Assisted dying is not legal in the United Kingdom, but debate over the issue continues, most recently in a series of articles published online February 7 in the BMJ.

The organization that represents physicians — the British Medical Association (BMA) — does not accurately represent their views on the issue, argues Dr Jacky Davis, consultant radiologist at the Whittington Hospital in London, in a personal view article.

The BMA has long been opposedto assisted dying, and its view is often quoted in parliamentary debate as representing that of physicians, she comments.

But a recent opinion poll of physicians (conducted in October 2017 by doctors.net) found that 55% agreed or strongly agreed that assisted dying should be made legal in defined circumstances; 43% disagreed, and 2% had no opinion.

Hence, the BMA should change its policy and adopt a neutral position — “a stance that would allow for constructive engagement while acknowledging the range of views of the membership,” she argues.

Dr Davis, who is also a member of BMA Council, a board member of Dignity in Dying, and chair of Healthcare Professionals for Assisted Dying, argues that the current disconnect between BMA policy and the views of physicians and patients “undermines the BMA’s credibility, and its continuing opposition excludes it from the public debate.”

“Assisted dying does not represent a leap into a dangerous unknown,” Dr Davis writes. “Other jurisdictions have proved that it is possible to change the law, and doctors have shown that such laws can work hand in hand with excellent palliative care.”

Public Morality Shift?

“It feels as if we are experiencing a rare example of public morality shifting ahead of legislative change,” writes Dr Bobbie Farsides, professor of clinical and biomedical ethics at the University of Sussex, in a commentary.

Prof Farsides acted as adviser to the House of Lords committee that considered the Assisted Dying Bill in 2015. At that time, very strong views were expressed both for and against the legislation, as previously reported by Medscape Medical News.

But the polarization of past parliamentary debates is “no longer reflected in society, given recent opinion polls,” she comments.

She was referring to a poll of the general public conducted in 2015 that found that 82% supported legislation for assisted dying.

“Given this is so, the law may well change soon,” Prof Farsides comments.

She has been involved in the debate about assisted dying for the past 20 years, after she wrote an editorial for the Journal of Medical Ethics (1998;24:149-50). “I argued that it was logically consistent to be a good palliative care doctor and to think that for some patients the best option would be a managed death,” Prof Farsides writes.

“I have never campaigned for or against legal assisted dying,” she states. Instead, she presents evidence from countries where assisted dying is legal and invites colleagues to draw their own conclusions.

“Patients are more aware than ever of what is, and is not, possible for them as they approach the end of their lives, and practitioners need to be prepared and able to respond compassionately,” she comments.

“Surely we have come to understand that there need be no contradiction between being a good palliative care doctor and respecting a patient’s wish to die and their request for assistance,” she concludes.

“Not a Proper Role for Doctors”

Arguing the case against passage of legislation in a “head-to-head” article is Dr Bernard Ribeiro, former president of Royal College of Surgeons and a member of the House of Lords. In 2015, when the Assisted Dying Bill was rejected in the United Kingdom, he argued that “assisting patient suicides was not a proper role for doctors.

“I hold to that view and I make no apology for using the term assisting suicide,” he writes. “In law, supplying terminally ill patients with lethal drugs with which to end their lives constitutes assisting suicide.”

This is “a matter for the courts, not for the consulting room,” he argues.

Dr Ribeiro emphasizes the uneveness of the physician-patient relationship. “The doctor holds most of the cards. We have professional expertise that most patients are in no position to challenge.”

He worries about vulnerable patients “who, not unreasonably, could interpret a doctor’s willingness to process a request for ‘something to end it all’ as meaning that in the doctor’s view, ending their lives is a course of action that would be in their ‘best interest.’ ”

Controversy Subsides After Legislation

“Although plans to adopt assisted dying have caused much controversy, most places have found that once the political decision has been made this tends to subside,” writes journalist Bob Roehr in a feature article in the BMJ.

“The pattern has been repeated many times, beginning 20 years ago in the state of Oregon,” he writes. Since that time, the pattern has been followed in five other states, including the most populous state, California. The pattern has also emerged in Canada.

Roehr highlights a disconnect in the United States between physicians and the American Medical Association (AMA) that is similar to the disconnect between physicians and the BMA in the United Kingdom.

The AMA opposes assisted dying, and the American College of Physicians (ACP) and the American Academy of Family Physicians are opposed to physician-assisted suicide.

Yet in a 2016 Medscape poll, 57% of US physicians showed support for assisted dying, and in a 2017 Medpage poll, 61% of healthcare professionals showed support.

The situation was different in Canada, where medical aid in dying was legalized in 2016, Roehr notes.

“The Canadian Medical Association initially resisted assisted dying. But after that country’s high court ruled it to be a fundamental human right, the association embraced the decision and participated in writing the law, provincial regulations, and training its members to implement that ruling,” he writes.

Stefanie Green, MD, president of the Canadian Association of Medical Assistance in Dying Assessors and Providers (CAMAP), says she is seeing a gradual increase in willingness among physicians to learn and participate in assisted dying when their patients express interest, he adds.

BMJ Calls for a Neutral Position

“The BMJ supports the legalisation of assisted dying,” says Dr Fiona Godlee, the BMJ’s editor in chief, in a statement.

“The great majority of the British public are in favour and there is now good evidence that it works well in other parts of the world, as a continuation of care for patients who request it and are in sound mind. We believe that this should be a decision for Society and Parliament, and that medical organisations should adopt at least a neutral position to allow an open and informed public debate.”

Taking an Emotional Toll

Physicians’ experience of how it feels to be involved in assisted dying is detailed in an essay written by Dr Sabine Netters, now a consultant in medical oncology and palliative care at the Isala Oncology Center, Zwolle, the Netherlands.

She describes her first experience of euthanasia, which occurred 10 years ago, when she was a medical trainee. The patient had metastatic cancer with paraplegia caused by spinal metastasis, which left him “paralysed from the waist down, unable to control his bowels, his skeleton ridden with cancers.”

“He makes me see that even when therapy fails, the doctor’s role is far from over,” Dr Netters writes. “Instead it adjusts, because the goal has changed from living longer to dying better.

“But textbooks offer no advice, and years of training have left me totally unprepared for this,” she adds.

She writes that after the patient has died from a lethal injection, surrounded by his family, “I’ve just helped kill someone, but I don’t see it in a negative way. It was beautiful.

“As a doctor I will do anything to save a life, and this evening that meant giving someone a dignified death,” she adds.

She also details the emotional toll that the process takes on the physicians involved.

“I hoped euthanasia would become less of an emotional burden to me as my experience grew,” Dr Netters writes, noting that she has helped five patients to die over the past 10 years.

“But it didn’t, and now I know it never will,” she writes.

“The general population, politicians, and legislators — perhaps even some doctors who have not been involved in the procedure — seem to think that assisted dying or euthanasia is just another medical intervention,” she comments. “It is not.”