Assisted dying: Why the RCP should be neutral

With the RCP preparing to poll its members about its stance on assisted dying, Professor Raymond Tallis, emeritus professor of geriatric medicine at the University of Manchester, outlines why the RCP should have a neutral position. 

There is a small, but significant number of dying people who experience unbearable suffering that cannot be relieved by even the best palliative care, who want the choice of an assisted death. A much larger group might not take this choice, but would have peace of mind if they knew the option was there if they needed it. We have a moral and clinical duty to respect the wishes of our patients. Therefore, the RCP should end its support for the prohibition on assisted dying.

Context

Support for an assisted dying law remains consistently high at around 80%, as confirmed by the British Social Attitudes survey in 2017.[i] This includes support amongst religious people[ii] and disabled people[iii], two groups often misrepresented as being opposed to law change.

Views amongst the medical profession are evolving. A 2015 medeConnect poll found 34% of doctors in support of law change, 42% opposed and the rest neutral. In February 2018 the BMJ featured a doctors.net poll which showed 55% of respondents agreed assisted dying should be made legal in defined circumstances. The cover-page asked “Why is the profession out of step with the public?” . The editorial argued that if medical organisations moved to neutrality on assisted dying public debate would be enhanced.[iv]

Since the RCP’s 2014 survey, there have been significant international developments. The law passed in Oregon in 1997, subsequently adopted by Washington State and Vermont, has now been passed in California, Washington DC, Colorado and Hawaii. In 2017 Victoria, Australia passed a similar law to Oregon’s, and Canada changed its law in 2016.

Common objections to a change in the law

“The current law works well”

It does not. Every eight days somebody travels from the UK for an assisted death in Switzerland. This option is available only to those who can afford the £10,000-£15,000 cost and who have a doctor willing to breach guidance from the General Medical Council to provide a medical report.[v] Additionally, in this country an estimated 300 suicides every year involve people with a terminal illness.[vi]

We have a moral and clinical duty to respect the wishes of our patients

Professor Raymond Tallis, emeritus professor of geriatric medicine at the University of Manchester

The claim that optimum palliative care can manage all symptoms is untrue. Even in hospices  approximately 12% of bereaved relatives report that their loved one received only partial pain relief in the last three months of life.[vii]

“The Law Would be Unsafe”

In 2009, Clive Seale estimated that around 0.2% of deaths were the result of a doctor responding to an explicit request from their patient to end their life by taking direct action to do so.[viii] This equates to around 1000 deaths a year, a similar number of deaths that would be predicted under an assisted dying law.

Doctors already provide estimates of prognosis; assess a patient’s capacity to refuse life-sustaining treatment; and are alert to potential pressure or coercion.[ix] Under an assisted dying law two doctors and a high court judge would need to confirm that the safeguards had been met; a far higher standard of regulation than current end-of-life practices such as palliative sedation, voluntarily stopping of eating and drinking and the withdrawal of life-sustaining treatment.

Legislative safeguards have been developed for a range of complex procedures and with over 100 million people worldwide now having access to some form of assisted dying we have ample experiences to learn from.

It would be safer and fairer to have a clear, regulated system that offers meaningful choice to dying people and appropriate protection to doctors.

“There would be a slippery slope’; vulnerable people would be at risk”

There is no evidence of a ‘slippery slope’. The Oregon law has remained unchanged since 1997. Voluntary euthanasia laws in Belgium and the Netherlands were always broader than those proposed in the UK. Such law change is not the subject of this consultation.

Research looking at how a change in the law affects vulnerable people in the USA found “there is no evidence for the claim that legalized physician assisted dying will have disproportionate impact on patients in vulnerable groups”.[x] Disability Rights Oregon has never received a complaint in regards to assisted dying.[xi]

“Legalising assisted dying would inhibit improvement of palliative care”

Palliative care and assisted dying are not mutually exclusive. Oregon’s assisted dying law has contributed to more open conversations about end-of-life options, increased palliative care training, and greater access to hospice care.[xii]

We are preventing our patients having meaningful control at the end of life

Professor Raymond Tallis, emeritus professor of geriatric medicine at the University of Manchester

90% of those who have an assisted death in Oregon are enrolled in hospice care.[xiii] The Oregon Hospice Association initially opposed assisted dying but with evidence of safe practice now recognises that “Oregonians need not choose between hospice and physician-aid in dying. Dying Oregonians can choose both from among the options on the end-of-life continuum of care.”[xiv]

What stance should the RCP have?

A neutral stance for the RCP is the only one that captures the full range of views that exist on this issue.

55.6% of respondents to the college’s 2014 consultation wanted the College to either support or be neutral on assisted dying. A change in stance would allow voices on all sides of the debate to be heard.

Neutrality would allow the college to constructively critique proposed legislation, benefiting doctors and patients. At present the only reference made to the RCP in Parliamentary debates is when our stance of opposition is cited by those who do not want the law to change. Opposition is a blunt instrument of little value in a debate that deserves a much more nuanced approach.

The Royal College of Nursing, which is neutral on assisted dying, gave detailed analysis of proposed legislation to Parliamentarians, highlighting areas for improvement.[xv] This shows what is possible.

In 2015, when the Californian Medical Association (CMA) moved from opposed to neutral on assisted dying its President, Dr Luther Cobb, noted: “Collaborative conversations that enhance safeguards for both physicians and patients were possible because of CMA’s shift in policy”.[xvi]

Conclusion

The present opposition of the RCP is not representative of the views of members and is at odds with the wishes of the majority of our patients. We are preventing our patients having meaningful control at the end of life.

International assisted dying laws have yielded a vast body of evidence. The dangers predicted by those who opposed legislation have not materialised, while the benefits of law change are clear.

The RCP should acknowledge the current law is not perfect, that legislative changes are happening around the world and that views amongst the profession are shifting. A neutral stance would allow the RCP to respect the diversity of views without alienating significant numbers of members and fellows.

Professor Raymond Tallis is emeritus professor of geriatric medicine at the University of Manchester, and an elected member of Council at the RCP.

Notes to editors

[i] Moral issues: Sex, gender identity and euthanasia, NatCen Social Research, June 2017.

[ii] Assisted suicide poll shows support among majority of religious people, The Guardian, 30th April 2013,

[iii] Disabled people back law to allow assisted dying, The Times, 11th December 2013.

[iv] Assisted dying: it’s time to poll UK doctors, BMJ, 8th February 2018.

[v] Suicide clinics a preserve of middle class, The Times, 12th November 2017. 

[vi] Assisted dying: more than 300 terminally ill people a year committing suicide, The Telegraph, 15th October 2014. 

[vii] National Bereavement Survey (VOICES): 2015, Office for National Statistics, 2016.

[viii] Seale C (2009) End-of-life decisions in the UK involving medical practitioners Palliative Medicine 23: 198-204.

[ix] Withdrawal of Assisted Ventilation at the Request of a Patient with Motor Neurone Disease, Association for Palliative Medicine of Great Britain and Ireland, November 2015. 

[x] Battin MP, van der Heide A, Ganzini L, van der Wal G and Onwuteaka-Philipsen BD (2007) Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impact on patients in ‘vulnerable’ groups Journal of Medical Ethics 33: 591-97.

[xi] Compassion and Choices, Medical Aid in Dying and People Living with Disabilities 2016. 

[xii] Quill TE (2007) Legal regulation of physician-assisted death—the latest report cards New England Journal of Medicine 356:1911–1913; Ganzini L, Nelson HD, Lee MA, et al (2001) Oregon physicians’ attitudes about and experiences with end-of-life care since passage of the Oregon Death with Dignity Act. Journal of the American Medical Association 285:2363–2369; Dobscha et al, (2004), Oregon physicians’ responses to requests for assisted suicide: a qualitative study J. Palliat Med. 2004 Jun;7(3):451-61.

[xiii] Oregon Death with Dignity Act, 2017 Data Summary, 2018. 

[xiv] Hospice & Oregon’s Death With Dignity Act, Oregon Hospice and Palliative Care Association.

[xv] Royal College of Nursing briefing ahead of Second Reading of the Assisted Dying Bill (No.2), House of Commons, 2015.

[xvi] California Medical Association removes opposition to physician aid in dying bill, CMA, May 20th 2015.