The Pharmaceutical Journal
Vol 277 No 7427 p614-615
18 November 2006

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Pharmacy involvement where assisted suicide and euthanasia are permitted

In the first of two articles, Colin Meek investigates pharmacists' involvement in physician-assisted suicide and euthanasia in countries where one or both of these interventions is legal, and the potential implications for pharmacy in Britain if assisted suicide were to be legalised

Physician-assisted suicide series

If a doctor asked you for advice about what lethal drug to use to help someone commit suicide, how would you respond? And how would you react if you were asked to dispense a lethal drug to help a patient commit suicide? As physician-assisted suicide (PAS) and euthanasia are still illegal in the UK, most pharmacists will not have grappled with these ethical questions. Yet there is a chance that PAS may be legalised in some form in some part of the UK in the near future. If that happens, pharmacists will almost certainly be asked to dispense lethal drugs and doctors will ask pharmacists for advice about the most suitable drugs to prescribe. Inevitably, any planned legalisation will confront the profession with a range of questions, such as:

· How should a pharmacist’s right to exercise conscientious objection be established?

· Should pharmacists who are willing to participate in PAS have a duty to refuse to dispense under certain circumstances, for example where the required procedures have not been followed or they suspect a vulnerable patient may be at risk?

Fortunately, pharmacists in the UK can look to the experience of colleagues in other countries. PAS is legal in Switzerland, the Netherlands and Oregon in the US. Euthanasia is also legal in Belgium and the Netherlands. These various laws that have legalised the prescription and supply of lethal drugs are framed in different ways and their impact on pharmacy practice varies. For example, in 2003 PAS accounted for just one in 714 deaths in Oregon while in the Netherlands, in the same year, one in 38 people died as a result of PAS or euthanasia.

This first article describes the legislation in each of the four countries, how that legislation has affected pharmacists and how pharmacists are responding to these laws. The second paper in this series will draw on this international experience to examine some of the critical issues that will face pharmacy practice in the UK were assisted suicide to be legalised.

The Netherlands

The Dutch Termination of Life on Request and Assisted Suicide (Review Procedures) Act, which came into force in 2002, codified requirements that have evolved in case law and medical ethics since 1973 and defines the conditions that doctors must satisfy in order to perform euthanasia or PAS without prosecution. For example, doctors must be satisfied that the patient has made a voluntary and considered request, and be satisfied the patient’s suffering is unbearable and there is no prospect of improvement. The doctor must also consult a colleague who has seen the patient.

Under the Act, an advance directive counts as a well-considered request for euthanasia, meaning that treatment can be withdrawn from a patient who is unable to consent. The Act does not cover neonates but, with additional safeguards, the law is not limited to adults and the patient does not have to be terminally ill.

Pharmacy practice and Dutch law Research shows that most pharmacists in the Netherlands are directly affected by PAS or euthanasia. Results of a survey published in 2000 show that 78 per cent of community pharmacies had received at least one request to dispense drugs for euthanasia or PAS in the years 1991–93 and 11 per cent received between six and 10 requests. The same research found that 88 per cent of the hospital pharmacies received at least one request in 1993.¹

Despite pharmacists’ involvement, the Act does not explicitly refer to their role. If a doctor is prosecuted for illegal euthanasia, however, the pharmacist who supplied the drugs will not be prosecuted under normal circumstances. The pharmaceutical inspectorate holds the position that although the pharmacist and doctor should discuss the prescription, the pharmacist does not have to investigate whether the doctor is conforming with legal requirements.

The Royal Dutch Pharmaceutical Society (KNMP) has issued guidance for pharmacists on dispensing drugs for euthanasia and PAS. These state, for example, that pharmacists have a right to refuse to dispense. Practice protocols in hospitals and the community setting also exist for co-operation between pharmacists and doctors. One local protocol has made standard packages of drugs available (an intravenous one for performing euthanasia and an oral one for performing assisted suicide) and detailed technical guidelines exist on the drugs that should be used for the purposes of euthanasia and PAS.

Despite these efforts to ensure best practice there is some research to show that GPs do not always adhere to KNMP guidance on administration. One study published in 1992 found that GPs sometimes used inappropriate drugs (for example, a combination of morphine and brallobarbital or insulin) or dosages that were too low. Sometimes drugs were administered in inappropriate ways (for example, rectally or subcutaneously). In 12 per cent of cases there were complications such as the drug not leading to death or doing so too slowly.² Four years on from the introduction of the Act, Royal Dutch Medical Association says that its focus of policy development is now on the improvement of the quality of medical decision-making in cases of euthanasia and assisted suicide.

There is also evidence to show that the role pharmacists play in reality is often different to the role that is defined in the professional guidance. The KNMP guidelines state that written requests for drugs for euthanasia must comply with requirements for opioid drug prescriptions, yet one study has found that more than 40 per cent of requests that are dispensed by community and hospital pharmacists do not comply.

The KNMP guidelines also state that requests from doctors must be made in writing and pharmacy technicians should not be involved. But this study also found that 26 per cent of honoured requests were not made in writing (to community pharmacists) and pharmacy technicians were involved in 6 per cent of cases in the community and 31 per cent of cases in hospitals.¹

Switzerland

The Swiss penal code states that a person who assists someone else to commit suicide will only be punished if that person is motivated by self-interest. This is the legal basis for PAS. However, this penal code provision is qualified by a number of other laws that impact on a physician’s ability to assist a suicide. For example, the civil code states that if a person lacks capacity then his or her request for PAS has no legal validity. Furthermore, under the Swiss penal code, euthanasia remains a crime.

Pharmacy practice and Swiss law Pharmacists in Switzerland are rarely involved in PAS for three reasons. First, it is estimated that the number of physician-assisted deaths amounts to only 0.2 per cent of all deaths. Secondly, most PAS cases are carried out by voluntary organisations such as EXIT. These organisations offer services to people who want to commit suicide including facilities where the suicide can take place. Although the Swiss Academy of Medical Sciences has set out strict guidance for doctors on PAS, most suicides are not directly supervised by doctors. Lastly, according to the Swiss Law on Pharmaceutical Products, pharmacists cannot dispense drugs that may result in death. The one exception to that general rule permits the prescription of lethal barbiturates to relieve pain. This means that pharmacists who work with doctors in institutions such as hospitals and hospices can dispense barbiturates according to strict end-of-life protocols.

Pharmacists are not mentioned in the various relevant laws that make PAS legal in Switzerland and the Swiss Association of Pharmacists (SAP) has not issued any guidance to the profession about PAS. SAP says, however, that local protocols between doctors and pharmacists probably exist. Pharmacists who ask the association for advice when they receive prescriptions for drugs that may be lethal are advised not to dispense because they cannot check whether the patient is terminally ill or has legal capacity.

Pharmacists have no right to a conscience clause. On the contrary, they must dispense products requested in a prescription unless they suspect that the prescription may result in the death of a patient.

Belgium

Belgium’s Euthanasia Act of May 2002 is similar to the one in place in the Netherlands and details how doctors can perform euthanasia without being prosecuted. The Belgian Act differs from the law in the Netherlands (and that in place in Oregon and Switzerland) because PAS remains illegal.

Pharmacy practice and Belgian law As in the Netherlands, many pharmacists in Belgium are directly affected by the legislation. Officially, PAS or euthanasia accounted for 0.6 per cent of all deaths in 2004. A study in 1998, however, looked at 1,925 deaths and the authors concluded that 1.3 per cent of all deaths in the country occurred as a result of PAS or euthanasia. It is predicted that the official figure of 0.6 per cent will rise sharply as more doctors comply with the new law.³

Pharmacists in Belgium are given good protection from prosecution. Revisions to the law on euthanasia in 2004 state that the pharmacist who dispenses a lethal drug does not commit any offence if the doctor states on the prescription that he or she is acting in accordance with the law. The pharmacist must deliver the drugs for euthanasia in person to the requesting doctor.

The Belgian Pharmaceutical Association (APB) has finalised guidance for pharmacists on the Euthanasia Act and this describes in detail how drugs for euthanasia should be prescribed, delivered, administered and returned if they are not used. It also includes information on how the products should be ordered and priced.

Prescriptions must make the intended use of the drug clear. This gives pharmacists the opportunity to refuse to participate and that right is legally protected. If the pharmacist is suspicious that the intended use of a prescription is for euthanasia, but the prescription does not make this clear, then the pharmacist can refuse to dispense. Many hospitals also have their own protocols and guidance for euthanasia.

Since the Euthanasia Act is so young it is difficult to know if Belgian pharmacists are deviating from their own guidelines. The APB, however, states that the current law is strictly observed.

Oregon

Under the Oregon Death with Dignity Act that came into force in 1997 a physician can help a patient commit suicide without fear of prosecution as long as strict conditions are met. For example, patients must make one written request to die (signed in front of two witnesses) and two oral requests to die separated by at least 15 days, and two doctors must independently judge that the patient has six months or less to live and determine whether the patient is capable. The Act legalises PAS, but prohibits euthanasia and any lethal drugs that are prescribed must be self-administered. Those eligible must be 18 years of age or older, capable, be a resident of Oregon and have a terminal disease (this must be incurable and irreversible and expected to lead to death within six months).

Pharmacy practice and Oregon law Any pharmacist can receive a prescription for a lethal drug but, in reality, only a small number are asked to dispense as PAS accounts for less than 0.1 per cent of all deaths in the state.

In 1999 the Act was amended to ensure that pharmacists are told about the intended use of the drug and physicians and pharmacists are under no obligation to take part. PAS is monitored by the Oregon Department of Human Services through a system of physician and pharmacist compliance reports, death certificate reviews and follow-up interviews. Pharmacists and physicians must take part in the official reporting procedure if they honour a PAS request.

Most drugs for PAS cases are dispensed by pharmacists who are members of the American Society of Health-System Pharmacists. Professional guidance from this body, however, represents “guiding principles” for pharmacists’ participation in the legal and ethical debate about PAS rather than best practice advice.

Rules for doctors have a big impact on the way pharmacists and physicians communicate when a patient makes a request for PAS. Doctors must personally find out if the pharmacist is willing to dispense drugs for the purposes of PAS. This Board of Medical Examiners’ rule also states that physicians must personally issue prescriptions for lethal drugs to pharmacists. This rule is also intended to encourage co-operation and communication between pharmacists and physicians.

There are no standard recommendations for drugs for assisted suicide. The Department of Human Services has said that neither the Board of Pharmacy nor the pharmacists’ body in Oregon was willing to make recommendations on drugs for assisted suicide because of the fear of litigation. The ASHP has not issued any guidance on which drugs should be used for PAS and how they should be administered.

Issues for UK pharmacists

Experience in other countries shows that legalising assisted suicide, euthanasia or both can have a profound impact on pharmacy practice. In the Netherlands and Belgium, a large proportion of pharmacists are not only asked to dispense lethal drugs, but they can be expected to offer advice to physicians. Inevitably, such legislation will conflict with the personal beliefs of some pharmacists. In the light of this international experience, the second article will examine the critical issues that will face pharmacists in the UK if assisted suicide were to be legalised here.

Statement This article was commissioned by Eileen Neilson, head of policy development, Royal Pharmaceutical Society, on behalf of the Society’s Law and Ethics Committee.

References

1. Lau HS, Riezebos J, Abas V, Porsius AJ, De Boer A. A nationwide study on the practice of euthanasia and physician-assisted suicide in community and hospital pharmacies in the Netherlands. Pharmacy World and Science 2000;22:3–9.

2. Onwuteaka-Philipsen BD, Muller MT, Van Der Wal G. Euthanatics: implementation of a protocol to standardise euthanatics among pharmacists and GPs. Patient Education and Counselling 1997;31:131–7.

3. Deliens L, Mortier F, Bilsen J, Cosyns M, Stichele RV, Vanoverloop J et al. End-of-life decisions in medical practice in Flanders, Belgium: a nationwide survey. Lancet 2000;356:1806–11.