ABSTRACT
The Assisted Dying for the Terminally Ill Bill seeks
to legalise, for people who are terminally ill, who are mentally
competent and who are suffering unbearably, medical assistance
with suicide or, in cases where the person concerned would be
physically incapable of taking the final action to end his or
her life, voluntary euthanasia. We have examined both the principles
underlying the Bill and its practical implications if it were
to become law. We have also looked at the experience of other
countries which have enacted legislation of this nature, and we
have in addition made some analysis of public opinion in Britain
on the subject.
The Bill is founded on the principle of personal
autonomy. Its supporters believe that terminally ill people should
have the right, subject to prescribed safeguards, to have medical
assistance to die in the same way that patients, whether or not
terminally ill, already have the right to refuse life-prolonging
treatment. The Bill's opponents take the view that the two situations
are not comparable, that it would be impossible to ensure that
any safeguards were not abused and that the law should not be
changed to permit intentional killing, whatever the motive.
On a practical level, we have heard conflicting views
as to the likely effects of the Bill in giving benefit to some
people or risking harm to others. It has been put to us, for example,
that breaching the law on intentional killing would lead to a
"slippery slope", whereby the terms of any law which
were to be enacted would come to be applied more widely through
incremental extensions of its provisions or elasticity in their
interpretation and that experience of the 1967 Abortion Act and
of voluntary euthanasia in The Netherlands provides evidence of
this. On the other hand, it has been argued to us that the Bill
contains an array of safeguards designed to prevent the emergence
of a "slippery slope", that any relaxation would require
further legislation, that the Bill is not comparable with the
Abortion Act and that the evidence from Holland in fact provides
reassurance.
We have also been told that the Bill would improve
rather than (as its opponents have argued) damage doctor-patient
relationships by allowing a more open and frank discussion of
end-of-life concerns and that surveys have shown that the Dutch
trust their doctors more than do people in many other European
countries. On the other hand, we have been told that openness
between doctors and patients, including discussion of end-of-life
issues, has increased greatly in recent years and that the situation
in The Netherlands is untypical in that most Dutch people remain
with the same doctor for many years and know—and are known
by—their doctors well. From the point of view of the medical
profession, while some doctors are comfortable with what the Bill
proposes and while the Royal Colleges of Physicians and General
Practitioners adopted a neutral stance on the principle underlying
the Bill, the General Medical Council wrote to us that "a
change in the law to allow physician-assisted dying would have
profound implications for the role and responsibilities of doctors
and their relationships with patients".
It was also suggested to us, on the one hand, that
with an appropriate "conscience clause" medical practitioners
should have no more difficulty in implementing the Bill than have
doctors in other countries which have enacted legislation of this
nature and, on the other, that the composition of the medical
and nursing professions in this country, with many doctors and
nurses originating from non-European cultures, might pose serious
problems for its implementation. And we heard it suggested that
the Bill would put some vulnerable groups of people, such as the
disabled and the elderly, at risk but that opinion polls had suggested
that majorities of people in these groups supported legislation
along the lines of the Bill.
We visited three countries which have enacted different
laws in this area. In the US State of Oregon medical assistance
with suicide (but not direct action to end a patient's life) has
been legal since 1997. The number of people availing themselves
of the new law has been increasing, though by 2003 only 42 people
(roughly one in 700 of those who died in Oregon in that year)
were taking their own lives in this way every year. In The Netherlands,
where a law permitting medical assistance with suicide or voluntary
euthanasia was enacted in 2002 effectively codifying case law
which had developed over the previous 30 years, approximately
one in 40 deaths (most of them voluntary euthanasia) is attributable
to this source, and there is evidence of around 1,000 additional
deaths every year as the result of action by doctors for which
no explicit request has been made. In Switzerland the law has
allowed since 1942 assistance with suicide provided that the person
giving such assistance is not motivated by self-serving ends.
Assistance with suicide is not, however, seen in Switzerland as
being confined to doctors; and, though as citizens doctors are
able to give such assistance and any lethal prescription requires
a doctor's signature, most assistance with suicide is provided
by Swiss "suicide organisations".
Recent opinion polls suggest a high level of public
support for a change in the law to allow terminally ill people
to end their lives prematurely. Such polls have usually taken
the form of simple Yes/No questions posed without an exploration
of the surrounding context—for example, as to the availability
and effectiveness of palliative care. Recent surveys also suggest
that the attitudes of medical professionals are more ambivalent
than public opinion as a whole and generally hostile to a change
in the law. Our own postbag, which included over 14,000 letters
and emails, suggests a narrow majority in favour of the Bill.
It is clear that Lord Joffe's Bill will be unable
to make progress in the present session of Parliament due to shortage
of time. We have therefore chosen to report now with an account
of the evidence we have received (Chapters Two to Six) and with
recommendations on how this matter should be handled hereafter
(Chapter Seven) rather than ruling on the acceptability or otherwise
of this particular Bill.
In brief, we recommend that:
- an early opportunity should be taken in the next
session of Parliament for a debate on our report;
- if in the wake of such a debate a new bill should
be introduced by a Member of the House, this should be referred,
following a formal Second Reading, to a Committee of the whole
House for detailed examination in the light of our report;
- in the event that such a bill should be brought
forward, those responsible for framing it should give serious
consideration to a number of key issues which have emerged during
the course of our inquiry and which, we believe, lie at the heart
of the debate on this subject.
The principal issues to which we wish to draw attention
are as follows:
- It is clear to us from the evidence we have received
that the demand for assisted suicide or voluntary euthanasia is
particularly strong among determined individuals whose suffering
derives more from the fact of their terminal illness than from
its symptoms and who are unlikely to be deflected from their wish
to end their lives by more or better palliative care. In any new
bill which may be brought forward seeking to legalise assistance
with suicide or voluntary euthanasia consideration should be given
to focusing primarily on this group of people.
- It is also clear to us from the experience of other
legislatures that there is a strong link between the scope of
legislation in this area and its take-up by terminally ill people.
In particular, where legislation is limited to assistance with
suicide, the take-up rate is dramatically less than in places
where voluntary euthanasia is also legalised. If therefore a new
bill should be brought forward, it should distinguish clearly
between assisted suicide and voluntary euthanasia and thereby
give the House the opportunity to address these two courses of
action separately.
- The present Bill is explicit in regard to the procedures
which must be followed by a patient seeking assistance with suicide
or voluntary euthanasia and those which must be followed after
his or her death. But it is relatively silent about the procedures
which a doctor must follow in giving effect to a patient's request
once the latter has passed the various tests required. Any future
bill should therefore make clear the actions which it would authorise
a doctor to perform.
- While we support the principle that any future
bill should contain robust safeguards, the detailed formulation
of these should take account of the evidence which we have received.
In particular, any definition of terminal illness should reflect
the realities of clinical practice as regards prognosis; account
should be taken of the need to identify clearly psychological
or psychiatric disorder as part of any assessment of mental competence;
and consideration should be given to including a test of "unrelievable"
rather than "unbearable" suffering or distress.
- If any future bill is to claim credibly that palliative
care is regarded as complementary rather than alternative to assisted
suicide or voluntary euthanasia, consideration will need to be
given to finding a means by which applicants can experience the
effects of good palliative care rather than simply be informed
of the existence of such treatment.
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