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Tim Hanlon is a primary care pharmacist in the British
Forces Germany
Health Service
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As a professional pharmacist, could you assist someone to end his or
her life? Your reaction may be to recoil in horror from the mere suggestion
that your professional skills could be used to kill rather than cure,
or you may see a real and practical application for your skills to end
human life.
Love or hate the idea of pharmacy’s involvement in physician-assisted
suicide (PAS), the debate has, at long last, arrived for the pharmacy
profession.
PAS is currently illegal in Britain since it is covered under the Suicide
Act 1961, but no one could have missed the recent string of articles
and news stories about PAS in the media. Lord Joffe has proposed a Bill
to the House of Lords which would make PAS legal in the UK, just as it
is in a number of other countries. News stories have filled our newspapers
and been broadcast on our radios and television screens about Dignitas
and the Swiss clinic which assisted Anne Turner and other British people
to end their lives abroad because the choice to die in this manner in
Britain is currently denied them. PAS has become headline news over the
past weeks. All of these stories have one glaring omission in common:
there is no mention of the role of the pharmacist in connection with
physician-assisted suicide.
PAS describes an aspect of euthanasia (voluntary, active) when a health
professional (usually a GP or specialist) provides a competent patient
with pharmaceutical means to end his or her own life.
How is a pharmacist involved in PAS? We know from the Netherlands, where
PAS is available, that a pharmacist is routinely involved in PAS by dispensing
the medicines to the individual (or to their doctor) necessary to take
their own life.1 To qualify as PAS, the patient must self-administer
the fatal dose, which almost always indicates an oral dosage form, commonly
a combination of barbiturates and a muscle relaxant. There is nothing
thus far to suggest that a change in UK law, as proposed by Lord Joffe,
would cut community pharmacists out of this loop.
In the event that PAS is decriminalised or made legal, a patient will
be able to obtain the means to end his or her life legally from their
doctor and pharmacist. They may even have the right to require such a
service, dependent upon the direction of legislative change. So, agree
or disagree with it, pharmacists would be directly involved in ending
life if PAS becomes legal. If, as a pharmacist, you have not yet formed
an opinion on PAS, you should start to think carefully about it now.
The pharmacy profession in Britain has, for whatever reason, resisted
entering this particular end-of-life ethical debate for some years now.
Apart from a small number of letters and articles, little debate has
taken place. The danger of not entering a debate at an early stage is
that the profession is then forced to react and adapt to legal change
rather than proactively trying to ensure that appropriate measures and
professional considerations are taken into account which can influence
that same legal change.
What do we already know about pharmacy and legal change regarding PAS?
When PAS was made legal in Oregon in January 1995, the President of the
Oregon Society of Hospital Pharmacists reported concerns that under the
Death With Dignity Act, no one was required to inform the pharmacist
about the purpose of the prescription, leaving the pharmacist in ignorance,
but potentially partly liable for bad consequences, eg, persistent vegetative
state (PVS), where death did not occur as planned.2
Given that the role of pharmacy (pharmacist or technician) is rarely,
if ever, considered in connection with PAS, it is worrying to consider
that it is entirely conceivable that, in the event of a change in the
law to legalise PAS in Britain, there would be no imperative for a pharmacist
to be informed of the purpose of a prescription intended to end a patient’s
life in a case of PAS and that a pharmacist in Britain could be liable
to prosecution if the patient in PAS did not die following an attempted
suicide, but rather ended up in a PVS.
Some may say that ignorance is bliss, but the world of pharmacy has moved
on since Oregon, which was over 10 years ago. Pharmacists are taking
on extended roles. These advances in professional roles are incompatible
with an attitude expressed by some that they are merely acting as agents
of supply. This argument is not extended to other areas, such as antihypertensive
therapy. Under these circumstances, most pharmacists would agree that
they are partly responsible for achieving the intended outcomes of drug
treatment. Why would this be any different with PAS?
Some research from 1998, which I undertook with Marjorie Weiss and Judith
Rees at the University of Manchester, suggested that a quarter of community
pharmacists surveyed would not wish to be informed about the intended
purpose of a prescription for use to end life in PAS.3 This ostrich-like
attitude of ignoring a key moral and ethical issue is not the act of
a mature profession and suggests a confused approach to this issue compared
with the profession’s mature approach to other developments, such
as pharmacist prescribing.
Whether Lord Joffe’s Bill is successful this time or not is not
the most significant issue. There have been others before Lord Joffe
proposing such legal change and there will be others after him. It is
likely that PAS will become legal at some stage. What is particularly
significant is that the profession of pharmacy considers its position
on this issue, in line with other professions, and that each individual
pharmacist considers his or her ethical stance on the issue in order
to influence any future professional proposals in relation to PAS.
In the conclusion of a Broad spectrum article that I wrote with Dr Weiss
on PAS and the role of the pharmacist over five years ago,4 we said that
the pharmacy profession needed to take part in the process of change
rather than being changed by the process. I have not changed my mind
on this issue. The time for debate is now.
References
1. Laus HS, Riezebos J, Abas V, Porsius AJ, De Boer A. A nation-wide
study on the practice of euthanasia and physician-assisted suicide in
community and hospital pharmacy in the Netherlands. Pharmacy World and
Science 2000;22:3–9
2. St Jean Wittenburg A. Oregon’s Death With Dignity Act lacks
pharmacist’s perspective. American Journal of Health-System Pharmacists
1995;52:131–2
3. Hanlon TRG, Weiss MC, Rees JA. British community
pharmacists’ views of physician-assisted suicide (PAS). Journal
of Medical Ethics 2000;26:363–9
4. Hanlon TRG, Weiss MC. A role for the pharmacist in
physician-assisted suicide? Pharmaceutical Journal 2000;265:649 |
The
Pharmaceutical Journal