'First do no harm'—a clear line in law and medical ethics
Ilora Finlay Professor of Palliative Medicine
Cardiff University and President Elect, RSM
We have a bill before Parliament that would fundamentally change
the way doctors practice medicine and the way that those with distress
are managed. Lord Joffe's Assisted Dying for the Terminally Ill bill
(ADTI) is designed to enable an adult who has capacity and who is
suffering unbearably as a result of a terminal illness to receive
medical assistance to die at his own considered and persistent request.
At first sight this seems a compassionate and laudable aim, so why
would anyone object?
The problems lie in the very nature of the bill itself, and in the
reason it is presented as it is. This is the third such bill Lord
Joffe has laid before Parliament in as many years. The previous version
was the subject of a lengthy select committee inquiry whose report
is a comprehensive and up-to-date overview on the topic of physician
assisted suicide/euthanasia. The select committee made a number of
important recommendations to produce better safeguards in any future
bill, which might be presented; but the proponents of the latest
bill have chosen to ignore almost all of these, claiming there are
stringent safeguards in the new bill and that it is modelled on Oregon's
Death with Dignity Act (ODDA).
However, unlike the ODDA, this bill would authorize doctors not
only to prescribe lethal drugs but also, in 'appropriate' cases,
to set up an intravenous line, with the patient being required simply
to trigger the release of drugs into his or her vein, taking us to
the very edge of euthanasia. The select committee recommended that
the doctor's duties must be clear; yet ADTI is inexplicit about actions
that would be lawful for a doctor to take (it talks only of 'assisting
the patient to die'), posing problems for doctors as to whether they
were operating within the law or crossing the line.
So what are the so-called safeguards? They restrict assistedsuicide
to adult patients who are terminally ill, who do not 'lack capacity'
and who are 'suffering unbearably'. The require assessment of all
applicants by two doctors, they require that an applicant is offered
a consultation on palliative care and they require two witnesses
to a declaration. There is also a 'conscience clause' to enable doctors
and others to opt out of taking part in the process.
It may sound reasonable enough. But how will such safeguards work
in practice? How will those doctors, nurses, pharmacists, clerical
staff who conscientiously object really avoid dealing with those
seeking assistance to commit suicide? What will be the effect on
other patients in a ward who overhear such discussions? And how impartial
will be a second opinion? Or will we seek one from someone whose
views are likely to concur with our own?
The select committee heard evidence that accurate prognosis is not
possible beyond 8-12 weeks; so it recommended that terminal illness
'should be defined in such a way as to reflect the realities of clinical
the bill ignores this, with its arbitrary requirement that death
is predicted '... within six months'; even Anne Turner, who recently
committed suicide in Switzerland, fell well outside that requirement.
The bill requires that the patient must be 'suffering unbearably';
but who can objectively assess how bearable or unbearable suffering
is? Only the patient can answer this question, and Lord Joffe himself
admitted to the select committee that it could be no more than the
patient's own opinion. So this is no more than a token safeguard.3 Because
of concerns such as these, the selectcommittee recommended that 'unrelievable'
suffering would bea more objective test,4 but
this has been ignored.
Proponents have argued that ADTI would comfort those facing death,
but others have highlighted the new decision this treatment option
brings. Anyone within an expected 6 months of death would be faced
with this enduring choice: whether they should 'go for' assisted
suicide, feeling they have become a burden, and fearful of tomorrow
being worse than today.5 And
how could such coercion, real or perceived, be detected?
The bill seems confused as to whether its main objective is terminal
illness or suffering. Terrible suffering exists outside terminal
illness and is arguably greater when it has to be endured for years.
The insertion of a condition on suffering opens the door to future
extensions beyond terminal illness; as Lord Joffe himself said, he
wanted his last bill '... to be of much wider application' and would
welcome an extension to include those patients who were younger and
who were not terminally ill but who were 'suffering unbearably'.6
After performing euthanasia, 42% of Dutch doctors report feelings
of discomfort, and 43% later sought support in coping - usually from
family, friends or colleagues.7 The
process is not without complications: the attending physician found
it necessary to intervene by administering a lethal drug in 18% of
Dutch physician assisted suicides.8 And
the Dutch experience suggests such acultural change occurs, with
euthanasia deaths (at 1 in 32 ofall deaths) now accounting for six
times their road accidentdeath rate.
In The Netherlands only about 54 % of euthanasias are officially
such study has been done in Oregon; but Oregon has no tracking system
to detect illegal prescriptions for barbiturates - the drug used
for physician assisted suicide - so the incidence of PAS could be
much higher than official figures suggest. By contrast, in the UK
recent data show no evidence of physician assisted suicide and indicate
that any covert euthanasia is much less frequent than in other countries
- and especially those which have legalized 'assisted dying' - probably
because palliative care has influenced decision-making for the good.10
For centuries medicine has depended on the age-old principle of
'First do no harm'. The law of the land mirrors medical ethics exactly
here. A patient is free to refuse life-sustaining treatment - that
is not suicide. Ineffective treatments can be discontinued: we do
not have to keep our patients alive at all costs. But we must not
deliberately and intentionally end or help to end a patient's life.
This rule of both medical ethics and law has been described as a
'bright line'-a line which is not invariably observed by doctors
any more than by others, but a line, nonetheless, which is not in
the least ambiguous. But, if Lord Joffe's bill succeeds, it will
become a blurred line, as doctors would become the gatekeepers on
assisting patients to commit suicide. They would have to make subjective
- and in many cases non-clinical - judgements aboutsuch things as
whether a patient who asks for lethal drugs isof sound mind, or is
free from internal or external coercion,or has suffering which is
'unbearable'. After 'do no harm',it would be necessary to add the
- Gilbert J. HL Paper 86-II, Page
552 (session 2004-05). London: Stationery Office,2005
- HL Paper 86-I, Paragraph 269.
London: Stationery Office, 2005
- HL Paper 86-II, Page 49.
London: Stationery Office, 2005
- HL Paper 86-I, Paragraphs 255-256. London:
Stationery Office, 2005
- Randall F. HL Paper 86-II, page
554-7. London: Stationery Office, 2005
- Lord Joffe. HL Paper 86-I, Paragraph
92. London: Stationery Office, 2005
- Haverkate I, van der Heide A, Onwuteaka-Philipsen
BD, van der Maas PJ, van der Wal G. The emotional impact on physicians
of hastening the death of a patient Med J Aust2001; 175:519
- Groenewoud JH, van der Heide A, Onwuteaka-Philipsen
BD, Willems DL, van der Maas PJ, van der Wal G. Clinical problems
with the performance of euthanasia and physician-assisted suicide
in the Netherlands. N Engl J Med 2000;342:551
- Sheldon T. Only half of Dutch doctors
report euthanasia. BMJ2003; 326:1164[Free Full
- Seale C. National Survey of End-of-Life
Decisions made by UK Medical Practitioners. Palliat Med2006; 20:3