United Kingdom Parliament -House of Lords Select Committee on Assisted Dying for the Terminally Ill Bill

United Kingdom Parliament
House of Lords Select Committee on Assisted Dying for the Terminally Ill Bill
Selections from the First Report: Written Evidence

Related Links
Belgium: Redefining
Palliative Care and
Forcing Physicians to
Refer for Euthanasia

Chief Justice favours assisted
suicide, willing to order
assistance (Canada) (1993)

Conscience Situation OK
- For Now
(Oregon, USA, Sept., 2005)

Introduction
In 1993/1994 the British parliamentary Select Committee on Medical Ethics reviewed the law on euthanasia and concluded that the procedure should not be legalized. In 2003 Lord Joffe introduced a private member's bill into Parliament, the Patient (Assisted Dying) Bill, which progressed only to second reading. In March of the following year he introduced the present private member's bill (Assisted Dying for the Terminally Ill), drafted "to enable a competent adult who is suffering unbearably as a result of a terminal illness to receive medical assistance to die at his own considered and persistent request; and to make provision for a person suffering from a terminal illness to receive pain relief medication." It received Second Reading and was referred to a House of Lords committee for detailed examination.

The bill included an exemption for conscientious objectors (Clause 7) which was criticized by some submissions because it suggested that there could be conscientious objection to pain relief per se. It also required an objecting physician refer a patient to a colleague willing to process a euthanasia request. This elicited protests during the examination of witnesses and in written evidence and an adverse judgement from the Joint Committee on Human Rights, as a result of which Lord Joffe agreed to remove the provision for mandatory referral.

Reflecting on practical issues, the Committee cautioned that the bill might prove unworkable because many health care workers would refuse to participate in the procedure. In its conclusions, the Committee supported the deletion of the mandatory referral on the grounds that forcing physicians to refer for a procedure to which they objected for reasons of conscience is probably contrary to the European Convention on Human Rights. The Committee also recommended the expansion of protection of conscience provisions to include other health care workers, and that the exemptions also take into account the multidisciplinary nature of the care given to the terminally ill.

The conclusions of the Joint Committee on Human Rights and the Select Committee with respect to referral are most welcome and deserve notice from persons in positions of influence or authority who continue to try to force objecting health care workers to refer for morally controversial procedures. [Administrator, Protection of Conscience Project]

Memoranda and Letters:
ALERT
Affinity
Association for Palliative Medicine
Association of Catholic Nurses for England and Wales
Association of Catholic Women
British Humanist Association
British Medical Association
CARE
Christian Medical Fellowship
Catholic Union of Great Britain and the Guild of Catholic Doctors
General Medical Council
Help the Hospices
National Council for Hospice & Specialist Palliative Care Services
National Group of Palliative Care Nurse Consultants
Nursing and Midwifery Council
Office of the Chief Rabbi
Royal College of Physicians of Edinburgh

Dr Colleen Cartwright and Associate Professor Malcolm Parker
Raymond Hoffenberg MD PhD FRCP
Dr Louise Gibbs et al, Consultants in Palliative Medicine, St Christopher's Hospice, London

Related Links
Referral:
A False Compromise

Related Links Belgium: Redefining Palliative Care and Forcing Physicians to Refer for Euthanasia Chief Justice favours assisted suicide, willing to order assistance (Canada) (1993) Conscience Situation OK - For Now (Oregon, USA, Sept., 2005)	Introduction In 1993/1994 the British parliamentary Select Committee on Medical Ethics reviewed the law on euthanasia and concluded that the procedure should not be legalized. In 2003 Lord Joffe introduced a private member's bill into Parliament, the Patient (Assisted Dying) Bill, which progressed only to second reading. In March of the following year he introduced the present private member's bill (Assisted Dying for the Terminally Ill), drafted "to enable a competent adult who is suffering unbearably as a result of a terminal illness to receive medical assistance to die at his own considered and persistent request; and to make provision for a person suffering from a terminal illness to receive pain relief medication." It received Second Reading and was referred to a House of Lords committee for detailed examination. The bill included an exemption for conscientious objectors (Clause 7) which was criticized by some submissions because it suggested that there could be conscientious objection to pain relief per se. It also required an objecting physician refer a patient to a colleague willing to process a euthanasia request. This elicited protests during the examination of witnesses and in written evidence and an adverse judgement from the Joint Committee on Human Rights, as a result of which Lord Joffe agreed to remove the provision for mandatory referral. Reflecting on practical issues, the Committee cautioned that the bill might prove unworkable because many health care workers would refuse to participate in the procedure. In its conclusions, the Committee supported the deletion of the mandatory referral on the grounds that forcing physicians to refer for a procedure to which they objected for reasons of conscience is probably contrary to the European Convention on Human Rights. The Committee also recommended the expansion of protection of conscience provisions to include other health care workers, and that the exemptions also take into account the multidisciplinary nature of the care given to the terminally ill. The conclusions of the Joint Committee on Human Rights and the Select Committee with respect to referral are most welcome and deserve notice from persons in positions of influence or authority who continue to try to force objecting health care workers to refer for morally controversial procedures. [Administrator, Protection of Conscience Project]

	Memoranda and Letters: ALERT Affinity Association for Palliative Medicine Association of Catholic Nurses for England and Wales Association of Catholic Women British Humanist Association British Medical Association CARE Christian Medical Fellowship Catholic Union of Great Britain and the Guild of Catholic Doctors General Medical Council Help the Hospices National Council for Hospice & Specialist Palliative Care Services National Group of Palliative Care Nurse Consultants Nursing and Midwifery Council Office of the Chief Rabbi Royal College of Physicians of Edinburgh Dr Colleen Cartwright and Associate Professor Malcolm Parker Raymond Hoffenberg MD PhD FRCP Dr Louise Gibbs et al, Consultants in Palliative Medicine, St Christopher's Hospice, London

Related Links Referral: A False Compromise Assisted Suicide: What Role for Nurses?	From the Memorandum by the Association for Palliative Medicine [Memorandum] 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]

Related Links Referral: A False Compromise Assisted Suicide: What Role for Nurses?	From the Memorandum by National Council for Hospice & Specialist Palliative Care Services [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]

Related Links Referral: A False Compromise Assisted Suicide: What Role for Nurses?	From the Memorandum by the Royal College of Physicians of Edinburgh [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]

Related Links Referral: A False Compromise Assisted Suicide: What Role for Nurses?	From the Memorandum by the Christian Medical Fellowship [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]

Related Links Referral: A False Compromise Assisted Suicide: What Role for Nurses?	From the Memorandum by the Catholic Union of Great Britain and the Guild of Catholic Doctors [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]

Related Links Referral: A False Compromise Assisted Suicide: What Role for Nurses?	From the Memorandum by Dr Colleen Cartwright and Associate Professor Malcolm Parker [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]

Related Links Referral: A False Compromise Assisted Suicide: What Role for Nurses?	From the Memorandum by The National Group of Palliative Care Nurse Consultants [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]

Related Links Referral: A False Compromise Assisted Suicide: What Role for Nurses?	From the Memorandum by Help the Hospices [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]

Related Links Referral: A False Compromise Assisted Suicide: What Role for Nurses?	From the Memorandum by Affinity [Memorandum] 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]

Related Links Referral: A False Compromise Assisted Suicide: What Role for Nurses?	From the Memorandum by CARE [Memorandum] 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]

Related Links Referral: A False Compromise Assisted Suicide: What Role for Nurses? Establishment Bioethics	From the Memorandum by the British Humanist Association [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]

Related Links Referral: A False Compromise Assisted Suicide: What Role for Nurses?	From the Memorandum by the General Medical Council [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]

Related Links Referral: A False Compromise Assisted Suicide: What Role for Nurses?	From the Memorandum by the British Medical Association [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 http://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]

Related Links Referral: A False Compromise Assisted Suicide: What Role for Nurses?	Memorandum by the Office of the Chief Rabbi [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]

Related Links Referral: A False Compromise Assisted Suicide: What Role for Nurses?	Memorandum by ALERT [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]

Related Links Referral: A False Compromise Assisted Suicide: What Role for Nurses?	Memorandum by the Association of Catholic Nurses for England and Wales [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]

Related Links Referral: A False Compromise Assisted Suicide: What Role for Nurses?	Memorandum by The Association of Catholic Women [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]

Related Links Referral: A False Compromise Assisted Suicide: What Role for Nurses?	Memorandum by the Nursing and Midwifery Council [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]

United Kingdom Parliament House of Lords Select Committee on Assisted Dying for the Terminally Ill Bill Selections from the First Report: Written Evidence

United Kingdom Parliament
House of Lords Select Committee on Assisted Dying for the Terminally Ill Bill
Selections from the First Report: Written Evidence