The Pharmaceutical Journal
Vol 277 No 7428 p639-640
25 November 2006

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Pharmacy and assisted suicide: what can be learnt from experience abroad?

In the second of two articles, Colin Meek reflects on experiences abroad and explores the issues that will face pharmacists in their practice if physician-assisted suicide or euthanasia were to become legalised in the UK

Physician-assisted suicide series

Few issues polarise opinion as much as the proposal to legalise euthanasia or physician-assisted suicide (PAS). The House of Lords Select Committee set up in March 2004 to examine the Assisted Dying for the Terminally Ill Bill received more than 14,000 written submissions on the issue and heard from professional witnesses who were deeply divided on what impact legalisation would have. When the House of Lords voted to delay the revised Bill’s progress in May 2006 more than 80 peers turned up to speak in an impassioned debate. While some described the Bill as “morally indefensible”, Lord Joffe, the peer who tabled the Bill, said nobody should have to endure unbearable suffering.

But what may be lost in the heat of debate is the impact a change in the law may have on pharmacy and medicine, and on how doctors and pharmacists communicate with each other and with their patients. The first article in this series (PJ, 18 November, p614) examined how pharmacists are responding to laws in countries where PAS, euthanasia or both are legal. This article will draw on that experience to explore the key issues that will face pharmacy practice in the UK if PAS is legalised here.

Pharmacy in law

The various laws that legalise euthanasia or PAS or both in the Netherlands, Switzerland, Belgium and Oregon in the US vary hugely in what they say about pharmacists. In the Netherlands, the Dutch Termination of Life on Request and Assisted Suicide (Review Procedures) Act refers only to doctors. In Switzerland, none of the various laws that impact on the patient’s ability to seek help with suicide defines the role of the pharmacist or offers pharmacists legal protection from prosecution.

In Belgium, however, revisions made in 2004 to the 2002 Euthanasia Act state that pharmacists who deliver drugs for euthanasia do not commit any offence if this is done on the basis of a prescription in which the doctor states that the drug is to be used for euthanasia. Oregon’s Death with Dignity Act guarantees physicians and pharmacists the right to refuse to participate in assisted suicide and, in 1999, the Act was amended to ensure that pharmacists must be informed about the intended use of the drug.

But future legislation to legalise PAS in the UK may define the role of the pharmacist far more precisely and in ways the profession may not necessarily support. In contrast to the approach taken in the Netherlands, Switzerland, Belgium and Oregon, the House of Lords Select Committee report on the Assisted Dying for the Terminally Ill Bill (see Panel right) recommended that any future legislation to legalise assisted suicide should “set out the procedures under which a prescription for lethal medication may be given and the necessary drugs obtained, along with the responsibilities, rights and immunities of the persons involved, such as doctors and pharmacists.”

In the absence of a legal definition for the role of the pharmacist in the Dutch legislation, the Royal Dutch Pharmaceutical Society (KNMP) stepped in to issue detailed best practice guidance. Likewise, guidance given to pharmacists in Belgium and Oregon is not in conflict with the protection and role given to pharmacists in law.

A UK law that precisely defines the “responsibilities, rights and immunities” of pharmacists in relation to PAS, therefore, would be unprecedented and the consequences difficult to predict. Although pharmacists in the UK are likely to want protection from prosecution or legal protection for a conscience clause, the proposal for a rigidly defined role in relation to PAS may be more controversial. Such legislation may, for example, conflict with best practice guidelines that the profession may want to adopt or lack the flexibility to encompass new pharmacist roles involving, for example, prescribing or specialisation in end-of-life care.

Guidance for pharmacists

Just as the legislation on PAS and euthanasia varies greatly from country to country so, too, does the guidance that pharmacists can turn to. The guidance adopted by the KNMP in the Netherlands describes best practice for those who choose to participate in PAS and euthanasia and also affirms the right of the pharmacist to refuse to dispense. For example, the guidelines state that pharmacy technicians must not be involved in euthanasia and that the drugs must be handed personally to the physician who prescribed them. But research described in the first article shows that compliance with these guidelines may be poor.¹

The guidelines adopted by the American Society of Health-System Pharmacists (ASHP) do not cover best practice. Instead, these guidelines aim to provide pharmacists with a framework for their participation in the debate about the appropriate care of patients at the end of life.

A completely different approach has been taken in Belgium, where revisions made to the 2002 Act have given pharmacists legal protection. Here, doctors, pharmacists, experts in euthanasia, pharmaceutical wholesalers and government representatives have co-operated in a task force to devise detailed best practice guidelines for pharmacists and doctors. These describe precisely how drugs for euthanasia should be prescribed, dispensed, delivered, administered and returned if they are not used.

Survey research shows that 90 per cent of UK pharmacists want to see best practice guidance made available on PAS in the event of a change in the law.² If legislation looks likely then two of the first questions the profession will need to answer will be what guidance should be made available to pharmacists and who should draft it.

The conscience clause

Pharmacists in the Netherlands, Belgium and Oregon all have a right to refuse to dispense drugs for euthanasia and PAS. That right is either protected by law or recognised by professional guidance or both. What is less clear is how that right to refuse is balanced with safeguards to make sure that the patient’s wishes are respected. Guaranteeing the pharmacist a conscience clause means that patients, or their agents, may present a prescription to a pharmacist who may refuse to dispense the drug, resulting in a situation that would be distressing for the pharmacist and the patient or the patient’s agent.

It is often assumed that the conscience clause is balanced by placing an obligation on pharmacists who refuse to dispense to refer patients or their agents to other pharmacists who will dispense. There may, however, be other strategies that can work better for patients, pharmacists and doctors.

The right to refuse to dispense abortifacients and contraceptives has sparked heated debate among pharmacists in the US. Some argue that, as something cannot be ethical or moral by degrees, pharmacists who refuse to dispense medicines for assisted suicide should not have to refer patients to other pharmacists who will. Others argue that the conscience clause creates a “crisis for the profession” as this is in conflict with what some states (such as Oregon) take to be the interests of the terminally ill.

Rules put in place in Oregon, however, have solved these ethical dilemmas. There the Death with Dignity Act conscience clause is balanced by a duty imposed on doctors that means they must personally find out if the pharmacist is willing to dispense the drug for the purposes of PAS. This rule should mean that patients will only be put in touch with pharmacists who are willing to co-operate. Rules in Belgium are similar and mean that patients are not directly involved in obtaining the drug.

Most UK pharmacists would support a conscience clause in the event of a change in UK law to allow PAS.2 Rules put in place in Belgium and Oregon show that this can be delivered without making the patient responsible for finding a pharmacist who is willing to co-operate.

Refusal to dispense

Evidence from the Netherlands shows that ethical concerns are not the only reasons why pharmacists refuse to dispense drugs for PAS or euthanasia. One study published in 2000 found that 10 per cent of community pharmacists in the Netherlands have refused to dispense euthanasia drugs. The reason most often cited by the pharmacist was that the doctor had not followed the KNMP guidelines.¹

In Belgium, a pharmacist can refuse to dispense if he or she is suspicious that the intended use of a drug is euthanasia, but the prescription does not make this clear.

Pharmacists in the UK may be given a right or duty to refuse to dispense if doctors fail to meet their professional obligations. If a change in the law is likely, pharmacists here will need to decide when they would refuse to dispense drugs for PAS or whether they should assume that all prescriptions for lethal drugs are valid.

The role of professional bodies

One study published in Pharmacy World and Science in 2000 found that a proportion of pharmacists were breaking professional guidance by, for example, involving pharmacy technicians in dispensing drugs for PAS or euthanasia.¹ While professional guidance in Belgium is the most comprehensive, the Belgian Pharmaceutical Association has no plans to monitor compliance with this best practice statement.

If, following a change in the law in the UK, the profession draws up best practice guidance the Royal Pharmaceutical Society will need to decide if compliance with that guidance should be monitored.

Administration of lethal drugs

Concern exists about how lethal drugs are administered in the Netherlands and Oregon. It was reported in 1992 that in the Netherlands GPs did not always perform euthanasia and PAS in accordance with professional guidelines. Sometimes less appropriate drugs were used, dosages were too low or they were administered inappropriately and that this led to a significant number of complications.³

The House of Lords Select Committee Inquiry into assisted dying heard the claim that the complication rate during PAS cases was between 15 and 25 per cent in Oregon but that these complications were not reported. The inquiry also heard that in Oregon 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 is willing to make recommendations on drugs for assisted suicide because of the fear of litigation.

More recently, however, pharmacists have put in place detailed protocols for the prescription and administration of drugs for euthanasia in North Holland and detailed guidance on the administration of lethal drugs is now also available to pharmacists and doctors in Belgium.

Again, markedly different guidance is available to doctors and pharmacists on drug administration in the countries where PAS or euthanasia are legal. If there is a change in the law in the UK to allow PAS it is likely that doctors and pharmacists will have to play a pivotal role in drafting best practice guidance on the administration of lethal medicines.

Issues for UK pharmacists

The way PAS or euthanasia might affect pharmacists will depend on how the law or professional guidance defines the role of the pharmacist and what guidance is made available. But the international experience described here shows that less obvious factors can also have a big impact such as:

· How the pharmacist’s right to a conscience clause is balanced with safeguards that make sure the patient’s decision is respected

· In what circumstances participating pharmacists should refuse to dispense

· The role that professional bodies adopt

· What mechanisms are put in place for the supply and administration of lethal drugs and their control

Research suggests, however, that pharmacists in the UK are divided on what responsibilities and duties they should have in relation to PAS and that a similar divide exists among pharmacists who would be willing to dispense drugs for PAS. A survey of UK community pharmacists published in 2000 found that 25 per cent did not want to know if the intended use of a prescription was for PAS and 38 per cent said it was appropriate for a physician not to inform the pharmacist about the nature of a prescription to be used for PAS. On the other hand, 53 per cent said it was their right to be told when they were being involved in PAS.²

Whatever the conclusion of that debate within the profession, what is certain is that pharmacists have an opportunity to shape future legislation and the way PAS may be performed in the UK, rather than have the legislation shape pharmacists’ involvement in ways that may not represent best practice or be in the best interests of patients.

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. Hanlon TRG, Weiss MC. British community pharmacists’ views of physician-assisted suicide (PAS). Journal of Medical Ethics 2000;26:363–9.

3. 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.