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They Don't Do It And They Don't Want It!

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25th March 2009

New Study - 'British Doctors don't do it and they don't want it'

A survey of end of life decisions by doctors shows that 'assisted dying' is very rare in Britain. And another survey shows that the majority of doctors don't want it legalised.

Professor Clive Seale, of the Centre for Health Sciences at St Bartholmew's and the London School of Medicine and Dentistry, has published another report in his series on end-of-life decision-making by British doctors. His reports, which are intended to inform the public debate on whether 'assisted dying' should be legalised, will provide little encouragement to those who want to see the law changed. Professor Seale's reports are based on anonymous responses from nearly 4,000 doctors working in various fields of medicine. It follows similar surveys carried out in previous years.

What Doctors Are Doing

Professor Seale's first report, on the decisions that doctors take when treating patients who are at the end of their lives, compares results obtained for 2004 and 2007-08. He concludes that in Britain "euthanasia, physician assisted suicide and the ending of life without an explicit patient request are rare or non-existent at both time points". He calculates on the basis of the responses received that euthanasia with or without a patient's request might have occurred in 0.49% of deaths in 2007-08 and he records no cases of physician assisted suicide. The euthanasia figure is very similar to previous findings by Professor Seale and it leads him to the conclusion that "the incidence of assisted dying in the UK is very low indeed".

Professor Seale records two other conclusions. He points to a sharp drop between 2004 and 2007-08 in 'double effect' and non-treatment decisions. These are decisions, both of which are legal and in accord with medical ethics, to administer drugs to relieve distressing symptoms in dying patients which in rare instances could have the unintended effect of accelerating death; and to withhold or discontinue treatments which are regarded as likely to be ineffective or to be unduly burdensome to the patient.

Conversely, the survey points to a relatively high level (16.5%) of what is called Continuous Deep Sedation (CDS), meaning the administration of sedatives to dying patients to relieve restlessness in the final hours of life or to help deal with pain or other symptoms that have not been fully controlled by other methods. Professor Seale points to an apparent contrast between the British rate of CDS and lower rates obtaining in some other countries. He cautions, however, that "a better understanding of the context in which these decisions are taken is needed to assess this".

It was predictable that the pro-euthanasia lobby, having failed to secure a conclusion which would have supported its thesis that there is widespread flouting of the law by British doctors, should latch onto Professor Seale's comments on CDS. Dignity in Dying (formerly the Voluntary Euthanasia Society) is quoted in the media as claiming that "doctors are assisting patients to die without safeguards" and pointing to lower rates of CDS in Belgium and Holland. We therefore asked Baroness Finlay of Llandaff, a leading professional in end of life medicine with knowledge of clinical practice in Holland as well as the UK, for her comments on Professor Seale's findings. Baroness Finlay told us:

"Professor Seale's report correctly refers to 'a very different medical culture' between Britain and Holland, which probably explains the apparent difference in CDS rates. In Dutch clinical practice continuous deep sedation is given according to a protocol that aims to keep the patient deeply unconscious until death, however long that takes, using higher doses than are generally used in the UK. In Britain, sedation at the end of life, where it is administered by doctors, is given at the lowest possible dose to relieve distress; and in some patients the dose is reduced after a time and allows the patient to communicate as much as he or she wishes. By contrast, Dutch patients are maintained in a deep coma until death. I agree with Professor Seale that we should not jump to false conclusions about the figures that have emerged from his survey. To suggest from this that doctors are engaging in euthanasia here is absurd".

What Doctors Think About Assisted Dying

Professor Seale's second report records the results of a survey of medical opinion about whether the law should be changed to permit physician-assisted suicide or euthanasia. It concludes that two thirds of doctors in Britain are opposed to a change in the law to allow these practices in the case of patients who are terminally ill. The figure rises to over 80% in the case of patients who are not terminally ill.

Professor Seale concludes that "the majority of British doctors do not support legalising assisted dying". It is, he observes, important to have an accurate measure of medical opinion on this controversial subject because "majority support, or at least neutrality, from the medical profession has been an important factor in enabling the passing of permissive legislation in Oregon, The Netherlands and Belgium". That is not the case in Britain. All the Medical Royal Colleges and the BMA have declared their opposition to 'assisted dying'.

The report draws attention to a contrast between the views of doctors, most of whom are opposed to a change in the law, and those of the population at large, most of whom appear to favour - or to be prepared to acquiesce to - such a change. In the same way it notes that those doctors whose work brings them into regular contact with dying people tend to be rather more opposed to legalising 'assisted dying' than others who are less involved with the terminally ill. This is hardly surprising. Those who work with the dying, day in and day out, are able to see how vulnerable most terminally ill people are and to understand what 'assisted dying' actually means, not only for the patient who might ask for it but also for the doctor who would have to provide it. They are the people who would have to square such a sea change in the law with the ethical principles to which, as physicians, they subscribe; and they are the people who would have to face the General Medical Council and, perhaps, the Criminal Courts if they were to get it wrong. It would be foolish therefore to contemplate such a fundamental change in the law in the face of principled opposition from the very professionals who would have to carry it out.

Professor Seale refers in his report to concerns expressed by doctors about medical involvement in 'assisted dying'. He quotes one respondent as giving the view that, "if the law and patient choice dictates euthanasia, it should be conducted by professionals other than doctors, as it may blur perceptions of a doctor's role and leave vulnerable people reluctant to seek medical help for symptom control". This is an important issue, though it is one that the pro-euthanasia lobby is unlikely to address seriously. 'Assisted dying' is being deliberately associated with clinical care in an effort to make an unpalatable concept more acceptable to Parliament and the public. Given however that the principal argument advanced for 'assisted dying' is the promotion of personal autonomy and control, which is not the responsibility of the medical profession, rather than the relief of symptomatic suffering, which is and which can be performed effectively without any change in the law, it is hard to see why doctors should be implicated in ending or helping to end the lives of sick people.

In Conclusion

Professor Seale has produced two interesting reports which neither favour nor oppose the legalisation of 'assisted dying'. We welcome this impartiality. We welcome also the confirmation they bring that illegal action is not taking place in this country other than in very marginal terms and that the majority of British doctors remain opposed to a change in the law to enable them to kill their patients or help them to kill themselves.

Doctors rarely help terminally-ill patients to die, survey reveals
Euthanasia wins support of only one in three doctors
Majority of docs against euthanasia

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