House of Lords Select Committee on Assisted Dying for the Terminally Ill Bill
Written Evidence (Extracts)
Memoranda and Letters:
Association for
Palliative Medicine
1. SUMMARY AND RECOMMENDATIONS
6. The APM welcome the conscientious objection clause in the Bill since
palliative care physicians should not be required to be involved in the
administration of euthanasia and physician-assisted suicide.
4.10 Integrity of the profession and impact on medical practice
The potential effect on relationships between patients and their doctors and
the impact on current medical practice should be considered:
1. The risk of losing trust and damaging care is high. This is an area of
practice where research is needed to establish the consequences of
legislation.
2. Would euthanasia and physician-assisted dying be legitimate treatment
outcomes that doctors would be obliged to raise with all dying patients?
3. How will the new law be enacted if a majority of doctors
conscientiously object to performing euthanasia and physician-assisted
suicide? There would be a legal requirement for an "objector" to refer on to
someone who has no objections. There would need to be local lists of
participating doctors and nurses. The stress on these professionals could be
enormous.
4. There is a strong possibility that some palliative care doctors could
also refuse to carry out the required assessment consultation, fearing that
they might become implicated in euthanasia. [List
of Memoranda & Letters]
National Council for Hospice & Specialist Palliative Care Services
[Extract from the
Memorandum]
Pain relief: (cl 15)
24. There is absolutely no need for a conscientious objection clause in
relation to the administration of pain relief (cl 7(2)). This clause risks
confusing the administration of pain relief with PAD in the public mind and
in statute. That would harm the physician-patient relationship, and
encourage popular misconceptions about the role of pain relief in end of
life care.
Death as a deliberate intervention
25. If PAD is legalised, it becomes a legitimate form of treatment given
with society's approval. It will be a recognised way of bringing an end to
suffering. Physicians will be under a professional duty to raise it as an
option with their patients if they complain of suffering unbearably, as it
will be considered to fall in the category of "best interests". It will be a
patient's right to be informed of all available options.
26. The means by which a patient receives information about assisted
dying will be of immense importance. It will have a significant impact both
on the patient and his relationship with his healthcare professionals. The
Bill does not deal with this.
27. There is a risk that, if healthcare professionals are to be required
to raise the issue of PAD for discussion with their patients, the
conscientious objection clause (cl 7) might be undermined.
28. Whilst the Bill's emphasis is on the role of doctors in providing
PAD, responsibility will inevitably be placed on all health care
professionals, particularly nurses, whose specific responsibility it is to
care for and support patients and families at the end of life.
29. The title to clause 7 refers to the duties and conscientious objection
of "physicians", rather than more broadly to healthcare professionals. [
List
of Memoranda & Letters]
Royal College of
Physicians of Edinburgh
[Extract from the
Memorandum]
(e) Improving patient autonomy
. . . Doing all that can be done to achieve the ideal of patient-centred
professionalism, through medical education and by maintaining standards of
clinical practice, is currently a major priority of the British medical
profession. With this in mind, the medical profession may reasonably ask
whether enactment of the present Bill will not distract attention from, and
in fact present new obstacles to, the real task of respecting and enabling
patient autonomy. Many doctors, moreover, are likely to have strong
reservations about carrying out what is required by the terms of the Bill
and may choose to avail themselves of the Bill's provisions for
conscientious objection. Those who are willing to carry out euthanasia
therefore may have a larger number of cases of this kind referred to them
than is conducive to optimal patient-centred care. [
List of Memoranda & Letters]
Christian Medical Fellowship
[Extract from the
Memorandum]
3. Section 7 introduces a legal obligation for doctors with a
conscientious objection to refer any patient requesting assisted dying to
doctors with no conscientious objection. This amounts to forced complicity,
and presumably those who refuse to comply are thereby committing an offence
under the Act?
4. Section 7(2), whereby an attending physician who conscientiously
objects, is obliged to refer the patient to another attending physician
makes a mockery of the definition of attending physician given in the bill
as the doctor who has "primary responsibility for the care of the patient".
[List of Memoranda & Letters]
[Extract from the
Memorandum]
Clause 7 (Duties of physicians, and conscientious objection)
This clause, despite its wording, does not grant conscientious objection.
It is recognised in law that a person who commissions another to commit a
crime is not innocent but guilty by their complicity. So it is morally. A
person who cannot perform an act, but passes the patient onto others in the
knowledge that they will perform the act is morally equally culpable of that
act. Those who hold convictions about the immorality of euthanasia will be
unable to comply with this Act as they will not be able, in conscience, to
refer the patient onto other willing physicians. To refer a patient to
another physician for euthanasia would be acting against one's conscience.
The right to practise in accordance with one's conscience or religious
belief is protected under article 9 of the Human Rights Act. [List
of Memoranda & Letters]
Dr Colleen Cartwright and Associate Professor Malcolm Parker
[Extract from the
Memorandum]
2(e) Duties of physicians, and conscientious objection
Sections 7(2) and 7(3).
This Section appears to be more "active" than would usually be required
for a matter of conscience. Some physicians would find even referring the
patient to someone who would assist him to die to be against their
conscience. A better option would be that anyone who has a conscientious
objection should not be obliged to participate but must not actively impede
a patient accessing such assistance (once it is legally available). An
official information service may be needed for people who want such
assistance.Also, while the physician may or may not know who "does not have
such a conscientious objection", to make such referral obligatory (ie "he
shall . . .") may put unfair pressure on the physician and may affect his
future professional relationships. [List
of Memoranda & Letters]
National
Group of Palliative Care Nurse Consultants
[Extract from the
Memorandum]
7. The conscientious objection clause is wholly inadequate and fails to
take account for the pivotal role that nurses have in initiating discussions
around end of life care. . .Second, for any practitioners who are motivated
enough to train in palliative care, the internal conflict and discord
between the values espoused in the Bill and those in authentic specialist
palliative care practice are unsustainable. This discordance undermines
inter-team working. The positive model of collaborative and complementary
working developed by many palliative care services will be threatened and
undermined. In addition we can anticipate that the requirement for a
consultation with a palliative care specialist may have a very detrimental
effect on Palliative Care Teams with issues of conscientious objection and
personal values and views on this issue undermining teamwork and common team
values. [List of Memoranda & Letters]
Help the Hospices
[Extract from the
Memorandum]
Multi-disciplinary care
17. The high standard of hospice care is founded on integrated
multi-disciplinary working. Irrespective of moral belief, almost all
respondents expressed considerable concern about the impact on
multi-disciplinary working of introducing euthanasia. They feared patient
care could be compromised, and the hospice movement weakened, through
conflict arising from differing ethical beliefs and the exercise by some
professionals of their right of conscientious objection. [List
of Memoranda & Letters]
Affinity
[Extract from theMemorandum]
AFFINITY (formerly the British Evangelical Council, which was founded in
1952) is a network of evangelical Christian denominations, church groupings
and independent causes. It is probably the largest association of
exclusively Bible-centred churches in the United Kingdom, representing
approximately 1,200 congregations.
4.9 The Bill allows for conscientious objection (p. 4, lines 30-43), but
what is the point of such a waiver, if the morally-sensitive doctor has to
refer the patient "without delay" (p. 4, line 37) to a pro-euthanasia
doctor? And what if the ethos of the hospital is anti-euthanasia and one
cannot be found? And will some hospitals become centres of excellence for
the training and implementation of euthanasia to which patients will be
transported? Perish the thought! [List of
Memoranda & Letters]
CARE
1. INTRODUCTION
1.1 CARE is a supporter-based Christian charity incorporating more than
160 pregnancy crisis centres, fostering and remand fostering initiatives and
day care for people with learning disabilities. In addition to social care
and educational programmes, CARE undertakes research and lobbying on
associated issues in the parliaments and assemblies of the United Kingdom,
European Union and United Nations.
Clause 7 (Duties of physicians, and conscientious objections)
Clause 7 provides that no person is under a duty to, whether by contract
or by any statutory or other legal requirement, to participate in any
diagnosis, treatment or other action authorised by the Bill to which he has
a conscientious objection.
CARE argues that the clause is ineffective, since there is an obligation
to become materially involved in a process of referral. It is both illogical
and unreasonable to conclude that a physician whose conscience would be
violated by performing or participating in assisted dying or voluntary
euthanasia would then be content with passing his patient to a doctor who
will commit euthanasia. [List of Memoranda
& Letters]
British Humanist Association
[Extract from the
Memorandum]
ABOUT THE BRITISH HUMANIST ASSOCIATION (BHA)
1. The BHA is the principal organisation representing the interests of
the large and growing population of ethically concerned but non-religious
people living in the UK. It exists to support and represent people who seek
to live good and responsible lives without religious or superstitious
beliefs. It is committed to human rights and democracy, and has a long
history of active engagement in work for an open and inclusive society. The
BHA's policies are informed by its members, who include eminent authorities
in many fields, and by other specialists and experts who share humanist
values and concerns.
15. We agree with the provision for opt-out on grounds of conscience for
medical staff. The Bill should not interfere with the right of the religious
to obey their own conscience. We support the requirement (7.2) that, in
cases of conscientious objection, physicians must refer the patient without
delay to another physician who does not have such objections. However, we
point out that in some cases, eg hospices run by religious organisations,
the entire staff may have conscientious objections to meeting a patient's
request, and so referral to doctors from another institution would be
required and must be enabled. [List of
Memoranda & Letters]
General Medical Council
[Extract from the
Memorandum]
9. It is likely that there would be a significant number of clinicians
with a conscientious objection to involvement with assisted dying, and we
are pleased to note the inclusion of clause 7(1-3) relating to this. We
would expect a doctor to respect a patient's wishes, including their right
to refuse life-prolonging treatment, but it would not be a doctor's duty to
assist a patient to die. As the Bill is currently drafted, a doctor with a
conscientious objection would need to `take appropriate steps to ensure that
the patient is referred without delay' to a doctor with no such objection.
We understand the need to ensure continuity of care for a terminally ill
patient, and agree that it is a doctor's duty to ensure it. However, we
believe that this clause would be of great concern to some doctors with a
conscientious objection who would want a statutory right to withdraw
entirely from the situation. The Committee will need to consider whether
such a doctor, by ensuring the patient's referral, would still feel
complicit in the act of assisting the patient to die. [List
of Memoranda & Letters]
British Medical Association
[Extract from the
Memorandum]
INTRODUCTION-THE BRITISH MEDICAL ASSOCIATION
1. The British Medical Association (BMA) is a voluntary professional
association representing UK doctors in all branches of medicine. It has
128,000 members-almost 80 per cent of UK practising doctors. It is a
democratic institution in which members elect the colleagues who decide
policy. (See
https://www.bma.org.uk/ap.nsf/Content/About+the+BMA+-+History+and+ structure)
Unwanted choices
26. Health professionals explaining all options for the management of
terminal illness would have to include mention of assisted suicide if this
was available. The BMA is concerned that patients might feel obliged to
choose that option if they feel themselves to be burdensome to others or
concerned, for example, about the financial implications for their families
of a long terminal illness. By removing legal barriers to the previously
"unthinkable" and permitting people to be killed, society would open up new
possibilities of action and thus engender a frame of mind whereby some
individuals may feel pressured to explore fully the extent of those new
options. The choice of exercising a right to die at a chosen and convenient
time could become an issue all individuals would have to take into account,
even though they might otherwise not have entertained the notion. [List
of Memoranda & Letters]
Office of the Chief Rabbi
[Extract from the
Memorandum]
5. In addition, such legislation would place unfair psychological
pressure on ill patients. An ill patient will, in all likelihood, find it
difficult to make dispassionate decisions, and may be pressured to terminate
his life, feeling that he is a burden to family, friends or society. No one
should be placed in a position of having to choose whether to live or die.
Similarly such legislation would also raise difficult ethical questions
for doctors. The traditional role of the doctor is to heal, and where that
is not possible, to contain suffering and distress, but permitting a form of
euthanasia would leave them to make the ultimate moral decision. Medical
professionals have a special and unique role as "partners in creation", but
they should not be asked to make decisions that go beyond their capabilities
and moral horizons (ie to take action with the purpose of causing death).
Furthermore, this legislation would create huge dilemmas for doctors with
conscientious objections to euthanasia, whether grounded in religion or not.
[List of Memoranda & Letters]
ALERT
[Extract from the
Memorandum]
ALERT is an organisation funded only by donations from people in this
country. The newsletter is circulated to about 700 people. It was founded in
December 1991 to provide well-documented information on, and to warn people
of, the dangers of euthanasia legislation and pro-death initiatives, and to
defend the lives and rights of the medically vulnerable, recognising that
all human beings are of equal value.
5. DUTIES OF PHYSICIANS AND CONSCIENTIOUS OBJECTION (SECTION 7)
This section in effect adds a compulsory aspect to the legislation in
overriding a physician's conscience. To follow his conscience is the first
duty of any moral individual and a good conscience is essential to the
practice of medicine. If laws are immoral it becomes a duty to disobey them.
Such a clause makes the Bill all the more harmful, in presenting as a duty
what is by nature reprehensible. Dr Shipman's actions were universally
condemned, and to suggest that doctors may act in this manner, albeit with
the consent of the patient, will change forever the face of British
medicine. [List of Memoranda & Letters]
Association of Catholic Nurses for England and Wales
[Extract from the
Memorandum]
5. PROTECTION FOR THE PHYSICIAN AND OTHER MEDICAL PERSONNEL
Concern is raised over pressure that may be put upon the consultant
physician from professional colleagues, or relatives to support the action
should they feel it is in the best interest to assist them to die. This
pressure could easily be exerted on other health professionals, who work
closely with the patient, and we see nurses very much in this group, to
persuade the physician on behalf of the family. It is understood all
physicians will be clear about their right to refuse to participate in this,
however in emotive situations they may become vulnerable and open to
persuasion.
You will be aware nursing staff are often questioned on ethical issues,
and these questions, with increasing frequency, relate to whether something
had been "done" to the patient to speed the death because of service
pressures. This we know is not the case, but the question will become more
common place should this bill be passed. [List
of Memoranda & Letters]
The Association of Catholic
Women
[Extract from the
Memorandum]
20. The provisions of Section 7(1) and of Section 10(1-3) relating to
protection for physicians and other medical personnel are silent with regard
to discrimination in career progression. [List
of Memoranda & Letters]
Nursing and Midwifery Council
[Extract from the
Memorandum]
3. The NMC recommend that conscientious objection in paragraph 7(2)
should not just be identified for medical staff and should include nursing
staff. Although medication will be prescribed by the physician nurses may be
ultimately responsible for the administration and titration of the
medications to keep the patient free from pain and distress as stated in
paragraph 15. [List of Memoranda & Letters]
Raymond Hoffenberg MD PhD FRCP
[Extract from the
Memorandum]
20. I appreciate that many people object to assisted dying on religious
grounds. It stands to reason that there should be a "conscience clause" that
permits doctors who have this belief to recuse themselves. No doctor should
be obliged to carry out any measure that is contrary to a firmly held belief
or principle. [List of Memoranda & Letters]
Letter from Dr Louise Gibbs, Dr Emma Hall,
Dr Victor Pace, Dr Debra Swann and Dr Nigel Sykes, Consultants in Palliative
Medicine, St Christopher's Hospice, London
[Extract from the
Letter]
While approving of the inclusion in the draft Bill of a conscience clause
for doctors who feel unable to take part in assisted suicide/euthanasia, we
deprecate the legal requirement for such doctors to refer such patients to
another doctor without similar scruples. This amounts to forced complicity
in the euthanasia/assisted suicide process and would be an unjust and
intolerable imposition upon the doctors concerned. [List
of Memoranda & Letters]