case of a fully competent patient and if there is any doubt about that it has to be investigated. I think that is the basis on which the Bill proceeds.

  Ms Wates: Yes, but a sound judgment is a well-informed judgment. I suppose he might judge that the patient was competent but not well informed.

  Q2036  Chairman: As I understand the rules, the doctor is not supposed to indulge in any procedures or accept a decision not to proceed with procedures without giving full information to the patient of the various options available and the consequences in the doctor's view of the various options that are open. It is part of the doctor's informed concept which is fundamental to the doctor/patient relationship in this country now. The doctor would be obliged to explain in some detail exactly what the situation was if the patient did ask for this particular treatment.

  Ms Wates: Surely the doctor's point of view on the patient's situation would make a huge difference to the information that he presented and the weight that he put on the information. You cannot get away from that.

  Q2037  Lord McColl of Dulwich: Professor Finnis, vis-a"-vis the question in Oregon of this leading to euthanasia, is it your understanding that the Euthanasia Society does see this Bill as a precursor to euthanasia?

  Professor Finnis: You mean in this country?

  Q2038  Lord McColl of Dulwich: Yes. The other question is dealing with the question of excluding doctors and nurses from taking part in this oral euthanasia. Some of us found it quite a chilling experience when we visited Holland during the last Select Committee on euthanasia because we were particularly anxious to know how the doctors felt about doing euthanasia and we asked one particular doctor and he said, "It was terrible. We agonised all day." But he said the second case was much easier and the third was "a piece of cake". We found that rather chilling.

  Professor Finnis: I have not investigated the present attitudes of the Voluntary Euthanasia Society in this country. I have made no attempt whatsoever to keep track of its policies. I do know that in the past prominent members of it have said more or less openly that they regarded assisted suicide as a step on the way to euthanasia, and that is certainly the case in the United States as well, though again I have not made a study of particular policies of particular groups. I have discussed these matters extensively with leading supporters of the general movement such as Professor Ronald Dworkin with whom I have given seminars for 20 years and debated the matter in public as I have described. There is no ambiguity about the reluctance to take it all in one bite and so Professor Dworkin's books only speak about assisted suicide and leave in shadow what all the principles and arguments in the book move towards, which is also euthanasia for the competent and to some extent for the incompetent. I think it would be very surprising to me if it could be established that the policies of the Voluntary Euthanasia Society did not extend to euthanasia as a next step in a process which they regard as one of liberation—and I understand their arguments.

  Q2039  Baroness Finlay of Llandaff: This morning we heard from a doctor, who is not a consultant in palliative medicine and therefore not on the specialist register, her view of her role in providing the palliative care. She also spoke about the questionnaire that you referred to, Dr Gilbert, and in it she outlined that indeed in palliative medicine many doctors have discussions with patients about a desire to die and sometimes those discussions go on and they may be discussions that persist, and yet we heard from Baroness Greengross that she felt that there was a need to campaign very strongly for open communication with patients. I wonder how you marry up the openness of the questions that are on the questionnaire with the fairly solid block of resistance from those dealing with these patients all the time that put a doctor, such as Dr Dacombe, in a very small minority in welcoming any moves in this direction.

  Dr Gilbert: I think that is very interesting. There is a clear basis from the survey for recognising that these sorts of issues about wishing for an earlier death are not terribly uncommon in palliative care practice. Certainly my own experience and that of my colleagues in the south-west that I know well would be that such matters do have an opportunity to be openly discussed and that one tries to concentrate on what are the distressing issues for that patient and those close to them at that time. One of the things that might puzzle outsiders as a result of the data is how could one understand a position where there is such overwhelming opposition to such permissive legislation as we are discussing today and yet this openness in discussing issues around death and dying. All I can do is extrapolate from my own experience that although many people want to talk about the timing and the nature of their death, my experience is that it does not put me as a clinical practitioner in a difficult position at all to have people discuss these issues and I do not feel disempowered in a way that you might expect me to fell, or restricted by the current laws of this country.

  Dr Randall: My experience is of patients expressing the fact that they are fed up with this existence, they feel a burden and wish it was all over and that does give you the opportunity to ask if there is anything in particular that is the source of this distress and, where possible, to address that. I think a lot of the satisfaction one gets from one's job is what can we alleviate from this knowing that it is part of the human condition and there is no way one is going to be able to alleviate all ills. It is very interesting that so many of the people caring for dying patients are opposed to legalising assisted suicide and euthanasia given that we are the people who will be having most of these discussions with patients.

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