Physician-assisted dying: Complex issue that requires open and honest debate

Last month the Dying with Dignity Bill 2020, which aims to legalise assisted dying/suicide in Ireland, passed the second stage in the Dáil and it now moves to committee stage, where it will be subject to further scrutiny.

According to the Bill’s explanatory memorandum: “The rationale behind the Bill is to give to a person the legal and medical right of the authorisation of assisted dying where that person is suffering from a terminal illness.”

The Bill sets out the terms under which it would be legal for an eligible terminally ill person over 18 who wishes to end their own life and has the capacity to do so, to die with the assistance of a medical practitioner.

According to the Bill: “Subject to the provisions of this Act, it shall be lawful for a medical practitioner to provide assistance to a qualifying person to end his or her own life.”

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The ways in which a doctor could assist a terminally ill person to end their lives would include prescribing an eligible person under the legislation the drug, which according to the Bill, can be “orally ingested by the person”.

In cases where it is impossible or inappropriate for the terminally ill person to swallow the medicine, a doctor can prescribe and provide the drug in a way in which the person can self administer it, or in cases where this is not possible, the doctor could then administer the drug directly.

The issue of physician-assisted dying is complex and brings up a myriad of ethical, legal and moral issues that require open and honest debate.

It is imperative that both sides of the debate are heard, including those of medical professionals who, if assisted dying is legalised in Ireland, would ultimately be tasked with carrying it out.

In 2017, the Royal College of Physicians of Ireland (RCPI) published a position paper on assisted suicide, which it updated in October this year.

According to the paper, the “RCPI officially opposes the introduction of any legislation supportive of assisted suicide because it is contrary to best medical practice. RCPI promotes a considered and compassionate approach to caring for, and proactively meeting the needs and concerns of patients who may be approaching the end of their life. That RCPI would as a body promote adherence to the medical council’s current Guide to Professional Medical Conduct and Ethics for Registered Medical Practitioners guidance on end of life care.”

‘Irrevocably change’

Dr Feargal Twomey is chair of the Irish Palliative Medicine Consultants' Association (IPMCA) and the official RCPI spokesperson on physician-assisted dying and euthanasia.

Dr Twomey, who is a consultant in palliative medicine at Milford Hospice in Limerick and University Hospital Limerick, said the dignity Bill would “irrevocably change” the doctor-patient relationship. “We feel that there is no role whatsoever for a medical practitioner of any kind, in any part of assisted suicide or dying, even if it is legislated for in this country. If society makes the decision that it wishes to legislate for this, then society will need to provide the service – it isn’t a role that should be part of normal healthcare.

“Speaking personally, it is a world away from what I understand to be compassionate and caring palliative care, which is provided by specialists in palliative care like myself, but also by many primary care doctors and nurses and doctors and nurses in all specialties across the Irish healthcare system,” Dr Twomey said.

One of the arguments put forward by those in favour of legalising assisted dying is that it would relieve unbearable pain and suffering at end of life. However, Dr Twomey said that, while he couldn’t speak for everyone, based on the experiences of the members of the IPMCA who have cared for thousands of highly complex palliative care patients with severe symptoms over many decades, it was “an extremely rare event” that extreme pain and distress could not be managed. “It has been painted as you either have an experience of unremitting pain and suffering, or you have help from someone to kill yourself and that is a dichotomy that I just don’t see in my practice,” he said.

“I see palliative care as helping people to live as well as they can.” Death, he said would come to us all, “but how we die and how we live until we die are important”.

Dr Twomey said there was a lack of understanding of palliative care and all it could do to help people live until they die.

Another concern outlined in the RCPI position paper on assisted suicide is that legalising it would lead to what it refers to as a “creep and slippery slope”.

According to the paper, “there is concern that legalising assisted suicide would lead to significant unintended consequences for healthcare system and society that societal attitudes would gradually change; that there would inevitably be a creep from restrictive to permissive eligibility and potentially to include non-voluntary and involuntary euthanasia. With that, there is the possibility that life would be devalued in society, particularly concerning for vulnerable people – sick, disabled and elderly. This argument includes the idea that people who are very ill or with severe disabilities may feel pressured to request assisted suicide or euthanasia to avoid being a burden to their families.”

In its conclusions, the RCPI states: “Within the discourse around assisted suicide there are a number of arguments in support of and against assisted suicide and euthanasia. It is the position of RCPI that the potential harms of assisted suicide outweigh the arguments in favour of legislation for assisted suicide. A majority of professional healthcare and medical bodies worldwide are of the same view.”

Survey

In February 2020, the British Medical Association (BMA), the main doctors' union in the UK, carried out one of the largest surveys of medical opinion on physician-assisted dying. The survey received responses from almost 30,000 BMA members, which included doctors across a range of specialties and medical students.

Asked if they personally supported a change in the law in the UK on doctors administering drugs with the intention of ending an eligible patient’s life, 46 per cent of BMA members said they would oppose such a move, 37 per cent said they would support it, while 17 per cent were undecided.

On the question: “Would you be willing to participate in any way in the process if the law changed on doctors administering drugs with the intention of ending an eligible patient’s life?” More than half, or 54 per cent, said they would not be willing to participate, 26 per cent reported that they would and 20 per cent were undecided.

Overall, BMA members in Northern Ireland were generally more opposed to physician-assisted suicide than those in the other nations and there were no significant differences found between members in England, Scotland and Wales.

The specialties that tended to be generally more supportive of physician-assisted dying according to the survey were: anaesthetics, emergency medicine, intensive care and obstetrics and gynaecology. The specialties that tended to be more opposed were clinical oncology, general practice, geriatric medicine and palliative medicine.

According to the BMA, the results of the survey would not determine policy, but would inform a debate on its policy in this area planned as part of its annual meeting in 2021. Currently, the BMA is opposed to all forms of physician-assisted suicide.

The Dying with Dignity Bill includes a section on conscientious objection meaning that doctors or assisting healthcare professionals are not obliged to assist someone to die if they have a conscientious objection.

A number of prominent medical bodies in Ireland are yet to form a formal position on the new leglislation.

The Irish College of General Practitioners (ICGP), said: “The proposed legislation, if passed, would permit assisted dying in Ireland in limited circumstances, enabling medical professionals to provide assistance to some terminally ill patients to end their own lives. The ICGP notes the significance of this Bill for all levels in society including medical professionals. The ICGP will give this Bill due consideration. It does not have a position on it at this time.”

In a statement, the Irish Medical Council said it “provides guidance on a wide range of matters related to the professional conduct and ethics for registered medical practitioners in the Guide to Professional Conduct and Ethics for Registered Medical Practitioners (the guide). The guide outlines principle-based guidance for doctors on a wide range of scenarios which are likely to arise over the course of their professional careers. The guide makes reference to legislation throughout, and this document is intended to underpin more detailed practice guidance for doctors, who also have a duty to ensure compliance with all laws and regulations pertaining to their practice. Any relevant legislative developments are considered in reviewing the Guide to Professional Conduct and Ethics for Registered Medical Practitioners. This was most recently done following the enactment of Health (Regulation of Termination of Pregnancy) Act 2018.”

Under the section on end of life care the medical council’s most recent ethical guide (8th edition 2019), 46.9 states: “You must not take part in the deliberate killing of a patient.”

In the assisted dying debate, much like a number of ethical and moral questions Ireland has faced in the past, the medical profession once again finds itself as a central protagonist and many doctors hold conflicting professional and personal views on the issue.

Concern

Dr Twomey is clear in his personal and professional opinion that doctors should not have any part to play in assisted dying. However, he said his main concern was the lack of any real debate or public consultation on the issue to date. “We absolutely need a debate, it is a very complex issue. It has legal, moral, ethical, societal and medical, and wider healthcare ramifications. I think it’s really important that the community get to hear all sides of the debate,” he said.

The call for increased debate on the Dignity with Dying Bill was echoed by the Irish Hospice Foundation which, in a statement issued after the Dáil voted to progress the Bill to committee stage, said: "We believe there has not yet been a sufficiently detailed and diverse debate in Ireland. There are many national and international voices yet to be heard. We urge the committee to seek out these voices, relevant case studies and international research, ensuring the debate is open, non-exclusionary, and further, that the committee is a safe and effective space, for a wide range of views to be heard.

“The Irish Hospice Foundation believes every person deserves a ‘good death’, including that their pain and suffering is managed to the best extent possible. Every person facing dying, death and bereavement has to deal with many personal challenges.

“We want to ensure that they receive the optimal services, empathy and care. In the end, we all desire a solution which meets the needs of the Irish public and which reflects the society we now live in.”