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.
CONCLUSION
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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