Assisted dying - a medical view

1. Assisted dying- a medical view Dr J Martin Leiper, Consultant in Palliative Medicine, NHS Tayside

2. Secret ballot 1 • Should physician assisted suicide for terminal illness be legalised in Scotland? • Please put “yes” or “no” or “not sure” on you paper. • Please fold paper in half and pop in box.

3. Not all practising doctors are trained in ethics Sept’05

4. Basic ethical principles • Beneficence - doing the patient good • Non-maleficence - not doing harm • Respect for patient autonomy (patient’s wishes) • Respect for justice (to the patient and the community) (Beauchamp and Childress 1977)

5. Withdrawal & withholding of medical treatment Voluntary euthanasia Assisted dying Principle of double effect Refusal of treatment Advance statements (living wills)

7. Palliative care - intends neither to hasten nor postpone death “the closer their experience of end -of -life patients, the less sure professionals are about he prospect of a change in the law in favour of euthanasia” House of Lords Select Committee Report 2005

8. Cancer Debility Therapy Non cancer Friends gone Bureaucracy Delay Unavailable doctors Treatment failure Irritability Somatic (body) Loss of: income role Fatigue Helplessness Disfigurement Total Suffering Depression Anger Anxiety Fear of pain, hospital, death Spiritual unrest Finance, Uncertainty

9. How often requested?

10. “Euthanasia is already happening” – eh no. • “…..we looked at allegations that doctors were already ending the lives of patients prematurely, though we found no reliable evidence of that.” Lord Mackay of Clashfern, 10th Oct 05 (select committee member) - Hansard

12. “Joffe” bill • Competent adult • Terminal illness • Suffering unbearably • “Assistance to die” – prescription to self administer.

13. Lords Select Committee • Mandatory psychiatric assessment? • “Unbearable suffering” vs. “unrelievable” or “intractable” • Could patients experience palliative care before taking a decision?

14. Select Committee Report • Do doctors need to be involved? • Future bill should distinguish between assisted suicide and voluntary euthanasia – “responsibility for the ultimate act rests with the patient”

15. “Joffe” Bill (revised 05) • Verbal and written request to 1st Dr • 2nd opinion from consulting Dr • Psychiatric review if doubt as to competence • Compulsory meeting with palliative care • Witnessed written declaration • Dr prescribes lethal dose and patient self administers - assisted suicide

16. Joffe Bill Competent adult Terminal illness - “months” “Unbearable suffering” Verbal and written request 2nd Dr opinion Compulsory pall care consult Assisted suicide Dying with Dignity Scotland Competent adult Terminal illness < 6 months Verbal and written request 2nd Dr opinion Assisted suicide Failed Feb 2006 Failed Mar 2006

17. Doctor - patient relationship • Trust • Testing the water “just gim me the wee blue peel - doc”

18. Competence • Adults With Incapacity Act

19. Prognosis

20. Understanding palliative care Patients often say • “I wish I had known earlier” • “I wish I had come here earlier”

21. Public awareness of palliative care Report of the findings of the first national survey in Scotland into public knowledge and understanding of palliative care December 2003 Jennifer Wallace

22. Palliative care Assisted dying

23. Assisted dying Palliative care

24. Robert Pope

25. Who is in control? • Young man, divorced, depressed – life no longer worth living • Older man – widower, depressed, frail, incontinent – life no longer worth living

26. Oregon • Massive dose of oral barbiturate • After ingestion may live 30hrs or even wake up • 60% had to change doctor to get drugs • Only 20% of hospitals have pal care programme • Palliative medicine is not a speciality • No central register of prescriptions • 5% patients get psychiatric consult (was 30%) Baroness Finlay of Llandaff (Prof. of Pal Med)

28. Role of palliative care professional in Joffe proposals • To encourage? • To discourage? • A duty to offer euthanasia? Just tick the box!

29. UK Professional Bodies • Association for Palliative Medicine against • Royal College of GPs against • British Medical Assoc now against • Royal College of Physicians (Lon) neutral • Royal College of Physicians (Edin) hesitant • British Geriatric Society against • Pharmaceutical Soc thinking • Royal College of Nursing against • GMC no comment • Scottish Partnership for Pal Care against • Help the Hospices more pal care

30. carenotkilling.org.uk

31. Palliative Medicine • Acknowledges suffering • Cannot always relieve suffering • Realises pal. care is not always acceptable • Does not perform euthanasia • Not supportive of proposals • Feels “used” in as second opinion • May opt out of any proposals in future

32. Who suffers in the end? • Person with chronic illness in nursing home VS • Human freedom and right to die (be killed)

33. Volume III of our report has evidence from Dutch physician Bert Keizer, who wrote: • "I would rather die in a country where euthanasia is forbidden but where doctors do know how to look after a dying patient in a humane manner than I would in a country where palliative medicine is ignored but euthanasia can be easily arranged". Baroness Finlay of Llandaff (Prof. of Pal Med)

34. Secret ballot 2 • Should physician assisted suicide for terminal illness be legalised in Scotland? • Please put “yes” or “no” or “not sure” on you paper. • Please fold paper in half and pop in box.