The provocatively titled play "Whose life is it anyway" by Brian Clark anticipated over 20 years ago a debate which has taken an inordinate time to touch the pharmacy profession. Tim Hanlon and colleagues are to be congratulated on first publishing objective research in the United Kingdom on the thorny subject of pharmacists' involvement in voluntary or "physician-assisted" suicide.1 For pharmacy to be recognised as a mature health profession, able to take its place alongside medicine and nursing, it must engage with these uncomfortable topics. It must develop its own corpus of academic study and raise awareness of the reasoning and values that should underpin the involvement of pharmacists in the full spectrum of health (and death) care.
We have already seen how in the supply of emergency hormonal contraception, where the purpose of use is glaringly obvious, there is a conflict between the strict limitations of licensing conditions and the health professional's ethos of judging what is in the best interests of the "client" and acting accordingly. Other health care colleagues have difficulty in understanding our willingness to subsume this discretion to the letter of the law.
Let us examine one of the key findings of Hanlon et al, and the researchers at the School of Pharmacy.2 A substantial proportion of pharmacists would prefer not to know if a medicine is to be used to assist suicide. This is certainly inconsistent with our pronouncements on concordance and is arguably indefensible. Pharmacists, particularly in community pharmacy, have argued long and loud that to do their job properly they need to know as much as possible about the condition of the patient and the expected outcome of their treatment. This is surely to ensure that the recipient is fully aware of these expectations, shares them and can then maximise the value of the intervention. Why should such considerations be negated when a medicine may be to hasten the end of a life which the patient considers to be insupportable?
There is a difference, of course. If we were to see a person about to throw him- or herself off a multistorey car-park, we would probably try to stop them. If a customer tried to purchase large quantities of paracetamol with the stated intention of "ending it all", we would not supply it. But these situations might be in extremis, products of someone so ill, at least mentally, as to be "incoherent" as suggested in the letter from Norman Fearon.3 Modern medicine, however, has protracted the process of dying to unconscionable lengths. If a decision voluntarily to end one's life has been taken in the full knowledge and understanding of a dismal prognosis and demeaning death — perhaps has been documented in an advance directive or "living will" — does not the situation change?
Why should pharmacists wish to interfere with the patient's right to self-determination in these circumstances? An appeal to religious or cultural proscription is not conclusive. What if the patient is not a Christian? What if he is a Buddhist who wishes to make merit in this life to anticipate a better one in which he is perhaps not an intolerable burden on his family? What if the patient has no faith at all? When liberal philosophy increasingly requires health professionals (and society in general) not to judge or limit help for others with whose life decisions they disagree — drug misusers, homosexuals, prostitutes — why would many draw the line about when to terminate one's life? Strong religious convictions are admirable precepts for personal certainty, but most would not agree that such convictions should be visited upon the recipients of care if they do not themselves subscribe to them. This is the basis of the Code of Ethics "conscience clause", which should indeed be reviewed to consider extension beyond matters sexual to matters of life and death.
In this area the law is not much help. Much turns on the intention behind the administration of medicine. If it can be legitimately argued that the medicine will control pain or alleviate intolerable discomfort but may also inadvertently hasten death, then death resulting from administration of the medicine has generally not been considered by the courts to be murder. Deliberate injection of potassium chloride, even with the supposed consent of the patient, certainly has.
It is worth noting that the advent of the Human Rights Act, covering as it does fundamental constitutional rights such as freedom from torture and freedom of speech and conscience, only refers to a right to life, not a right to death. This is unsurprising given that the European Convention of Human Rights was drafted immediately after the colossal loss of life which accompanied the 1939-45 war. But 50 years on, the lack of such a right seems a glaring omission.
Just as the choices and possibilities for conception approximate ever closer to Aldous Huxley's "brave new world" of test tube breeding to create a balanced world planned by a few alphas, run by a larger contingent of betas and an underclass of slave epsilons, so the moment of our extinction becomes ever more fraught. Most of us will not expire suddenly. Most can anticipate at least some precognition of our end. If an individual wishes to anticipate that, using reasoning, considering options, consulting relatives, and making clear instructions, why should a third party be placed in serious jeopardy for carrying out these instructions? Going further, is there not now a clear case for recognising, in law, the validity of instructions made in this way?
Professor Wingfield is professor of pharmacy law and ethics at Nottingham University and pharmacy practice consultant at Boots the Chemists Ltd. The views set out in this article are her personal views and are not necessarily representative of the position of Nottingham university or Boots
REFERENCES
1. Hanlon TRG, Weiss MC, Rees JR. British community pharmacists' view of physician-assisted suicide. J Med Ethics 2000;26;363-9.
2. Hackett E, Francis SA. Physician-assisted suicide: Debate among pharmacists needed (letter). Pharm J 2000;265;716.
3. Fearon N. Physician-assisted suicide: Disastrous (letter). Pharm J 2000;265:716.