LIVERPOOL - With politicians on the Isle of Man considering whether to pass a bill to legalise assisted dying, GPs in the UK have discussed its potential impact.
Doctors Should Be Prepared for Assisted Dying Law Changes
Doctors Should Be Prepared for Assisted Dying Law Changes
Becky McCall | 09 October 2024
LIVERPOOL - With politicians on the Isle of Man considering whether to pass a bill to legalise assisted dying, GPs in the UK have discussed its potential impact.
In July this year, members of the House of Keys voted 16 to 8 in favour of the Isle of Man's Assisted Dying Bill, allowing the proposed legislation to progress to the next stage in the self-governing UK Crown dependency.
In addition, Scotland and Jersey are considering changing the law to let terminally ill people seek assisted dying in their jurisdictions, while proposals to give terminally ill people in England and Wales the right to choose to end their life are to be introduced in Parliament this month.
Implications for UK GPs
Speaking at a special session of this year's Royal College of General Practitioners (RCGP) annual meeting, John Spicer, a GP and chair of the RCGPs Medical Ethics Committee, outlined the proposals as they stand in the Isle of Man, Jersey, and Scotland. He noted that "they could of course change as the parliamentary processes proceed. They all require capacity on the part of the person seeking assisted dying, a terminal illness to be present, have a residence requirement, and allow conscientious objection. All three areas differ slightly in these aspects."
The British Medical Association (BMA) adopted a neutral stance on assisted dying in 2021, with GPs advised to follow (BMA) advice along with current UK law, which prohibits assisted dying.
A 2019 RCGP survey found that 41% of members in favour of the college supporting a change in the law, with 10% backing a neutral stance, and 46% opposing a change.
Ethical and Legal Challenges
photo of Dr John Spicer, Dr David Mummery, Dr Michael MulhollandDr John Spicer, Dr David Mummery, Dr Michael Mulholland
Alongside Spicer, David Mummery, a GP in South London and a member of the RCGP Medical Ethics Committee , addressed the implications and current guidance if the law changes in the Isle of Man, or similarly, any other neighbouring jurisdiction that could attract UK citizens who seek assisted dying. Michael Mulholland, honorary secretary of the RCGP, and GP partner at Unity Health in Buckinghamshire, chaired the discussion.
In reference to the euphemistically termed 'suicide tourism', Mummery said: "Suicide tourism has been around for some time with Switzerland and other places, and people may want to travel to Isle of Man for assisted dying [if it is legalised there]. You [GPs in the rest of the UK] may get asked for documentation or advice, or letters."
Residency may be unclear on occasions, he added. "Someone who has relations in the Isle of Man or has been a frequent visitor may claim residency. There's also the potential for false documentation," he cautioned. Mummery also noted the importance of learning from countries like Canada, the US, and the Netherlands, where assisted dying is legal. "There's clearly a path that's been followed in other countries, so it makes sense to look at what's happened there. But in an area like assisted dying, it's inevitable that there'll be challenges," he said, citing the example of a law change in the US state of Vermont such that those resident outside the state can now travel there to end their lives.
Mummery summarised the main points of the 2019 BMA guidance relating to GPs practising in the UK where assisted dying remains illegal. Decisions around prosecution are made on a case-by-case basis by the UK's respective prosecution services of England and Wales, Scotland, and Northern Ireland. Although assisted dying is illegal in the UK, the law does not provide a clear definition of which actions might constitute assisting or encouraging suicide," he began, before attempting to clarify what may seem to be a grey area.
"If it becomes legal [in the Isle of Man and remains illegal in the UK] and you are faced with a request from a patient for [help with accessing] assisted dying, then doctors must respond professionally, compassionately, and continue to support the patient in their ongoing care." Doctors should avoid any action that the law might consider to be assisting, facilitating, or encouraging suicide, he said, adding that, "if you are unsure as to how a particular action might be construed by law, then you should seek up-to-date legal advice".
Mummery shared recommendations from the BMA on points for consideration if such a situation arose. These included doctors refraining from offering advice on what constitutes a fatal dose, on anti-emetics in relation to a planned overdose, suggest the option of suicide abroad, write medical reports specifically to facilitate suicide abroad, provide literature to patients on aspects of assisted suicide, or disseminate information via the media (including via the internet) which would be likely to encourage people to end their lives. Nor should they pu t patients in touch with other individuals or groups who may be able to assist, or organisations which promote assisted dying. They should also avoid facilitating any other aspects of planning a suicide to those who are unsure.
Travelling abroad to seek assisted dying is not illegal but, emphasised Mummery, "facilitating or encouraging someone to do so is a criminal offence and doctors need to be very aware of legal and professional sanctions that would apply to you if you advised a patient on this", he said, adding that, "If you're a doctor in England, Wales, or Northern Ireland, it is a factor tending in favour of prosecution, and there is GMC [General Medical Council] guidance related to this".
Requesting Medical Records to Seek Assisted Dying Abroad
Patients with capacity have a right to access their own health records via subject access request under General Data Protection Regulation (GDPR), and it is not necessary for patients to give reasons, Mummery noted. "Providing access to medical records, in accordance with GDPR, is an act that is lawful, or too distant from the encouragement or assistance to raise a question about fitness to practise," he pointed out.
Finally, Mummery discussed how a GP might respond appropriately under current UK laws should a patient requests help in obtaining assisted dying in a jurisdiction where it is legal. "Firstly, listen and acknowledge the request but be clear about the law," he began. "Provide objective advice about the lawful clinical options available and explore the patient's feelings, emotions, and thoughts and use the opportunity to address those concerns," he said, stressing the need to be non-judgmental and non-partisan. "Do not abandon the patient because they are clearly in a desperate and difficult situation."
An audience member commented that the RCGP was the only college that took a formal stance against assisted dying and reflected that, "this means we are not discussing how we can help GPs whatever their personal feelings are, for or against assisted dying, and I feel there is a little bit of unfinished business. And that is my question to you, because we are the only college against. What do you feel about putting a motion forward to go neutral?"
Chairing the session, Mulholland replied: "I think College counsellors are going to look at this again. There's a process going on at the moment, looking at how we take the next steps, and we will bring this back in November to the council to discuss the process moving forward. Whether the position will be neutral, negative, or positive, I am unsure, but that is my role as honorary secretary to guide the Council. It may be a neutral position, but we need to ask the council as to what the next step should be, or we may have a consultation with the members. As yet we are unsure."
Mulholland raised another question from the audience (anonymous, electronically submitted) which asked what was meant by 'other forms of support', as referred to in the earlier discussions. Spicer explained: "Medical Defence Organisations [MDOs] are there as sources of support in cases like this [approached by a patient seeking advice on assisted dying] – beyond their role in supporting doctors accused of many things, including medical negligence. GPs should also seek their colleagues' advice and support as they would in any challenging clinical circumstances."
An audience member who requested anonymity welcomed the proactive debate but noted the need to understand what the law will require before any potential vote can be useful, and to understand "how restrictive or protective it is for patients and professionals in the long-term".
Concerning neutrality, it was pointed out that it would be necessary to understand what neutrality means and that it might limit the sharing of opinions.
COI: Drs Mulholland, Mummery, and Spicer have declared no relevant disclosures.
Medscape UK
PBS has a documentary. on Assisted Death.
Elder Americans were going to Switzerland for that reason. I remember one man who was wheelchair bound, in his 90’s, he was so tremendously thankful to have that choice.