GPs and assisted suicide

Be it enacted by the King’s most excellent majesty.

I am sure the recent introduction of the so-called ‘assisted dying’ bills through both Westminster and Holyrood has caused us to reflect again on the interface of medicine, faith, and society. I, therefore, could not ignore the Westminster Bill’s standard introduction quoted above. Surely, part of the majesty and excellence of the King of Kings is evidenced in the perfections of his commands to us to preserve, protect, and respect life.

It may be that if these proposed laws were passed, those of us in primary care may be most affected as the potential ‘coordinating’ doctors. In this blog, I have, therefore, focused initially on the potential impact on primary care before considering the interface with biblical values.

The 4Cs framework described by Starfield and strived for by so many seems a useful framework with which to consider this topic.

First contact. We are indeed privileged to be the entry point for many on their healthcare journeys. This is a moment of vulnerability and trust where the dynamics of power between clinician and patient must be carefully balanced. I wonder if the introduction of assisted suicide legislation risks reopening the door of paternalism. The proposed Bill in England and Wales certainly allows the clinician to exercise their judgment and raise the issue of assisted suicide with a patient. The raising or, indeed, discussion of this issue by a trusted family doctor could be too powerful a signal to ignore. This may then affect the perceived overall reasonableness of such a choice by a terminally ill patient. I would suggest that this place of ‘first contact’ should be a power-neutral place where patients can be assured this subject will not be raised because, legally, it cannot be raised. If successful, the Terminally Ill Adults (End of Life) Bill may foster a distrust that may deter those in need from attending. This would compound their unmet needs for care and subsequent palliative care.

Continuity. One of the greatest joys of general practice is providing a constant, known presence for patients as they experience their own unique health needs. They do not have to tell their story repeatedly. We share in their story. I would suggest that palliative care fits more naturally into this story. Such continuity has been described as of paramount importance in end-of-life care. Rather than ending the story, it seeks to allow continuity in as much comfort as possible. Continuity of relationship between clinician and patient, but more importantly between a loved one and their family. Perhaps such continuity facilitates the depth of interaction necessary for improved symptom control, resolution of issues, healing of relationships, and an understanding and acceptance of their story’s final chapter.

Comprehensiveness. As GPs, we seek to provide care that meets each need in our patients’ lives. This should extend into end-of-life care. In primary care, we are surely best placed to provide comprehensive palliative care with the support of our expert palliative care colleagues. We have a vast array of both pharmacological and non-pharmacological palliative care resources theoretically available to patients. It would be interesting to see what impact the required investment in truly comprehensive and responsive palliative care would have on this debate. It seems clear that when our palliative care colleagues were recently surveyed, they felt the Bill would have a detrimental effect on services.

Coordination. This is our bread and butter. We daily navigate and negotiate care for our patients in an increasingly resource poor NHS. It seems this Bill leaves too many unanswered questions about how we would resource and coordinate such a ‘service’. For clinicians there are training needs, as well as administrative and logistical challenges. How, where, when, who? For patients, there must be robust governance, legal assistance, and capacity assessments. And then there are the unpleasant realities of the practical and ethical complications of a failed or partially complete procedure. Complexity is added to coordination. It is recognised that the needs of patients within primary care are increasingly complex and there is a consequent imperative for enhanced coordination and integration of services. This, therefore, does not seem an appropriate time to be committing resources to the coordination and integration required for the complexities of an assisted dying service.

There are, as outlined above, many cogent pragmatic concerns regarding the provision of assisted suicide. Fundamentally, though, the issue seems to raise an issue that is especially important to us as Christians in primary care. Whole person care. We practice this intuitively, encountering patients as a body/mind fusion; dualist interactionists whose minds remain even as the scaffolding of body and brain disintegrate. Scripture consistently speaks of our whole person comprising of body and soul/spirit. Genesis chapter two speaks of both body and soul. The Lord formed us from the dust and then breathed the breath of life into us. The psalmist speaks of our heart and flesh crying out for the living God. And particularly relevant to this debate, Paul reminds us that even though the external structures of the body deteriorate the inner soul can be renewed.

It could be argued that the proposed legislation focuses more on the physical and less on issues of mind, soul, or image-bearing. Perhaps it would be helpful to encourage our colleagues to consider that the attributes of personhood (agency, ethics, emotion, reason, morality, and aesthetic appreciation) which we value so highly, point to our intrinsic value. We would do well to help them consider if this intrinsic value truly is objective. For if they see it is, it will point to an external source of value that may challenge their concept of patient autonomy in assisted suicide. We may even point them to our Heavenly Father, the author and guardian of life.

There will be many in our profession who, due to such Judaeo-Christian or indeed other religious convictions, do not see patient autonomy as the high point of ethical decision-making. For them to be involved in assisted suicide may run the risk of moral injury – that sustained unease arising from the lack of alignment of moral principles and institutionally required actions. It has been noted that such moral injury can result in feelings of guilt and shame, with some experiencing mental health issues. We have seen this described by healthcare professionals who worked through the COVID-19 pandemic. It feels that as a profession. we are still recovering from the pandemic, and any further risk of moral injury through the introduction of the assisted dying bill should be opposed. Furthermore, protecting clinician wellbeing in this way is known to improve patient care which seems to be our pressing need.

It therefore seems that, as a minimum, clinicians will need to be able to opt out of any involvement in assisted suicide based on conscience. The General Medical Council allows us this provision. CMF’s written evidence to Parliament helpfully states this should also allow us to avoid being complicit in an ‘effective referral’ (referring to a colleague who will refer).

However, I think that for us as believers, the risk is deeper than that of moral injury. In his letter to the Romans, Paul describes the end result of silencing our conscience, to act against it, as sin. Jeremiah foresaw a time when God would write his law on our minds and put it in our hearts. These truths seem particularly relevant to our personal, professional and societal response to this debate.

So yes, in order to protect primary care, there are persuasive reasons for opposing the proposed legislation. However, for us, the greater concern is the threat to the ‘characteristic’ most worth protecting: our image-bearing, intrinsic value. And the greatest risk is that the idol of autonomy diverts our submissive gaze from the most excellent majesty of our King.

Dr Gordon Macdonald is a GP in the Greater Glasgow area.