Select Committee on Assisted Dying for the Terminally Ill Bill Written Evidence


Letter from Professor Richard Glynn Owens

  My name is Richard Glynn Owens, I am Professor of Psychology at the University of Auckland, on temporary attachment to the University of Wales. I was previously Professor of Health Studies at the University of Wales (from 1992-95). I am a specialist in the application of psychology to medical problems, and for 20 years have primarily worked in the care of dying people, treating (pro bono) dying patients from a number of hospices and hospitals including the Gwynedd Hospice at Home service, the Marie Curie Hospice in Liverpool, the Wigan Hospice, Ysbyty Gwynedd and elsewhere. In New Zealand I was a member of the board of trustees of the South Auckland Hospice. I am the author (with Dr Freda Naylor) of "Living While Dying", a guide for dying patients and those close to them, and recently conducted (with Dr Kay Mitchell) a large-scale study of decisions regarding euthanasia and similar issues in New Zealand and of the practice of euthanasia in New Zealand and the Netherlands. I have a deep commitment to the provision of good palliative care for those patients who are approaching the end of their lives.

  In the light of this, I have marked professional concerns regarding the Bill that is proposed to the House. A number of relevant issues will no doubt be brought to the Committee's attention by other commentators, including the observation that some patients who request euthanasia subsequently withdraw those requests if good palliative care is provided, and the commonplace claim in palliative care circles that around 95 per cent to 98 per cent of pain associated with terminal illness can be adequately controlled without recourse to the killing of the patient. Many observers have also raised concerns regarding the so-called "slippery slope", whereby a change which is initially humanitarian may lead to consequences not foreseen or desired by those who made it. Some commentators have also raised concerns regarding the possible impact on doctor-patient relationships that might result from the former being in a position legally to end the patient's life.

  Such concerns need to be considered carefully in the preparation of any legislation, and indeed may appear to call into question the need for euthanasia at all. Despite such concerns, however, I am, albeit reluctantly, forced to the conclusion that a change in the law to permit euthanasia under certain circumstances is both necessary and timely. That I come to such a conclusion despite these reservations may seem incongruous, and my reasons for doing so are summarised briefly below:

    (i)  The common withdrawal of requests; whilst this has been interpreted by some observers to mean that the patient "did not really mean it", this is far from the only interpretation, and indeed it is not surprising that in a context where euthanasia is illegal, a request will be dropped or withdrawn. The only real test of whether the patient "really means it" is to provide the opportunity, together with a provision for revoking the request. This is done in the present Bill.

    (ii)  The adequacy of pain control; although the figures cited are common within palliative care, there is actually surprisingly little good evidence of their validity. Nevertheless, I remain convinced that a well-conducted study would find that the claims are not far from the truth. In the present context, however, it is important to remember (a) that with the greatest expertise in the world, some forms of pain remain intractable—as with the Cox case many years ago—and (b) that pain is not the only legitimate reason for people wishing to end their lives.

    (iii)  The "slippery slope"; whilst much vaunted, this concept has neither been critically examined nor rigorously investigated. Although it is true that sometimes one change is subsequently followed by further changes in the same direction (for example the Clean Air Act of the 1950s being followed by other changes designed to enhance protection of the environment, like the removal of lead from petrol) these need to be considered in the context of the underlying processes. Often the shifts mark independent consequences of broader societal change, and of course in some instances they result from discovery that what seemed like a daunting prospect when making even a small change turned out to be less problematic than originally expected, leaving people confident to make others. There is no reason whatever to believe, as some are wont to claim, that provision of voluntary euthanasia would lead to people's lives eventually being ended against their will; indeed if such were to happen, one might more have expected that to be a consequence of a slippery slope from the days of capital punishment, with the slope taking us from one group being killed against their will to others. All too often the notion of a "slippery slope" is invoked without a logical basis or detailed analysis simply to shore up an otherwise inadequate argument.

    (iv)  The impact on doctor-patient relationships; although this has been raised by a number of observers, it does not appear to correspond with the evidence, nor to provide any kind of insuperable obstacle. Indeed, since we are talking of doctors acceding to patients' wishes, it is arguable that such a change would enhance rather than impair relationships. Moreover, if this were seen as a major objection, there is no real obstacle (as I note below) to moving the task away from the medical profession.

  It is perfectly clear that being at the end stages of one's life does not in itself preclude one from making clear, reasoned choices that are the consequence of thinking logically. From a purely civil libertarian perspective one would need especially compelling arguments to continue restricting the options available to needy individuals who are in the best position to determine their own preferences and values. I do not believe that the arguments commonly presented provide justification for such restriction, and therefore somewhat reluctantly support the passing of a Bill such as is presently proposed.

  In the light of these considerations, I believe that a Bill such as the one that has been drafted needs to be passed into law. I should remark, however, that there are matters of detail which the Select Committee may wish to consider further. Primary amongst these are;

    (i)  The Bill correctly alludes to the need to ensure that a patient is competent, but fails to address the requirements for expertise in those involved. Whilst it is likely that a psychiatrist may have some experience and knowledge of normal psychological processes, I would be disinclined to expect substantial expertise in this field below Consultant level. I would therefore, given the importance of the issue, suggest that the Committee consider requiring that any referral be required to be dealt with specifically by a Consultant, rather than simply a "psychiatrist". It should be remembered, however, that the key expertise in assessing cognitive processes lies not with psychiatry, which is concerned with mental disorders, but with psychology, which is concerned with the broad field of cognitive functioning. I would therefore suggest that the Bill provide for the option that the assessment of competence be made either by a Consultant Psychiatrist or a Consultant Clinical Psychologist. This would also have the additional benefit of increasing the number of available professionals. The notion that a solicitor has special expertise in this field seems incongruous, although of course it would be a necessary part of any solicitor's Code of Practice to draw attention to any evidence for incompetence.

    (ii)  It is assumed throughout the Bill that the ending of the patient's life shall be performed by a medical practitioner. There seems no reason in principle for such a restriction, and evidence from our own research suggests that this may not be essential, and that (for example) a nurse with appropriate expertise may be equally competent. I would suggest therefore that the Committee give consideration to changing the wording to suggest that the act be performed "under medical supervision", giving backup in the case of complications but not limiting the actual administration of the procedure to the medical profession. This of course may also go some way towards alleviating the concerns of those who worry about a possible impact on doctor-patient relationships.

    (iii)  Our own research into the provision of euthanasia by doctors in Holland (the only research of its kind, to date) has highlighted the extent to which such doctors find the procedures distressing. There is a very real risk that the provision of euthanasia will have a stressful impact on practitioners. I would suggest therefore that the Committee consider incorporating into the Bill a requirement that provision be made for counselling or other support for those who perform euthanasia.

  I have deliberately limited my comments on these issues to brief remarks, in the light of the undoubted wealth of submission that will be made regarding this proposal. I should emphasise, however, that I am entirely willing to attend the deliberations of the Committee if required to expand on these or other matters.


 
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