Assisted dying laws in The Netherlands and Belgium stipulate that only doctors are allowed to assist with suicide. In Germany and Switzerland, assisted suicide (excluding euthanasia) is not illegal, but a doctor’s input in Germany would breach the code of professional medical conduct and may contravene of a doctor’s legal duty to save a life. The Assisted Dying for the Terminally Ill Bill proposed in the UK in 2005 focused on only doctors being permitted to assist with a suicide. The Proposal on Assisted Dying of the Norwegian Penal Code Commission minority in 2002, however, was not limited to doctors. (Bosshard et al, 2006)

Professional medical organisations in all of these countries apart from The Netherlands uphold the position that medical assistance with dying conflicts with a doctor’s fundamental role. However, in Belgium and Switzerland, and for a time here in the UK (the British Medical Association dropped its neutral standpoint in 2006), these organisations ended their opposition to new legislation. Furthermore, now, all of the Medical Royal Colleges have also declared their opposition to it. Today, they regard the issue as first and foremost a subject for society and politics. This neutral stance contrasts with the official position of the Royal Dutch Medical Association which has played a key role in developing the Dutch practice of euthanasia as a ‘medical end-of-life decision’ since the 1970’s. (Sheldon, 2003)

The BMA’s policy states that assisted dying is not part of the moral ethos or the chief aim of medicine, and if permitted could be harmful to the way doctors relate to their own role and to patients. Their current policy maintains that physician-assisted suicide, voluntary euthanasia, or non-voluntary euthanasia should not be legalised in the UK. The policy also upholds the belief that the ongoing improvement in palliative care allows patients to die with dignity. This however is not strictly true, as the majority of people die in acute hospitals, which are not equipped to deal with palliative care. Finally, the BMA insist that if legalisation were to come to pass, there should be a distinct separation with those doctors who would be involved and those who would not. (British Medical Association, 2009)

But would assisting a suicide for someone who is clearly suffering be against the chief aim of medicine? Personally I think not. A doctor’s aim is to cure, so when all avenues have been explored, and there is no hope, surely the aim should be to fulfil the patient’s wishes, and do everything they can to relieve their distress. It could be argued that the BMA does not actually reflect the true views of its members.

However this cannot be an easy subject for doctors when discussion in the media, courts, and parliament repeatedly assume assistance in dying is to be exclusively a physician’s task. It is unjust to expect doctors to go against their own principles and expect them to help others to die.

Care not Killing (2009) state that it is no coincidence that those countries which have legalised assisted dying – Holland, Belgium and the US State of Oregon – have rather poor records in the area of palliative care. In comparison, British palliative care has been an acknowledged clinical specialty (for example, oncology or paediatrics) since 1987. Even in Oregon, where palliative care has improved, the terms 'palliative care' and 'hospice' do not mean the same thing as they do in Britain. Oregon does not have in-patient specialist palliative care beds or the intensive four-year palliative care training programme, for example, that puts Britain at the forefront of palliative care.

However, a study conducted by Bernheim in 2008 found that in Belgium, all indications suggest that the movement for legalisation of euthanasia promoted the improvement of palliative care and that the existence of sufficient palliative care made the legalisation of euthanasia ethically and politically acceptable. Belgium has some of the best-developed services of palliative care, third only to Iceland and the UK. This shows that the development of palliative care and the process of legalisation of euthanasia can be reciprocally reinforced.  Furthermore Goy et al (2003) found the majority of hospice nurses and social workers noted positive changes in the provision of palliative care by physicians since the introduction of the Oregon Death with Dignity Act, apart from the level of apprehension when prescribing opioid medications.

This evidence raises the question; why can’t we have both; excellent quality palliative care and physician-assisted suicide? Surely, it would be a huge step forward. There are many reasons why somebody would wish for an assisted suicide, those who are pro assisted suicide are reacting to the fear of experiencing dreadful pain, of being kept alive by life-support equipment, and of turning into a financial or emotional drain on their families. They fear becoming reliant on others or having a very poor quality of life. Too often, people suffer unnecessary pain in their final days, and such suffering can transpire even with good care. It’s about control. Personal wishes are surely what we should follow in today’s society of client care and client initiated care. In so many medical environments and in most medical care we are looking to include client’s decisions, why should this be different at the end of life? If we are asking how clients wish to be treated in life then such questions must surely be asked at the end of life.

The law, in the past, has changed with society. However, at present there are huge inconsistencies. The majority of the public here in the United Kingdom want to see a change in the law, at present it seems that legalisation is not imminent. As Oregonian and Dutch experiences show, good palliative care, including that provided by hospice, is compatible with physician-assisted death.  Any legislation should advocate exceptional palliative care as the standard and assisted suicide as a last resort, as Quill and Battin (2004) state. It is vital that there be continuing efforts to improve palliative care if legalisation were to come about in the United Kingdom; subsequently patients may not feel an assisted suicide is necessary.

References

Bernheim, J.L. (2008) Development of palliative care and legalisation of euthanasia: antagonism or synergy? British Medical Journal, 336(7649): 864-867.

Bosshard, G. et al (2006) A role for doctors in assisted dying? An analysis of legal regulations and medical professional positions in six European countries. Journal Of Medical Ethics. 34(1): 28-32

British Medical Association (2009) Assisted dying - a summary of the BMA's position. Available at: http://www.bma.org.uk/ethics/end_life_issues/Assisdyingsum.jsp

Care not Killing (2009) Physician-assisted suicide and medicine. Available at: http://www.carenotkilling.org.uk/?show=674

Goy et al. (2003) Oregon hospice nurses and social workers' assessment of physician progress in palliative care over the past 5 years. Palliative and Supportive Care. 1(3): 215-219.

Quill, T.E. & Battin, M.P. (2004) Physician-assisted dying: the case for palliative care and patient choice. USA, The John Hopkins University Press.

Seale, C (2009) Legalisation of euthanasia or physician-assisted suicide: survey of doctors’ attitudes. Journal of Palliative Medicine, 23(3): 205-212

Sheldon, T. (2002) World Medical Association isolates Netherlands on euthanasia. British Medical Journal; 325(7366): 675.

Stephanie Kehoe is currently working as a research intern in the Innovation in Society Unit. She recently completed an undergraduate degree in Health Studies (BA Hons.) Her specific interests are assisted suicide and euthanasia which her dissertation focused on, other interests include health promotion and health economics.  In October she is planning to begin a PhD around the ethics of health promotion.

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