The Pharmaceutical Journal
Vol 276 No 7384 p67-68
21 January 2006

This article
Reprint   Photocopy

PDF 448K, Acrobat Reader

Society puts impact of assisted dying on agenda as part of wider debate

The law and ethics committee of the Royal Pharmaceutical Society’s Council discussed voluntary euthanasia at its meeting on January 18. Debbie Andalo finds out what other health care professions think and looks at their responses to the emotive issue of assisted dying

Pharmacists are about to take the first steps in declaring where the profession stands on euthanasia and assisted dying. The issue was due to be discussed by the
law and ethics committee of the Royal Pharmaceutical Society when it met on 18 January.

The move follows the increasing public and political debate on assisted suicide and voluntary euthanasia. It comes as a Bill going through the House of Lords is attempting to change the law around assisted dying and only months after UK doctors took what they described as a “historic decision” to drop their long-held opposition to physician-assisted dying. Doctors at the annual British Medical Association conference last June voted narrowly to take a neutral stance instead.
At the same time the charity, the Voluntary Euthanasia Society, which from January 23 is to be renamed Dignity in Dying, claims public opinion polls since the 1990s consistently reflect 80 and 85 per cent support for a change in the law to allow assisted dying.

Ahead of that happening, assisted dying continues to happen in the UK, according to the charity’s chief executive Deborah Annetts, who says: “There is no doubt about that. Assisted dying does take place covertly and it’s the relative or the doctor who
helps. I read recently that pharmacists claim they never provide life-ending drugs, which I find quite interesting. Somebody is providing the doctor with drugs which they
then use to hasten death. What does the pharmacist think about when they have that prescription, or don’t they think it through?”

No professional guidance
Pharmacists have no professional guidance on what to do in cases of euthanasia or assisted dying. Instead, like other health professionals and members of the public, they are governed by law — the Suicide Act 1961, which makes it a criminal offence to help somebody commit suicide. Someone who helps end the life of somebody who is terminally ill or dying faces a murder charge. But this could all soon change.
The Society’s head of professional ethics Lynsey Balmer said before the law and ethics committee meeting: “We have been aware for some time that this is an issue that is causing considerable public and political debate, which we are following closely. We have therefore scheduled this for the agenda of the law and ethics committee.”
She says: “It is important that we consider the potential impact on the profession of this issue and help the Royal Pharmaceutical Society’s Council form a policy position that will be in the best interests of public and profession alike.”

Bringing the issue onto the agenda is a significant move for the profession which in the past appears to have been reluctant to become involved in a public debate, leaving it instead to doctors to lead the way. Deborah Annetts thinks pharmacists today are where doctors were on this issue four years ago.

She says: “It’s interesting to have seen the ripple effect — it started with physicians wanting to talk about it, then we moved to psychiatrists and it has moved through GPs and neurologists and health professionals working in palliative care. Now it’s pharmacists.”

Marjorie Weiss, a senior lecturer in pharmacy at Bath University, believes an open professional debate is long overdue. Dr Weiss was involved in a UK study in 2000 which revealed that out of 179 practising community pharmacists, 25 per cent said they would not want to know whether a drug they were dispensing was to be used in a physician-assisted death.

Another survey published around the same time came to similar conclusions — around a third of 288 hospital and community pharmacists questioned said they would not want to know the purpose of the drugs they were dispensing if they were to be used in a physician-assisted death or voluntary euthanasia. The same percentage thought it acceptable if the prescriber withheld the fact that the drugs were intended to be used to help end a life.

A quarter of them admitted they would dispense the drugs even if they knew they would be used in an assisted suicide — some of them unaware that they would be breaking the law.

Dr Weiss said at the time her report was published that it was unthinkable that a profession which wants to be seen as experts in medicines and is looking to widen its clinical practice should take such an ostrich approach. It is a view she still shares today. She says: “These pharmacists seemed to be saying we really don’t want to know. I think we need to engage with the issues — not pretend they aren’t there. Either as pharmacists we are experts in medicines or not. If we claim to be experts then we should engage with the issues and have a full discussion.”

Doctors’ stance
Last summer doctors at the British Medical Association took on the public debate which some parts of the pharmacy profession crave. Delegates at its annual representatives meeting voted by 93 to 82 to change current policy and drop its opposition to assisted dying.

But doctors were reluctant to go a step further, voting by 101 to 72 against a second motion calling on the BMA to support assisted dying. The BMA maintained its opposition to euthanasia.

The change of heart over its stand on assisted suicide was triggered by doctors’ belief that the issue of law around assisted dying was one which should be decided by “society and Parliament”. However, at the same time the BMA made it clear that any change in the law should include a “conscientious objector” clause so that any doctors not wanting to be involved in an assisted suicide could opt out without breaking their contracts.

BMA head of science and ethics Vivienne Nathanson said: “The BMA last summer came to a conclusion which was quantitatively different from what had been decided before. The law (in the future) may or may not change. We are not assuming that physician-assisted suicide will get through but what we are recognising is that it is properly debated and considered. What doctors were saying last year is that doctors have their own view about this issue, and they should make that view heard. But matters of this kind should be debated by the public and their elected representatives. We will continue to be a powerful lobby group — but Parliament has to be involved in this. I think the real question is whether the opinion of doctors should be the over-riding thing that is listened to?”

House of Lords
The peer who for the past four years has been trying to bring about a change in the law on assisted dying and voluntary euthanasia is human rights lawyer Lord Joffe. His revised Bill on assisted dying for the terminally ill was back in the House of Lords before Christmas and is expected to be debated again by peers this May. Lord Joffe welcomed the decision by the law and ethics committee to consider the issue. He says: “I’m delighted. It’s better the more health professionals take part in the process.” He believes that the pharmaceutical industry should have been invited to give evidence to the House of Lords select committee when it was considering his Bill. He says: “It is something that I am very keen that we should do now. It’s essential that they should participate in the whole process. There is a role for them to consider because the drugs we believe will be prescribed under the Bill have to be prescribed by the pharmacist.” Lord Joffe’s Bill has undergone significant changes in order to win wider appeal from the public, politicians and health professionals.

Proposals dropped
Proposals in the Bill to legalise voluntary euthanasia — where a doctor administers a lethal dose to a patient to help him or her die — were dropped following fierce opposition, particularly from Anglican bishops. Instead the Bill focuses on physician-assisted dying. The Bill includes proposals that two doctors should state that the patient who wants to take part in an assisted suicide is suffering from a terminal illness and is “suffering unbearably”. Alternatives to assisted dying, including palliative care, must be offered by both doctors ahead of any decision by the patient to go ahead with a declaration requesting an assisted suicide. The patient declaration has to be signed by two witnesses — one a solicitor. The Bill, in its current form, also includes a conscientious objector clause for physicians involved at any stage of the assisted dying process.

The Royal College of Nursing gave evidence to the House of Lords committee when it was considering the Joffe Bill. It is opposing any attempt to change the law on physician-assisted dying or voluntary euthanasia. RCN deputy president Maura Buchanan says: “We are totally opposed to any euthanasia or physician-assisted dying in any form. We feel that it is something which would put the nurse-patient relationship at risk and also risk the trust which the patient has for the nurse. This is not the way forward. I think there are a lot of things we need to look at in achieving good end of life care, that is, good palliative care.” She is dismissive of the opt-out clause in the Bill claiming it is irrelevant for nurses. She says: “If you look at abortion services for example, if you want to opt out of that you decide not to work in that service. But if you look at dying, people die anywhere where there is health care. If you are a health professional how can you opt out? It’s meaningless to say you can opt out of end-of-life care.”

Role of pharmacists
The RCN welcomed the announcement that the law and ethics committee of the Royal Pharmaceutical Society was to discuss the issue of assisted dying and voluntary euthanasia this week. Ms Buchanan says: “I think it is particularly helpful that pharmacists are getting involved. I think we underestimate how much pharmacists can contribute. I would welcome what pharmacists have to say in the discussion and the role they can play in better palliative care — which is what we want.” The Voluntary Euthanasia Society also believes that pharmacists have a contribution to make, but a significantly different one.

Medication, according to Deborah Annetts, can offer the terminally ill patient who chooses to end his or her life a dignified death — one without pain or discomfort. She says: “It’s pharmacists who are in a position to give people that dignified death if that is the option of choice.”

Whatever policy decision the Society finally decides, it is evident that its opinion is of value and is essential to the continuing debate on physician-assisted dying and voluntary euthanasia. Lord Joffe is realistic that changes in the law will not happen overnight but he welcomes the widening debate which his Bill has triggered. He says: “We are really pleased that the issue is being discussed in all professional and medical journals and within the royal colleges. It’s impossible to predict how long the legislative process will be, but one day I am sure that it will go through.”