The UK has become the latest country to consider assisted suicide legislation, with MPs, for the first time in almost a decade, set to vote on proposals allowing terminally ill people in England and Wales the right to choose to end their life.
Labour MP Kim Leadbeater, who is putting forward the Bill, said “now is the time” to hold a fresh debate on assisted dying – after MPs rejected a Bill on the issue in 2015 – while Prime Minister Sir Keir Starmer has supported a change in the law, reports the BBC.
Leadbeater said her proposals would give eligible adults nearing the end of their lives the right to choose to shorten their deaths if they wish.
The details have not been finalised but the Bll is likely to be similar to a proposal in the House of Lords, which would allow terminally ill adults with six months or fewer to live to get medical help to end their own lives.
The Bill is expected to be formally introduced on 16 October, with a debate and initial vote probably taking place later this year. It would have to be approved by MPs and peers before it becomes law.
Scotland, Jersey and the Isle of Man are also considering changes to the law.
However, Dr Lucy Thomas, a palliative care and public health doctor, said assisted dying was a last resort that courts, rather than doctors, were better placed to judge.
Choosing to end your life was not a “straightforward consumer decision”, she added.
Baroness Tanni Grey-Thompson, a former paralympian who is a crossbencher in the House of Lords, said she was against the proposed change, and had concerns “about the impact on vulnerable people, on disabled people, coercive control, and the ability of doctors to make a six-month diagnosis”.
Assisted suicide is currently banned in England, Wales and Northern Ireland, with a maximum prison sentence of 14 years.
Dr Gordon Macdonald, chief executive of Care Not Killing, a group which opposes changing the law, said news of the Bill was “clearly disappointing”.
He said: “I would strongly urge the government to focus on fixing our broken palliative care system that sees up to one in four Brits, who would benefit from this type of care, being unable to access it, rather than discussing again this dangerous and ideological policy.”
Energy Secretary Ed Miliband said last week that he would vote in favour of the Bill and described the current law as “cruel”.
And earlier this year, Health Secretary Wes Streeting said he was “conflicted” on assisted dying. The BBC has been told he thinks it is right to have a debate now but still has concerns.
The government has confirmed it will remain neutral on the Bill. A letter to Ministers told them they would be able to vote “however they wish”, but “should exercise discretion and not take part in the public debate”.
Part of palliative care?
However, whatever a person’s view on assisted euthanasia, or medical assistance in dying (MAID), an underlying question is whether it should be considered part of palliative care, write Harvey Chochinov and Joseph Fins in JAMA Network.
The Canadian Hospice Palliative Care Association takes the stance that MAID “definitionally fall(s) outside the scope of palliative care”, a historical perspective dating to Hippocratic injunctions against a fatal draught.
But with euthanasia and assisted suicide now becoming legal life-ending options in various jurisdictions, the insistence on separation between palliative care and MAID has been questioned.
Although some assert the purposeful hastening of death should always be outside the scope of medical practice, others believe respect for patient choice at life’s end is central to modern notions of patient-centred care.
Is MAID part of palliative care, based on characteristics embedded within the practice of medicine? It’s a contentious question, but there is universal agreement that palliative care itself is part of medicine. Hence, MAID can only be considered part of palliative care if this practice resides within the house of medicine.
If medicine does not include it, neither can palliative care.
Determining whether MAID is a medical treatment is worth considering through a useful heuristic offered by Thomas et al, which describes canons of therapy. The first, restoration, “counsels that the goal of all treatment is to restore the patient, as much as possible, to homeostatic equilibrium”.
Restoration aims to return the patient to a previously held state of wellness, capacity, or disposition. In advancing terminal illness, this means redefining homeostatic equilibrium by pursuing comfort care, the amelioration of pain, and to the extent possible, returning the patient to a state of greater engagement with their friends and family.
These activities are the mainstay of palliative care. It is hard to conceive of MAID as restorative because the very act makes any return impossible.
The next canon is means-end proportionality – that “every treatment should be well-fitted to the intended goal or end”.
One can only judge the proportionality of the means as it relates to the ends, which in palliative care is to relieve suffering. It is difficult to regard death as “well-fitted” – if cannot be titrated and trialled; hence, it does not qualify as a therapeutic, which means its pursuit resides outside the realm of medicine.
The next canon, parsimony, maintains “that only as much therapeutic force as is necessary should be used to achieve the therapeutic goal”. This is a central feature of good medical practice, whether it be in the choice of antibiotics or a surgical intervention.
This tailoring of a therapy to a specific condition, drawing on evidence-based guidelines, is violated under MAID, where patient preference effectively dictates practice. As example, Canadians seeking MAID are under no obligation to try other treatments they deem unacceptable. In those instances, physicians may have to dispense with parsimony – despite their clinical judgment pointing toward other options – yielding to the patient’s intent on receiving MAID.
The final canon, discretion, “counsels that an awareness of the limits of medical knowledge and practice should guide all treatment decisions”.
Since MAID was launched in Canada, eligibility has broadened from those whose deaths are reasonably foreseeable to individuals who are not dying but living with disability; with consideration now being given to mental illness, children, and those anticipating the loss of mental capacity.
Although some may see this as affirming individual autonomy, ethicist Paul Ramsey reminds us that physicians must recognise that medicine’s function is not to relieve the human condition of the human condition.
MAID and patient-physician relationship
In 2015, the British Medical Association’s end-of-life care and physician-assisted dying project examined perceptions and experiences of end-of-life care and palliative care.
Some members of the public believed that legalising death hastening would enhance their physicians’ ability to provide them a good death and more choice.
In contrast, others said it would undermine trust and increase their fear of physicians, particularly for those who are elderly, disabled, vulnerable, or religious; individuals who are opposed to MAID; and others who see themselves as a burden.
Although some physicians felt it could help them provide a good death, accommodate patient preferences, and improve end-of-life communication, others cautioned it might increase fear and suspicion of physicians (including hospices and palliative care physicians), harm their reputation, and change their fundamental role as healers.
MAID undermines the patient-physician relationship by violating the principle of non-abandonment, even when it is well intended.
At the height of patients’ distress, MAID truncates care and eliminates the possibility of healing. This distinguishes it from palliative medicine, which embraces patient and family at life’s end with fidelity and relationality extending into bereavement care for survivors.
MAID, hope, and palliative care
Unlike MAID, palliative care embodies an evidence-based response to human suffering. Intensive caring assures patients they won’t be abandoned; affirms their worth and ongoing value; takes an interest in them; sustains hope for possibilities of finding meaning and purpose; and maintains therapeutic humility when problems are intractable.
It is impossible to sustain this therapeutic stance when assessing a patient’s readiness for MAID. The former entails holistic medical care, whereas the latter shifts to a legalistic paradigm centred on determining eligibility for MAID.
Practitioner ambivalence and policy considerations
The moral argument, that the taking of human life is wrong, does not appear to be the most dominant ideological fence separating palliative care from MAID. Although some argue that MAID is bad for society and antithetical to the role of being a healthcare professional, others contend it provides those who are suffering with an autonomous choice to end their lives.
The policy arguments separating MAID and palliative care are rooted in the notion that palliative care affirms life, regards dying as a normal process, and is committed to “neither hasten nor postpone death”.
Organisations representing palliative care are resolute in asserting that MAID falls beyond their mandate. That said, the American Academy of Hospice and Palliative Medicine characterises its position as “studied neutrality”, which we take as emblematic of its ambivalence.
This ambivalence also permeates variable responses in different nations. A recent international scoping review examined the relation between palliative care and assisted dying where lawful.
Notwithstanding differences across constituencies, it describes the relationship between palliative care and MAID as varied and sometimes combined, including supportive, neutral, coexisting, not mutually exclusive, integrated, synergistic, cooperative, collaborative, opposed, ambivalent, and conflicted.
Swiss studies that were included indicated that physicians do not actively participate in offering assisted suicide as part of palliative care and do not consider it a medical act.
The single Canadian study of physicians reported that some agreed to take part in all aspects of MAID, others to undertake MAID assessments but to not administer the lethal medications, whereas others would not agree to take part in any aspect of MAID.
In Belgium, where the relationship is described as highly integrated, the review cites a lack of detail and nuanced insight regarding “how euthanasia is introduced within a palliative care context and whether and how this varies within and across institutions or professional groups”.
The authors concluded that “none of the selected articles explain how the synergistic relationship takes form in practice”, raising the question of how to provide patient-centred multidisciplinary palliative care for patients interested in opting for an assisted death.
These data suggest that medicine is uncomfortable with MAID because it resides outside conventional practice. Administering a lethal medication does not make it a medical act, albeit healthcare professional involvement and a medical environment provide an air of credibility and legitimacy.
Considering MAID as a legal intervention and a rights issue, centred on a singular intervention of ending life, reveals the complexity of an act currently cloaked as medical care.
Although this may cause patients and practitioners to feel less sanguine toward MAID, some healthcare professionals will continue to offer this service, albeit outside the scope of medicine.
This shift in perspective may also garner additional resources to promote care and deepen understanding for patients who are suffering or nearing death.
Harvey Max Chochinov – Paul Albrechtsen Research Institute CancerCare Manitoba; University of Manitoba, Winnipeg, Canada;
Joseph Fins, MD – Weill Cornell Medical College, New York; Yale Law School. Connecticut.
BBC article – MPs to get first vote on assisted dying for nine years (Open access)
JAMA Network article – Is Medical Assistance in Dying Part of Palliative Care? (Open access)
See more from MedicalBrief archives:
Why liberal Switzerland is opposing Sarco suicide capsule
The right to assisted suicide long overdue
Canada to legalise assisted suicide for mental illness