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

Memorandum by the Royal College of Anaesthetists

  The Royal College of Anaesthetists is pleased to have the opportunity to comment on the Assisted Dying for the Terminally Ill Bill although, having only received a formal request to do so on 6 August 2004, we have been unable to discuss this as fully as we would wish. Although we were not directly involved in the consultation process, and in advance of these recent deliberations, the Bill was discussed in Council in May. At that time Council determined the following minuted statement. "After considerable discussion, although it was realised that palliative care verged on the pain management activities of the College and indeed some aspects of intensive care did also, this was not thought to be very relevant to the work of anaesthetists. Moreover members of Council were very clear that they felt it inappropriate to support a bill which emphasised medical roles in ending lives."

  Following your formal invitation to comment, I have conducted a consultation process over the summer with members of Council to try to obtain a more detailed response. Although a number of the comments inevitably result from personal experience either during medical care with which the respondent has been involved or, indeed, from personal family circumstances, there is, nevertheless, no doubt that virtually every respondent would re-emphasise the minuted decision from our May Council meeting.

  Some of us also had the opportunity to discuss the Bill with Ms Deborah Annetts from the Voluntary Euthanasia Society who was involved with the drafting of the Bill. She clearly emphasised that the intentions of the Bill were not a substitute for inadequate pain relief or inadequate palliative care but it was intended to be specifically directed at independently minded people for whom no palliative care was available and who perceived their future life to be futile. The problem for anaesthesia as a specialty is that our work includes responsibility for critical and intensive care and also pain management services. Palliative care, on the other hand, is largely the province of physicians specifically trained in this key area, although anaesthetists with pain management expertise do become involved. We have anxiety that, because anaesthetists are so close to a number of terminally ill patients, the implications of the Assisted Dying Bill may impinge on our current practice and management of patients both in intensive care and in pain clinics.

  Although we feel unable to support the Bill in its current form, we would urge that specific discussion centres around the implications of it to these key areas of our activity. The discontinuation of treatment in critically ill patients when the outlook has become futile is something which many of our colleagues have wrestled with over many years. The decisions that are taken are difficult enough as they are without potential added complications of misinterpretation of the Assisted Dying Bill. In the pain management situation, particularly in acute situations in hospital where our consultants have specific responsibility for acute pain services, again there could easily be a fine line to draw between the relief of pain and assisting death. We are very concerned as a specialty that a Bill which is designed to help a very small group of people with specific conditions and personal circumstances should, as a result of the legislation involved, inadvertently detrimentally affect the care which we as anaesthetists, intensive care and pain management specialists are trying to provide for our patients. We appreciate that the Bill tries to be specific in these key areas and do not wish to muddle the situation, but nevertheless we feel that these issues, together with those surrounding anaesthesia and surgery in terminally ill patients, need to be carefully thought through if the Bill is to achieve its aims without impeding care for others.

  We are particularly concerned that the second stated purpose of the Bill is "to make provision for a person suffering from a terminal illness to receive pain relief medication" because we feel it has been included when there is already a legal framework and understanding for this and those specialised in the area believe that this is always possible to achieve. We would hope that the key effect of any such Bill would be to promote effective and funded pain relief and palliative care to eliminate the need for assisted dying apart from in a very small and specific group of chronically ill patients, usually with neurological disease. The provision of adequate pain relief and palliative care is not only the view of the Voluntary Euthanasia Society, but also that of the College.

  We believe that in parts of the UK, the failure to provide adequate pain relief (whether as medication or alternative strategies) is a consequence of (a) poor training of doctors and nurses in pain management, (b) reluctance to prescribe and/or administer opioids appropriately for terminally ill patients, (c) fear and misunderstanding by patients and their relatives about opioids, (d) wide variation in the provision of specialist pain management services (see CSAG report, Dr Foster report etc.) (e) wide variation in the provision of the expert palliative care services in hospitals, hospices and the community and (f) some PCTs fail to purchase any or sufficient services for their patients. Despite a recent single injection of Government money it is our understanding that the majority of hospice and community based palliative care is still provided by charitable bodies such as McMillan Nurses and not by the NHS.

  Terms such as "assisted dying" and "good death" appear to have been used to promote all aspects and definitions of euthanasia whereas these terms can quite legitimately be used to describe a death that enables the last weeks, days and hours of someone's life to be as painless and peaceful as possible. Although it is claimed that doctors are already actively assisting people to die, even those not well informed and knowledgeable about pain management know that, if strong pain relieving drugs are given, the result may also hasten death. It is not the intention to end life and cause death, however, it is a means of trying to provide a more comfortable life near and up to the time of death. This Bill on the other hand describes something quite different which is actually, within closely confined limits, assisting somebody to die.

  We would caution against the claims that the Bill supports the rights of the autonomous person. The care of a person with capacity and someone without should be of the same high standard. The Bill quite rightly excludes those who do not have capacity but in this case no capacity will then result in no rights for such people. However, the Mental Incapacity Bill that is presently following a similar route will allow another to consent on a person's behalf. It is not difficult to see how confusing and open to abuse these issues may become in the future.

  One Council member wrote the following "I have always understood the medical principle of do no harm, a basic ethical standard that any doctor should strive to avoid at all costs and at this simple level appears to me to encompass all that medical care is about. The distinct conflict between this and that of actively making someone die seems to me to be one that cannot be resolved. Does our society's failure to provide any patient with compassionate (and as far as possible) pain free care at the end of their life have to result in the futility resulting from the enactment of this Bill."

  Bills to facilitate assisted dying are not the answer to the deficiencies listed above and should not be contemplated until the NHS can guarantee expert pain management and palliative care services throughout the UK. The twofold purpose of the Bill is potentially misleading when the highly commendable provision of adequate pain relief medication is somehow linked to the highly contentious business of assisted dying. In addition, this link will serve to reinforce the belief of many patients, relatives, nurses and doctors that strong pain relief (ie opioid medication) is only suitable for use when death is very imminent. Cecily Saunders and all who followed after her battled for decades to destroy this misconception and it would be a retrograde step to reforge such a link.

  Looking at the assisted dying aspects of the Bill, there is a world of difference between the withdrawal of life sustaining support (or its initial implementation) and the deliberate decision to actively terminate life. The assertion that assisted dying is happening already is, we believe, exaggerated. While very few clinicians would actively administer a substance to kill a patient, they may decide not to administer a drug such as an antibiotic when it might in other circumstances be indicated, or they might not treat an abnormal pathological finding, but very few, if any, would decide to administer something to actively terminate life. Although one might argue that the end result might be the same, while one is covered within the doctor's accepted role in making a treatment decision based on all the information, the other is not.


   It is quite apparent from all the discussions I have had with members of Council of the Royal College of Anaesthetists that they would not support the Bill in its current form. Although there are a number of concerns centred around the inadvertent effects that the Bill might have on the way in which we treat patients in specific acute care situations, the overwhelming concern is with the adequate provision of pain relief and palliative care. We are of the unanimous view that the linking of the assisted dying elements of the Bill to those concerned with absent or inadequate provision of pain management and palliative care services is inappropriate and that this will do much to impede the current development of these services in today's NHS. We would urge that in the future, if aspects of the Bill are to be discussed which impinge upon the activities of anaesthesia, critical care and pain management, this is done at an early stage of drafting to ensure the relevance of such a Bill in today's NHS and to avoid potential conflict with the dedicated practice of those clinicians involved in these areas of patient care.

10 September 2004

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