A Highland GP on life the universe and anything…

On 24th April 2014 I was asked to speak at a Symposium on the Assisted Suicide (Scotland) Bill. The target audience were legal and medical professional practitioners. In effect those who might be called upon to administer, implement and enforce any system which permitted assisted suicide. It was hoped to add to the public debate in an informed way.

The event was held under the joint auspices of Ampersand Advocates and the Mason Institute (University of Edinburgh School of Law).  The event took place at the Royal College of Physicians, George Street, Edinburgh.

The first session focused on the principles underlying the Bill. I was there as RCGP Scotland, Deputy Chair (policy) to present the college’s position.

The Royal College of General Practitioners is the largest of the Royal Colleges with 49,000 members; 4,600 of which are in Scotland. Our motto “scientia cum caritas” defines our value of combining knowledge with care.

 

Within the past few months the RCGP has run a membership consultation, in response to a challenge by Dr Clare Gerada, the then Chair of RCGP UK.  She expressed a personal view that the college move from a position of opposition to a change to the law to a neutral stance on assisted dying. The consultation was organised by the RCGP ethics committee, and it resulted in extensive responses both from individual members and local faculties. Separate responses were received from Scotland, Wales and Ireland. The overwhelming result was the decision to maintain the college’s opposition to a change in the law.

It is always uncomfortable when a professional group’s views fly in the face of opinion polls. But it is heartening when they align with the views of the elected UK legislature when the same question is asked of them.

Needless to say there was a minority of GPs who would welcome a change in the law, and permit medically assisted suicide.

I hope I can put forward some of the reasons for our college’s opposition to such a change.

The profession has sympathy with the principle of allowing patients to control the time and manner of their death when they face unbearable suffering. An action demonstrating specific autonomy, in the hands of the patients, as their lives draw to a close.  But it arrives freighted with enduring consequence, not only upon the patient but also upon their families and healthcare professionals. It is something they can do. But it is not the only thing.

It would be wrong to legislate in response to relatively uncommon ‘dread neurological conditions’ when the legislation would have a far wider impact on society. The vast majority of cases quoted relate to motor neurone disease, multiple sclerosis and Parkinson’s disease.

There is concern for the patient’s family and carers, who may feel cheated of precious time and of the opportunity to look after the patient.

While patients may be influenced by a desire to avoid being a burden, it would be tragic for them to feel they need to opt for assisted suicide when other avenues are still open to them, such as adequate investment in home care provision.

There is also concern for the protection for the most vulnerable in society, patients who may feel they have less right to ask for the care and resources needed to maintain their human dignity.  What if other vulnerable patients, with non-qualifying chronic conditions, were to view their right to care in the same way?

The proposed legislation deals with the ending of physical suffering. Suffering may be physical but is almost always contextual and linked to a combination of the physical, psychological and social situation of the patient. GP values include recognising the importance of relationships and approaching patients with an organismic or humanistic and not a mechanistic approach, paying attention to, and valuing, the wider human condition.

It seems inconceivable that this legislation can be enacted without the patient’s GP being involved. The bill assumes that the role will be routine. This is not the case. Being able to accurately predict a patient’s illness trajectory is notoriously difficult, especially in non-cancer illnesses. Deciding on capacity is a subjective exercise and may vary from day to day depending on the patient’s condition. Equally, ensuring the decision is made with informed consent and that it is a voluntary one when the stakes are so high will not be straightforward. The law will need to adequately protect patients and doctors will fear legal sanction.

Many will opt out as conscientious objectors but that position is awkward and it may be easier to opt of general practice completely in favour of a move to other medical specialties, thus worsening the GP recruitment crisis. It may also put off students applying to medical school if assisted suicide is seen as a routine part of GP care.

Furthermore the role would need careful training. Might not this aspect of the curriculum jar with the continued aspiration to ‘First Do No Harm?’

The introduction of assisted suicide will also jar with the continued political effort to reduce suicide rates. Suicide is a tragic event that has long lasting effects on the patient’s family and acquaintances and to see it sanctioned by the medical profession, regardless of the different circumstances involved, sends out a message of confusion at an already desperate time.

It is hard to see assisted suicide delivering more good than harm. Medical advances mean many conditions can now be treated, and when no treatment is available there is an increasing understanding of the notion of frailty and futility. Patients are increasingly preparing ‘advance directives’ and when they do not exist, doctors are discussing with frail patients the idea of ‘anticipatory care plans’ to ensure the appropriate care, at an appropriate site, is provided. Palliative care is now routine and the hospice movement provides high quality care, training and advice across the country. End of life care is consistently the highest priority clinical area when ranked by the membership.

This bill, with the new duties expected of GPs, would require a radical re-write of the GMC duties of a doctor. It will be a threat to GPs’ identities as doctors and it is unsurprising it has not been welcomed.

 

To summarise: –

  • The response to exhaustive consultation of RCGP members resulted in no change to our continued opposition to a change in the law.
  • We wish to respect patients autonomy but this must not be at a cost to the protection and respect society provides to the most vulnerable in society
  • A change in law would could a serious adverse effect on how the public viewed their doctors, on GP recruitment and how GPs viewed their own identity and role in society
  • The proposals are based on a concept of unbearable suffering being physical rather than one that recognises it as contextual that may vary over time.

 

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