24 September 2014

Assisted Dying, what are the issues and options for Scotland?

By Dr Iain C Kerr

Introduction
My interest in death (which was a matter of great concern to the medical director of my Local Health Care Co-operative when it became clear that I was sympathetic to suicide in certain circumstances) began in the early 1970s, after I read of the works of two pioneers in the care of the dying. One was a Swiss-American psychiatrist called Elizabeth Kubler-Ross who was among the first to interview terminally ill patients and who found that many of them had a profound wish to discuss the issues around death and dying. The other was Dame Cicely Saunders who studied how doctors and nurses dealt with patients in general wards who had a terminal prognosis. She found that staff spent much less time with these patients. Therefore those who had the greatest need for communication had the least opportunity to experience it. I tried during my career to be open to discussion of these issues with my patients if they felt it appropriate.

My only experience is in general practice rather than in hospital practice. I prefer to use the term assisted suicide meaning that a competent person has expressed a wish to end his or her life and needs some guidance.


The Legal Landscape
The legal situation in Scotland is unclear. There is no crime of assisting suicide in Scotland but someone who assists a person could be charged with culpable homicide or recklessly endangering life. (In England the Director of Public Prosecutions has published guidelines about the circumstances in which it is likely that no prosecution will occur in cases of assisting suicide following the case of Purdy v DPP). Margo MacDonald MSP plans to bring a Bill to the Scottish Parliament to decriminalise assisting suicide. The Bill will restrict assisted suicide to people who fulfil certain criteria, and any practitioners assisting will be free from prosecution as long as guidelines are followed. Such a Bill will provide a structure to the process and clarify the issues, since we have long moved away from the circumstances in which the trusted family doctor could have eased the dying process in appropriate cases.

Palliative Care
The development of palliative care has been of enormous benefit to patients many of whom have been helped to achieve a dignified and comfortable death. However many people (especially perhaps doctors) are aware of situations where adequate palliation of symptoms has not been achieved for a variety of reasons.

The Minister introducing a Bill to the Quebec Parliament recently said, ‘Most people want to live as long as they can if their suffering is tolerable. Most people want to have palliative care, but we must have an answer for the difficult cases.’

At a meeting organised by Friends at the End a group supporting assisted suicide, I recently heard a talk by a caring and conscientious palliative care specialist. She said people would sometimes ask for a pill to end it all. On these occasions she asks, ‘If I could give you such a pill just now would you take it?’ and throughout her career only had three patients said ‘yes’. A member of the audience said, ‘These are the people whom we want to help.’

Is Human Life Sacrosanct?
The term ‘sacrosanct’ means sacred or holy by religious association. People may object to assisted suicide on religious grounds and that is perfectly acceptable. What is not acceptable is for those people to attempt to limit the choice in this matter of others who do not share their faith. My impression is that while the hierarchies of the Church of Scotland and the Roman Catholic Church oppose assisted suicide, many ordinary people who profess those faiths are supportive of it.

Ethical Issues
There are clearly a number of ethical issues surrounding assisted suicide. However as suicide is legal I do not think it is unethical to assist it, especially in the framework suggested by Margo MacDonald.

In 2012 the case was brought to the Supreme Court in British Columbia, when a disabled woman claimed that she suffered discrimination, because she was unable to commit suicide without assistance [Carter v Canada]. The judge in the case took evidence from a large number of expert witnesses both for and against the concept. She came to the conclusion that there was no ethical difference between suicide, assisted suicide and commonly employed end-of-life management techniques such as terminal sedation. There will of course be many different opinions about the ethics of the practice.

The Hippocratic Oath perhaps deserves mention. Doctors take the Oath (or in my case someone took it on behalf of all the graduates) and promise ‘not to give any deadly substance if asked.’ This refers to the practice 2000 years ago of ‘doctors’ being asked for poison to eliminate troublesome relatives or political rivals.

Objections
There are objections to assisted suicide on various grounds. The most commonly cited ones are: there may be difficulty in being sure that someone requesting assistance is mentally capax, and is neither suffering from treatable depression nor from coercion; vulnerable people, the elderly, chronic physically or mentally ill patients and others will feel pressure, real or imagined to request an early death; damage to the doctor-patient relationship may occur; the slippery slope argument (i.e. that it will inevitably follow that the terms of any law will be expanded in due course and euthanasia is likely to become the norm); and finally that personal autonomy should not be allowed to (somehow) damage the wellbeing of the community. Most objections, however, are based on appeals to emotion, or to what might happen if the law is changed.

Conclusions
Evidence is emerging from places where assisted suicide has been accepted for ten years or more such as Switzerland, Holland, Belgium, Luxembourg and the state of Oregon in the USA. After considering that evidence the judge in the Canadian case referred to above came to the conclusion that the predicted abuse and disproportionate impact on the vulnerable had not materialised and that in these jurisdictions practitioners have developed a system that - whilst not perfect - protects vulnerable people while allowing competent people to choose the time of their death. In conclusion I believe that there is a need for assisted suicide in Scotland for carefully selected cases and that the provisions in the Bill proposed by Margo MacDonald will ensure the integrity of the process.

This post was first published on 30 July 2013.

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