Proposals to give terminally ill people in England and Wales the right to choose to end their life will be considered by MPs this month. While the public debate about moral arguments, doctors are considering the practical reality of assisted dying, as a historic change to the law appears an increasingly likely prospect.
As public opinion on the issue has shifted in the past decade, so too has the medical perspective. In 2021 the British Medical Association voted in favour of changing its position on assisted dying from opposition to a change in the law to neutrality. Many doctors are swayed by the argument that patients should have freedom over their own bodies, including how they die when they are terminally ill. Others have ethical and pragmatic concerns or worry about how assisted dying could affect access to palliative care at a time when health inequalities are already rife.
One question is over the criteria that could be set to decide patient eligibility. The details of the bill have not been finalised but are expected to be similar to a proposal in the House of Lords that would allow terminally ill adults with six months or less to live to get medical help to end their own lives.
“Six months is a really tricky one to predict,” said Prof Mark Taubert, a consultant in palliative medicine at Velindre University NHS trust and Cardiff University School of Medicine. “I’ve had it go both ways. I’ve had cancer patients who I’ve thought would die over a weekend, who I have seen in my clinic again five years later, but also had a patient who I’ve thought would live another two years, who has deteriorated very quickly. Most doctors have come a cropper with this.”
Graham Winyard, a former NHS England medical director, also views the six-months-to-live criterion as problematic. “Partly because of the difficulty in estimating a person’s prognosis, but it also misses out a whole number of people who are deeply suffering,” he said.
According to Winyard, who is in favour of a change to the law, fewer than half those who have travelled to the Swiss clinic Dignitas would qualify under this criterion, which he says may exclude many patients with severe degenerative illnesses such as motor neurone disease.
“You’re facing a downward path. You don’t want to decline into gradual helplessness. There comes a point where you say you’ve really had enough,” he said. “That ought to be everyone’s right.”
Others feel the six months strikes a sensible balance and say it has been workable in other jurisdictions including Oregon in the US, which has had a similar criterion since assisted dying was legalised there in 1997.
David Bogod, a recently retired consultant anaesthetist based in Nottingham, said: “Prognosis is not an exact science, of course, but doctors routinely make such assessments.”
He said concerns about prognosis often assumed that people who request assisted dying are eager to die. “But the data from Oregon and elsewhere shows us that one-third of those who receive a prescription do not ultimately use it. It seems that what they are seeking is a fallback plan to allow them to die quickly and painlessly if their suffering becomes unbearable.”
Some have highlighted the less rigorous evidence base for using medicines to bring about death. Taubert said: “These are unlicensed drugs for the purpose of killing someone.” Discussing the potential for side-effects and complications may sound silly in a context where death is the desired outcome, he said, but he is concerned that without proper registries it is unclear which regimens are the most reliable and effective.
While the BMA’s position has shifted to one of neutrality, it has clear recommendations about how any law could be implemented. It has called for an opt-in model for doctors, so that only those who choose to participate would be expected or able to do so. The BMA also argues that assisted dying should not be integrated into existing care pathways, such that an oncologist or palliative care doctor would at a patient’s request provide this as an additional part of treatment.
On the question of who could provide patients with this new type of care, it is notable that the Association for Palliative Medicine – which represents those in closest contact with terminally ill patients – continues to oppose any change in the law that would license doctors to administer lethal drugs to a patient to enable them to take their own life. When surveyed in 2020, 85% of the association’s membership said they would not support a change to the law and would not be willing to administer euthanasia.
Taubert is among those against a change to the law, but is already preparing for the possibility. “I’m broadly against assisted dying, but if the public decides that’s the direction we want to go in, we’ll have to look at it,” he said.
His perspective is partly due to his own experiences in palliative care and concerns about inequality of access to good palliative care. “Usually I see good deaths,” he said. “Sometimes I still see bad deaths, but I’m not convinced that the deaths in Switzerland are much better.
“A lot of people don’t know what a good death looks like. Most people die peacefully, their body shuts down, sometimes they don’t need additional medication.”
Others say doctors are struggling with the ethics of caring for dying patients in distress, whom they may feel unable to help. “At a time when patient autonomy is rightly the key driver behind all that we do, it seems inexplicable to many of us that this fundamental right disappears just as it is most needed,” Bogod said.
