Who wrote this? Does this have any impact?
Author: Gareth Iacobucci
-Reports mainly on issues of interest to doctors in the UK
-Joined BMJ in 2012
-Reporter and editor before
-Educated in communication studies and journalism
-Has no personal or organisational conflicts of interest
So not really any impact so NO BIAS?
Who is it published by? Does that mean anything?
BMJ - British Medical Journal
-prestigious peer reviews medical journal and global healthcare provider
-Authors have to follow policy and regulations set out to ensure it’s an ethical publisher
NO BIAS
When was it published? What has happened since?
Published: 12 November 2024
Since then more has happened:
In Commons vote, MPs supported bill by 330 to 275 ON 29 Nov
What happened previous to the introduction of this bill? Context of this Bill.
Assisted dying has been debated for years.
-2015: Assisted Dying Bill
Allow terminally ill patients in last six months of their lives be prescribed medication to be self administered
Two doctors required to very mental health
House of Commons rejected the bill by 330 to 118
-2018: UK Supreme Court ruled that legal permission is not req to withdraw treatment from patients in permanent vegetative state
-Many other cases of attempts to bring about this bill from varying perspectives. Some also wanted a more broad eligibility criteria, extending to those who aren’t terminally ill BUT all of these fails
-2021: BMA adopted a neutral stance on assisted dying
Shift in public perception
Shown by many countries such as Canada adopting this law
Shown in public polls
Who are the different stakeholders/players?
Patients
Govt/judges/law
Doctors + healthcare professionals
BMA
Patients
Dignity in Dying
Care not killing
Dignitas
What has happened in other countries which have introduced similar bills?
State or Oregon, USA
-has Death with Dignity Act
-generally seen as successful as its framework has acted as guidance for other US states
-Since 1997, over 2,200 patients have used assisted dying
-people dying due to loss of dignity, autonomy, ability o enjoy life (rather than pain that could be alleviated through palliative care)
-data show no evidence that vulnerable populations are disproportionately choosing assisted dying. This counters the “slippery slope” argument.
-Patients seek assisted dying not primarily due to pain, but because of existential suffering, highlighting the importance of respecting personal choices.
BUT could better psychosocial support could mitigate need for assisted dying
Canada
-Medical Assistance in Dying law
-initially restricted to terminal illnesses, then expanded to include non-terminal conditions, provided the patient experiences intolerable suffering, NOW?, apply to patients with mental health conditions as their sole medical issue
-Most patients cited loss of dignity (68%) and inability to enjoy life (63%) as reasons
-inclusion of mental health conditions is controversial, worries that vulnerable patients may feel pressured to choose MAID due to inadequate mental health care
-inclusivity, appreciates holistic nature of patient care, not only physical reasons
-high public support?
-expansion to mental health conditions and non-terminal illnesses risks normalising assisted dying as a solution for systemic healthcare failings
-example of a slippery slope, shows how economic or social pressures could influence decisions
Switzerland
-doesn’t require patients to be terminally ill, just requires decision to be voluntary and well-considered
-permissive approach has made Switzerland a hub for “suicide tourism”
-non profits such as Dignitas oversee this
-Around 1,300 people per year die through assisted dying
-20% of these cases involve foreign nationals
-prioritises autonomy and individual freedom, allowing broader access
-by involving non-profits, allows a more streamlined, patient-centred approach.
-law may normalise assisted dying as a response to non-medical suffering
What is the current legal situation in regards to assisted dying in the UK?
England, Wales, NI, Scotland
Illegal
But other things are legal, withdrawing life sustaining care for those in a vegetative care
What is the proposed bill?
Introduction of Terminally Ill adults (End of Life) Bill
Proposes giving terminally ill adults right to chose to end own life
-Must be over 18 and terminally ill, expected to die within 6 months
-Have mental capacity, clear, settled, informed wish, no coercion or pressure
-2 declarations witnessed and signed declarations
-satisfy 2 doctors + high court judge
%7 day gap between two doctors making assessments
-further 14 day wait after judge has made a ruling, unless person expected to die immediately
-High court judge would have to rule
-high court judge must hear from at least one of the doctors, question patient making application, anyone else appropriate
-mental illness and disability are excluded as eligibility criteria
-must be administered by patient themselves + remain illegal for dr too
-No doctor will be obliged to participate in process
MPs voted in favour of this bill, 330 to 275, passing first vote in the Commons
What are the safeguards for this bill? Are they sufficient?
-Bill makes it illegal to coerce, pressure, induce people into dying
-self administered medication
-mental illness and disability excluded as criteria
-over 18, req mental capacity and for patient to be terminally ill in the last 6months of their life
-informed consent (educated of other choices)
-clear, settled and informed wish to end their own life
-written twice in writing
-legal helps enforce these safegaurd
BUT
-pressure may be created by the current issues in palliative care
-how can you really tell that a patient isn’t being influenced
-normalising assisted dying as an easier alternative
How are bills passed? Specifically healthcare bills? How far has this bill gotten?
Bill has passed first hearing and first vote in House of Commons , 330 to 275
Next bill is further scrutinised by commons committee amended, and then 2nd vote taken
Further vote and passed to House of Lords and similar voting happens, can only proceed to become law if both chambers support it in further separate votes next year
HOWEVER, concerns about bills progression
-insufficient time to talk about it
What would be the alternative to assisted dying
Palliative care/ end of life care
CURRENT ISSUES:
-Care sector includes all roles that support people who require specialised assistance to live their daily lives
-important in ensuring people’s physical/mental supported before GP/emergency
Challenges:
-Unfilled vacancies
Fewer members of staff, support dec
Manifest as inc emergency admissions
Also, non-prof care - people become unpaid carers
Causes:
-Avg pay of care sector worker did not inc relative to national living wage inc (2019-21)
-Govt inc the following year, but not sufficient
-Brexit meant EU workers could not work in care sector, creating vacancies
-Then reversed
Gp and primary care issues
-GP shortages
-inc demand as life expectancy rises
-recruitment issues
-practices are closing ?
-unsafe patient levels (gps working too many hours and handling too many patients)
-long waits for appointments
-unnecessary appointments waste time
-public satisfaction is low
-need to hire more gps
-medical schools trying to correct misconceptions about GP role
-NHS schemes to incentivise foundation year doctors to become GPs
-golden halo, one off payment for gps coming to work in certain areas needing gps
-international recruitment(st)
-funding to help gps woe, as primary care network
-digital solutions
SOLS
Who was the Bill proposed by?
Kim Leadbeater, labour MP
Where does the bill impact?
England and Wales
What is assisted dying
Assisted dying is when physician gives the patients the means to take lethal medication themselves but patient is already dying.
Sub term of assisted suicide (physician gives the patients the means to take lethal medication themselves).
What is palliative care?
Improves quality of life of patients experiencing life-limiting illnesses
Works to manage pain and other distressing symptoms
What is end of life care?
Care surrounding last year of your life
What does it mean to be terminally ill
Disease that cannot be cured or adequately treated and is likely to result in death of a patient
What does it mean to have full mental capacity
capacity is ability to give consent
Requires:
-understanding information
-retain information
-weigh up to make a decision
-communicate decision
What is the perspective of patients?
AUTONOMY
-patients right to chose
-provides patient with dignity and respect in dying moments
BUT to what extent does this challenge doctors responsibility to improve lives
JUSTICE
-excludes patients with disabilities and mental illnesses
BUT safeguards are necessary
-polling has suggested maj people are in favour
-may make some patients feel that they are less worthy/ a burden to NHS so there may be underlying pressure
-lack of patient-doctor trust as patients also think its doctors responsibility to protect life
What is the perspective of doctors?
This Bill outlines the responsibilities of doctors in the decision making process
-2 doctors have to approve before assisted dying is allowed
-doctors will guide the shaping and changing of the bill through the following stages such as the committee stage
-doctors will help to report and monitor what’s happening after its legalised
NON MALEFICENCE - doctor has duty to do no harm
-killing a patient goes against this as you are harming a patient
HOWEVER are you doing more harm by allowing the patient to just suffer, doctors responsibility to respect patient autonomy
BUT patients also can’t demand treatment, doctors have the right to reject treatment (but should provide suitable alternatives)
BENEFICENCE - doctor has duty to do good
-making a holistic judgement about whether this may be appropriate for the specific patient
-considering it in a more case by case basis
-worries about ‘normalising’ assisted dying, leading to lack of improvements in alternatives
-some think that this bill should not be legalised with the current state of care, to mitigate any underlying driving factors
-hard to make a judgement whether assisted dying is an appropriate course of action, how can you really tell that there is no external influence
What is the view of members of parliament?
-overall the mps in the House of Commons voted for the bill (330 to 275)
Kim Leadbeater is a labour MP who proposed this bill
-seems to be well versed and researched in this topic
-she has looked into other countries which have legalised it, and talked to various different people such as patients, healthcare professionals, legal experts and hospices
-believes that this bill is necessary as current law is not fit for purpose
-she says it has strictest safeguards in world (but open to changes)
HOWEVER, there is conflict
Notably, the Secretary of Health and Social care voted against the bill
-says that the end of life care in this country isn’t sufficient to allow for assisted dying to be an option (autonomy, non-maleficence)
-concerns about money being focused away from improving palliative care, and rather facilitating assisted dying (justice)
-concerns about how this may progress and impact vulnerable people if it’s normalised (justice)
What are the perspectives of key organisations
BMA - British Medical Association (trade union and professional body for doctors in the UK)
-have had a neutral stance since 2021
-enables law change as medical professionals not completely opposed
-enables important discussions in regards of this bill
-these doctors will guide and shape the changes made to the bill
Dignity in Dying (UK campaigning organisation)
-in support of legalising assisted dying
-believe current law is not working
-opinion polls are showing support so law needs to reflect public perception
-believe we should have CHOICE over where, with who and treatment, ACCESS to good quality options, end of life care, CONTROL how we die
Care Not Killing (alliance of multiple groups, including faith-based and pro-life organisations, in UK)
-opposed to legalising euthanasia or physician-assisted suicide
-state concerns about the bill being rushed
-concerns ab ignoring deep rooted problem in Britains poor palliative care system + social care crisis
-states data around the world shows changing law puts pressure on vulnerable to end their lives
How is the judiciary system involved?
-provides impartiality and acts as a safeguard
-BUT how able are doctors to make judgements about medical decisions?
What are the views of palliative and social care organisations
-some see it as supporting end of life care
-some see it as undermining its efforts
