UK Oral and Maxillofacial Surgery services are responsible for the care of patients with cancers of the mouth, jaws and face. These cancers can be particularly distressing: they cause difficulties with eating and speech and can be very disfiguring. Treatment can be prolonged and the outlook for some cancers remains poor.
The legal status of assisted dying for the terminally ill is an important issue for all parts of society, including those who are responsible for caring for patients with terminal illness. Medical practitioners and the wider healthcare team bring not only their professional expertise and opinions to the debate but also their views as informed citizens.
For these reasons, the views of UK consultant oral and maxillofacial surgeons were sought on the principal proposals currently before parliament, to make it lawful for a doctor to prescribe medication for suicide and in the case of a patient who cannot take that medication themselves, to provide means of self administration.
With the consent of the officers of the British Association of Oral and Maxillofacial Surgeons (BAOMS), personalised letters were sent to a representative sample of 197 UK consultant oral and maxillofacial surgeons. Those known not to be involved in the care of cancer patients, for example dental hospital consultants with no on call duties, were not included and for some hospitals with large teams of consultants it was not thought necessary to contact every one.
The survey was carried out in February 2006 with a closing date for receipt of views of 7 February 2006 to allow summary of findings to be available in the House of Lords Debate the following week. In the event, the Debate was postponed and the closing date was extended to the 28 February 2006.
Consultants were encouraged to think about the implications of these changes in the law for their own practice and in the context of legal euthanasia in the Netherlands. They were asked to indicate whether or not they support the proposed changes in the law.
128 consultants responded out of a total of 197 contacted: a response rate of 65%. Of those who responded, 31 (24%) supported the proposed new legislation, 92 (72%) were opposed to it and five (4%) expressed no definite view either way. It was clear that, in responding, consultants drew not only on their professional knowledge and experience as oral and maxillofacial surgeons but also on their own family experiences and on their fundamental beliefs.
The large majority were against the proposed legislation and for a range of reasons. The abuse of legalised euthanasia in Holland was cited where decisions were perceived to be '…made on the basis of convenience'. Guidelines in Holland were often deemed by respondents to be breached because abuses were 'difficult to spot'. '…imagine the Pandora's box waiting to be opened by such a change'. 'Such changes would lead to a Shipman figure going on unfettered'. More widely, others felt that the 'medicalisation of death is rarely beneficial' and therefore that the role of a physician in the dying process '…should not be directed at hastening death but, enhancing remaining life'. The boundary between these two objectives was seen as an indelible line despite the observation that it was sometimes crossed, usually accidentally. More widely still, Lord Joffe's proposals were seen to result from '…lack of spirituality in its broadest sense…' This was also seen to be at the root of the body parts issue at Alderhey Hospital.
Many respondents felt that assisted dying was no substitute for poor palliative care services, which, they believed, should therefore be funded more comprehensively. The obligations which assisted suicide would impose on medical staff and the medical care team and, most of all on patients were seen as too much to bear. '…I think that doctor's job is difficult enough without this extra burden and stress'. The inevitable beaurocratic and procedural burdens on those with responsibility to advise patients and facilitate death were seen as considerable and '… would further obstruct clinical duties and prolong the agonies for the family and patients'. The vulnerability of those considering the option of assisted suicide was repeatedly acknowledged. The economics of care for the dying are perceived to increase burdens on patients and very likely to influence end of life decisions if the law is changed.
The proposals were seen as a serious threat to the 'patient doctor relationship…' In the context of opposition to the proposals, lack of 'adequate pastoral support… for doctors was seen as 'sadly lacking'. Doctors who later regretted a decision to facilitate termination of a life were seen as likely to find themselves in a very difficult position.
Religious values were cited by several respondents. For example, 'As a cancer surgeon and a Christian this would have a real impact on my practice. I would not condone it' and '… from a Christian standpoint I find it difficult to accept termination of life before time'. Further, ' I believe that human life is sacred…'. Some respondents stated categorically that they would not 'participate in assisted suicide' and, '…the thought of being complicit in the premeditated ending of a patient's life is abhorrent to me'.
Recent highly publicised cases of assisted suicide were considered to be evidence that this therapeutic option should not be available in the UK: 'I thought that it was unethical to kill that female quadriplegic patient last year before she had time to come to terms with her disability'.
The minority for the proposal legislative changes supported them sometimes because of patchy provision of palliative care making the final stages of terminal care '… a lottery dependant upon the skills, training and the inclination of the palliative care team and the GP'. Autonomy was an important issue for others, for example: 'if you are an adult you are in charge of your own destiny as long as it does not hurt others' and '…their life is for them to keep or give away'.
One respondent felt that '… the scenario would be a planned death.' Another felt that a shift of public opinion was in train: 'one only has to look at the age of consent, same sex activity, the death sentence and the inexorable rise in women's rights to know that changes are a constant aspect of life', giving this as a reason to support the proposals. Another felt that 'by and large the patients that I treat … who are not cured are stuffed, they have a slow painful death with a disease which will mutilate their appearance and will smell'.
This UK-wide survey of consultant surgeons who treat patients with some of the nastiest, debilitating and deforming cancers provides a clear message: more than two thirds are opposed to the proposed changes in the law. The high response rate in this informal yet important exercise demonstrates strongly held views and the extent to which specialists wish to contribute to the wider debate. Overall, it is perhaps surprising that this particular national group of specialists, who treat many of the most unfortunate cancer patients are strongly against Lord Joffe's proposals. From the views expressed, the main reason for this is respondents' holistic outlook: most responded not just as highly specialised, technically outstanding professionals but also as family members committed to doing the right thing. The results of this survey suggest that the universal provision of high quality palliative care services would go a considerable way to addressing the current concerns of consultants.
The permission of the officers of the British Association of Oral and Maxillofacial Surgeons to conduct this informal survey and the participation of respondents are gratefully acknowledged.
Professor of Oral and Maxillofacial Surgery
Honorary Consultant Oral and Maxillofacial Surgeon
Cardiff and Vale NHS Trust