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The following constitutes the response of the BGS to the House
of Lords Bill on assisted dying for the terminally ill.
The British Geriatrics Society (BGS) is a professional association
of physicians, general practitioners and scientists with an interest in
geriatric medicine. It is the only society offering specialist medical
expertise in the whole range of health care needs of older people, from
acute hospital care to high quality long-term care in the community. It
now has over 2,000 members worldwide.
Geriatric
medicine is that branch of general medicine concerned with the clinical,
preventive, remedial and social aspects of illness of older people. Their
high morbidity rates, different patterns of disease presentation, slower
response to treatment and requirements for social support, call for special
medical skills. The purpose is to restore an ill and disabled person to
a level of maximum ability and, wherever possible, return the person to
an independent life at home.
The BGS is
pleased to have the opportunity to respond to this Bill and makes the
following points.
- The BGS
accepts the rights of individuals to determine the choice of treatment
and care they receive. We further accept that sometimes, but very, very
rarely, some symptoms are difficult to control and that even if they
are, people may still find their life unbearable. Yet a policy which
allows patients, in certain circumstances, to choose death, and to be
helped to die by their physicians, is not the ethically correct answer.
- The BGS
believes the duty of the physician to care for his/her patients is incompatible
with a duty to bring about death even at the request of the patient.
It is argued by proponents of euthanasia that curing disease and bringing
about death are not mutually exclusive roles, the intention in both
cases being the relief of suffering. It is further argued that the primary
role of the physician is to care for his/her patient, which must therefore
entail respecting their autonomous wish to die. However, the BGS believes
that crossing the boundary between acknowledging that death is inevitable
and taking active steps to bring about death changes fundamentally the
role of the physician, changes the doctor patient relationship and changes
the role of medicine in society. The focus would shift from providing
the best palliative care i.e. easing symptoms, to providing death on
demand. Such a shift will inevitably dilute the sanctity of life doctrine.
Once quality of life becomes the yardstick by which the value of human
life is judged, the protection offered to the most vulnerable members
of society is weakened.
- In the
experience of many geriatricians, the feeling for many older people
that life is unbearable in its later stages is a direct result of the
reaction of others to their frailty and the care and treatment they
are afforded. Our concern then is that many older people, because of
the care given to them by society in general and the NHS and Social
Care system in particular, will perceive themselves as a burden and
feel under pressure to end their lives. The BGS considers the best way
of helping these vulnerable people is to maximise their independence
and health, rather than acceding to their expressed wish to die.
- The BGS
believes that Older People are often unduly influenced by their families
and carers. It is important to remember that not all these people will
necessarily have the older person’s well being at heart. Even
if they do, it is noteworthy that almost all requests to end life –
made either directly or indirectly to us as geriatricians - come from
the patients’ families and not the older person themselves. Often
such requests are then forgotten if such degrading symptoms as urinary
and faecal incontinence, depression and unremitting pain are relieved.
The BGS thus questions the true need for the bill.
- Whilst
many older people are competent to make decisions about their wish for
assisted dying, many will not be. The proposal in the Mental Capacity
Bill is to appoint a health attorney with the legal authority to take
health and welfare decisions for a person in the event of his or her
loss of capacity. This could mean, under the terms of the Assisted Dying
bill, that a decision to end an older person’s life could be made
by a nominated health attorney. The complexities arising from such conditions
could therefore lead to serious abuse of this power. Furthermore, such
situations might interfere with the beneficial use of the Mental Capacity
Bill.
- We are
concerned about the addition of Section 15 to the Bill. The right of
any individual, whether terminally ill or not, to have their symptoms
controlled is undisputed. In our opinion there is no overlap in clinical
practice between symptom control and the wilful termination of life
(or assisted dying). To muddle the two is to cause considerable confusion
and to risk the danger that symptom control becomes an easier way to
hasten death than completion of the declaration and all the safeguards
therein - especially for people who are deemed incompetent.
- In the
same vein, the BGS would emphasise that the right of a patient to choose
or decline prolonged treatment and or intervention whatever the consequences,
supersedes all other guidance and wishes.
- Finally
the BGS is concerned that the ‘Assisted Dying for the Terminally
Ill Bill’, whilst it does not apply directly and solely to older
people, will lead to a change in attitude to death in society and also
within the medical profession. The prohibition on intentional killing
is the cornerstone of society and it is worth preserving the notion
that all lives are precious. The BGS accepts that this denies a very
small number of persons the right to have their life ended by their
physician if it is their autonomous wish. However it must be noted that
every society puts some limits on respect for autonomy, which must be
balanced against the greater good of society. The BGS urges Parliament
instead to strive to improve the medical and social care of older people,
placing them back in the centre of a society which respects their wisdom
and experience. Rather than defining the conditions under which physicians
may become killers, our efforts should focus on improving all aspects
of palliative care, such that the debate on assisted death becomes irrelevant.
- In summary
therefore, the British Geriatrics Society is totally opposed to the
introduction of the Assisted Dying Bill.
Nonetheless
it is recognised that the decision is for Parliament. If, despite our
objections, the Bill is enacted into law, we recommend the following additional
safeguards and caveats.
For
the Process of Signing the Declaration
- A cooling
off period of at least 14 days, after the declaration has been signed
and witnessed.
- A mandatory
psychiatric opinion to exclude a depressive illness – from a specially
trained psychiatrist
- Involvement
of the patient’s general practitioner in any discussion around
the signing of a declaration.
- Written
confirmation from the doctors and solicitors involved that neither they,
their families nor any charity with which they are associated or connected,
will benefit from the patient’s will.
- Obligatory
assessment by a specialist palliative care team.
- In the
case of older people, where the attending doctor is not a geriatrician,
there must be obligatory assessment by a consultant geriatrician.
A much clearer
definition of a ‘terminal illness’. The prognosis of a ‘few
months’ is not in our experience very easy to determine.
The
actual process of dying
We are concerned about the nature and process of the ‘assisted death’.
Will there be clinical and or best practice guidelines outlining the best
method?
We emphasise
strongly that the BGS believes that should the bill become law, no doctor
should be obliged to participate in the process of ending life. To do
so would risk confusing the role of the doctor and damage the patient’s
trust that their doctor is always working in their best interests. Indeed
we question whether the process should be undertaken by doctors at all.
The
endurance of the declaration in time
The Bill proposes that a period of no more than 6 months should elapse
between the declaration and the act of assisted death. Whilst accepting
that there should be some time lapse, we suggest that there needs to be
provision for the eventuality that the patient becomes incompetent in
the intervening period. In our opinion the declaration should become invalid
in such circumstances. Likewise, we would be most anxious to avoid the
use of Advance Directives (proposed as a statutory principle under the
Mental Capacity Bill) as a mechanism to request assisted dying. We cannot
and should not assume that a person could reliably determine in advance
their preference for dying in the event of an actual situation they have
not yet experienced.
Policy
Committee
British Geriatrics Society
August 2004
This response
will be posted to the BGS website shortly and Dr Gill Turner and Dr Jerry
Playfer will be presenting oral evidence at the House of Lords on 14 December.
Please direct any correspondence relating to both this and Tony
Luxton’s article to the Editor at Email
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