Iain Lawrie

Life or assisted death: the doctor’s dilemma

Life or assisted death: the doctor's dilemma
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The so-called assisted dying debate is again generating more heat than light.  Once again, we have the British Medical Journal – which is not, as some may suppose, the house journal of the BMA – ranting and raving that the law needs to be changed.  This is a long-standing obsession of the BMJ's editorial staff.  It is not the view of the BMA.

There are really two questions here.  One is whether the law should be changed to license doctors to supply lethal drugs to terminally ill people for use in suicide. The other is what, if any, role doctors should play if the law were to be changed.

If any such law were to be built around specific medical conditions, doctors obviously would have a role to play.  It would be for them to diagnose the patient's condition, offer an opinion on its likely outcome and suggest possible treatment options.  In a 2015 survey of 1,000 GPs, 39 per cent said they would be prepared to go that far – but no further.

The difficulty, which most doctors recognise, is that deciding whether someone should qualify for legalised 'assisted dying' involves much more than diagnosis and prognosis. Even these can pose challenges – prognosis of terminal illness is in many cases little more than guesswork.  But compared with assessing other criteria – such as whether there is a settled wish to die, whether there are any external or internal personal or family pressures at work in the background, whether the patient's judgement is being impaired by depression or despair – the medical part is relatively straightforward.

It is these personal, family or social judgements on 'assisted dying' that doctors are just not qualified to make.  We simply do not live in a world in which all doctors know their patients well, have been regular visitors to their homes and met their families and have talked with them at length about their values and feelings.  There are parts of the country where these conditions, or something like them, exist, but they are increasingly the exception.

If our regular doctors know little of us beyond what they pick up in the consulting room, what about the doctors who would be considering requests for assisted suicide? According to the same survey I have mentioned, only one in seven GP respondents said they would be prepared to consider a request for 'assisted dying' beyond advising on the strictly-medical issues  So these life-or-death judgements would end up being made by a doctor who had never met the patient before.  What sort of recipe is that for a knowledge-based assessment process? Doctors have a key role to play in suicide prevention.  When they encounter patients showing suicidal signs, they have a duty of care to protect them.  Are we now to say that that duty vanishes if the patient happens to be terminally ill?

We are told by campaigners for 'assisted dying' that legalisation is a matter for society, not for doctors.  What they mean by this high-sounding phrase is that the medical profession should hold its peace about whether assisted suicide should be legalised, yet its members should be expected to carry it out.  There are real dangers in embedding assisted suicide within clinical practice, which wraps it in an aura of benevolence and sends the misleading message that, if it's part of medical practice, it must be a best-interests activity.

It is for Parliament to decide whether assisted suicide should be legalised.  As recently as 2015 Parliament ruled decisively against such a change in the law.  But, if Parliament should ever conclude that such acts should be legalised, the assessment of individual requests and the decision-making should rest with the courts – and given the gravity of the matter with the High Court – not with doctors.  If 'assisted dying' is a matter for society and not for the medical profession, it is society, through the courts, that must have the responsibility for it.

Dr Iain Lawrie is a palliative medicine consultant and honorary clinical senior lecturer in palliative medicine