EAS Corrupts Medical Practice and Culture

Trust is the foundation of the clinician-patient relationship. The fact that a doctor might instigate death changes the relationship when a patient is ill and seeking care. There must be clarity that a doctor will never intentionally cause harm to a patient. Continued pressure on NHS resources, however, could lead to decisions being taken that would undermine that trust, as medical decisions would be made not in the best interests of the patient, but according to the priorities of the health system.

Last year, a paper was published in the journal Clinical Ethics which argued that granting terminally-ill patients help to die would both save money and potentially release organs for transplant. One of the authors, the ethicist David Shaw, described the potential savings of allowing assisted suicide as “the elephant in the room”, and the paper went on to assess the extent to which licensing euthanasia could help patients using the same formula which bodies such as NICE deploy to weigh up the expense and benefits of new drugs.

Recent research suggests that such attitudes are not merely hypothetical, but already part of clinical practice. One study showed that organ donors in Belgium (including 23.5% of all lung donors) had been euthanised, raising concerns that patients may be given an emotional inducement to be killed, believing that they can be better use being euthanised and harvested. This prospect of voluntary euthanasia as a source of organ donation, despite the instrumentalisation and exploitation of patients this may often involve, has prompted concerns from north American doctors, as the possibility opens up in Canada (the CMAJ having released guidance on the issue), just as others have anticipated this new source.

Similarly, in October 2020, the Canadian Parliamentary Budget Officer (PBO) released a Cost Estimate Report for Bill C-7, which expanded euthanasia and assisted suicide in Canada beyond the terminally-ill (see previous section). This looked at projected ‘Medical Assistance in Dying’ (MAiD) deaths in 2021, as well as likely costs and savings due to them, estimating that under the law as it stood, 6,465 people would die by MAiD in 2021 – 2.2% of all deaths – with net healthcare savings of $86.9 million, and that expanding the law would add 1,164 deaths in the first year alone, leading to increased healthcare savings in 2021 of $149 million. An extra saving of almost £87 million.

$149 million is almost exactly ten times the annual value of the official funding which was withdrawn from the Delta Hospice Society in British Columbia, after it refused to offer euthanasia and assisted suicide. The funding met 94% ‘of the society’s costs to operate 10 beds at the Irene Thomas Hospice’. This illustrated the corruption of the medical system in Canada, in which economic efficiency and institutional discrimination against those with conscientious objection to euthanasia combined to undermine genuine patient choice and palliative care.

The PBO went on to acknowledge that:

Our estimates have only taken into consideration the health care costs from the perspective of provincial governments. Therefore, out-of-pocket costs paid by patients or their relatives have not been considered. For example, palliative care is usually free of charge when provided in a hospital or a government funded hospice, but there could be costs billed to patients in nursing homes or wanting to receive palliative care at home’.

Not only in academic theory, but in public policy practice, assisted suicide and euthanasia risks dehumanising patients by treating the ending of their lives as an economic and medical benefit.


Moral Hazard

Such situations, and the other realities of PAS / PAE, have serious negative mental consequences on doctors who involve themselves in those practices. Evidence from the United States and other jurisdictions indicates psychological damage on up to half of those doctors who participate in assisted suicide, with long-term persisting consequences to up to a fifth of the same cohort. Factors contributing to this include the emotional burden and discomfort with being involved in the process of causing the death of a patient, assessing their capacity to make the decision, and having to judge if they fit legally required criteria. In Canada, a majority of those doctors who have refused to participate in assisted suicide did so not based on religious or moral grounds, but because of fear of the repercussions on their mental health.

In the British Medical Association’s most recent poll of practising UK doctors, the majority (58%) of those who expressed an opinion were unwilling to prescribe lethal drugs.

Correspondingly, consistent minorities of doctors involve themselves in PAS / PAE in those jurisdictions where these are introduced into medical practice. In Belgium, where euthanasia and assisted suicide have been legal for almost two decades, only 13% of psychiatrists were prepared to participate in the assisted suicide process. One study found that of 52 GPs interviewed only 9 (17%) had performed an assisted death.


Corruption of Medical Culture

Of the minority of doctors that do involve themselves, however, concerns have been raised that these may be those most susceptible to a corruption of medical culture that sees the death of patients, including those with disabilities or chronic rather than terminal illnesses, as desirable.

A study in 2013 that looked at opinions of health care professionals and the public after eight years of euthanasia legislation in the Netherlands found an increase in support for euthanasia or assisted suicide for non-terminal conditions. Among professionals, a significant minority (24%-39%) were found to be in favour of ending the lives of individuals who experience mental suffering due to loss of control, chronic depression or early dementia. Further, a third of doctors and 58% of nurses were in favour of euthanasia in the case of severe dementia, given the presence of an advance directive.

In Oregon in 2020, 142 physicians prescribed lethal drugs for 370 patients. That year there were 6,191 active physicians in Oregon. One study looking at Oregon’s system between 2001-2007 showed a majority (61%, 165 out of 271) of the lethal prescriptions were written by a minority (18%, 20 out of 109) of the participating physicians. More striking still, just 3 physicians were responsible for 23% of lethal prescriptions (62 out of 271). Consistently, a large proportion of lethal prescriptions have been written by a small number of physicians.

A similar problem may exist in Canada, the euthanasia system in which jurisdiction has operated since 2016. According to the First Annual Report on Medical Assistance in Dying (MAiD) in Canada as it operated in 2019, of the 91,375 doctors then operating in Canada, 1,196 engaged in euthanasia of their patients – 1.3% of Canadian doctors. Of the 439,975 Canadian nurses, 75 were engaged in euthanasia procedures – 0.017% of nurses in Canada.

What all this suggests is that the few doctors (and nurses) who are willing to engage in the majority of euthanasia and assisted suicides, may actually tend to be the least scrupulous minority in their profession. It would potentially be these however, who would be responsible for ensuring that the patient applying for assisted suicide or euthanasia would be making a voluntary decision.


Involuntary Euthanasia

In March 2012, the Dutch introduced mobile units to deal with what they call the 80% of people with dementia or mental illness currently being “missed” – their words – by the country’s euthanasia laws. Similarly, the 2011 annual report of the five Dutch Regional Euthanasia Review Committees found that 13 psychiatric patients were killed by euthanasia in 2011, up from 2 in 2010. This again, despite a notional legal requirement that the patient should be mentally competent. In 2017, the number of such deaths had risen to 83 which represents a 500% increase in just five years.

In 2013, more than 1 in 60 deaths in the Flanders region of Belgium occurred with no consent from the patient – those who are in comas, confused, or the elderly whose deaths were facilitated because their lives are considered not ‘worth living’.  6.3% of total annual deaths in Flanders that year were a result of ‘physician assisted-dying’, of which 25% constituted “hastening of death without explicit request from patient”.  In other words, 1 in 4 physician-assisted deaths in Flanders occurred without patient’s consent.  The cruel irony of this path is that legislation introduced with the good intention of enhancing patient choice actually diminishes or disregards choice for the most vulnerable.


Widespread Medical Opposition

Given these pernicious consequences on medical practice, it is surely indicative that medical bodies such as the Royal Colleges of Surgeons and General Practitioners and the Association of Palliative Medicine have all stated their opposition to assisted suicide.

The Royal College of Physicians (RCP) was until recently opposed to assisted suicide, including assisted suicide proposals which approximate those recently considered by the House of Lords and the current Proposals, but adopted a neutral position on the issue in 2019, despite a plurality (43.4%) of an online survey of its members and fellows favouring that the RCP actively oppose the introduction of assisted suicide. This stance was taken after the Council of the College decided to require a 60% supermajority in order to retain the previous status quo of the College’s opposition to the legalisation of assisted suicide. The lack of any mandate given by the College’s members to change the policy is irregular and was subject to legal challenge during which the High Court found the decision making process followed by the College to be irrational. Subsequently the RCP released a statement iterating that they do not support a change in the law.

The Annual Representative Meeting (ARM) of the British Medical Association (BMA) voted in September to take a stance of neutrality on the issue, by 149 votes to 145 – only a 4 vote majority. It should be noted that delegates at the BMA’s ARM in 2005 also voted narrowly to change the position to neutrality, a decision which was then overturned by another vote at the ARM in 2006. Further, in the poll that the BMA conducted of its members in 2021 on the issue of assisted suicide, the specialties most opposed to assisted suicide were GPs, Palliative Care Specialists, Oncologists, and Geriatricians. These are the medical professionals who have the most significant experience in caring for those at the end of life.

Meanwhile, the World Medical Association has maintained a consistent opposition, stating its position most recently as that:

The WMA reiterates its strong commitment to the principles of medical ethics and that utmost respect has to be maintained for human life. Therefore, the WMA is firmly opposed to euthanasia and physician-assisted suicide. No physician should be forced to participate in euthanasia or assisted suicide, nor should any physician be obliged to make referral decisions to this end”.