Select Committee on Assisted Dying for the Terminally Ill Bill First Report



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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