Legalisation of assisted dying could place nurses in a tricky position
Changing the law is unnecessary and potentially dangerous, argues Steve Fouch
Nurses are already actively involved in the discussions with our patients and their families around end of life decisions and planning. Furthermore, experiences from the Netherlands and Belgium, which have had euthanasia legislation for several years, suggests that nurses will also end up taking key roles in assisting in the administration of lethal medication. We need to be aware of the issues before we find ourselves taking on roles at odds with the principles of the profession.
Legislation considered in the UK parliament during 2014 would have legalised assisted dying in strict circumstances. Two medical practitioners would have had to sign off on the decisions, stating that the patient is terminally ill with less than six months to live and is mentally competent. And herein lie several problems. For example, some campaigners for euthanasia are already complaining about this narrow focus, as it excludes those living with mental illness, dementia or disability, as well as other people who might want assisted suicide.
Thus, someone with a terminal condition and a related depressive illness would be denied what is permissible for someone with only the physical condition. This imposes a mind-body dualism that not only contravenes modern scientific thinking, but more importantly does not reflect the reciprocity of mental and physical symptoms experienced by patients.
Should such a law be passed, it is likely (as has happened in the Low Countries) that there will be ongoing pressure for incremental extension. In Belgium and the Netherlands we have seen the continual expansion of the law, including the recent legalisation of euthanasia for children in Belgium, and inclusion of patients in comas and with dementia in the Netherlands. Dutch and Belgian doctors and legislators are growing increasingly concerned about how the boundaries and criteria of assisted dying are being continually pushed back.
Furthermore, anyone working in palliative care (or most branches of medicine for that matter) will know that terminal prognoses are seldom accurate, and most doctors are unwilling to offer precise timescales.
People may understandably fear pain and suffering in the end stages of an terminal illness, but most pain and other symptoms in terminal illness can be well managed by good palliative care. Others fear a loss of dignity and autonomy, but again good nursing care and involvement of patient and family in care planning can address most key concerns. Where there is good palliative care, the requests for assisted death are extremely rare.
Disability rights groups do not want such legislation, arguing that it would put those living with disabilities at risk by removing essential legal safeguards and labelling their lives as less valuable. The pressure to ask for an assisted death may well come from close relatives, many with kind motives, but a minority may have less care and concern for an elderly relative who may be worth more dead than alive. As advocates for our patients, do we really want to be having to discern the real motivations behind requests for assisted suicide?
Many feel that there are wider problems with the whole concept of assisted suicide. About 3% of deaths in the Netherlands are now from euthanasia or assisted suicide. Evidence from Oregon suggests that the numbers seeking assisted suicide will continue to mount year on year, much as has happened in Holland and Belgium. If we had the same proportion requesting and receiving assisted suicide in England and Wales as in Oregon, we could have 1,200 or more cases each year just to begin with.
The reality is that the UK has arguably the best palliative care in the world. It could be better resourced and more accessible to all patients in all settings. That is certainly a cause for which all nurses should be advocating strongly. However, for terminally ill people, assisted suicide to avoid suffering at the end of life is unnecessary. It is worth noting that the standards of palliative care in the countries where euthanasia and assisted suicide are legalised are often not at the same level as the UK. Could assisted suicide undermine our palliative care standards in the long term?
And if we see incremental extension to other groups where care and support is currently less well resourced, including older people and those living with disability, mental illness or dementia, the economic and social pressures for people to end their lives will only grow.
The British Medical Association and Royal College of GPs, after consultation with members, still remain strongly opposed to assisted suicide. The RCN takes a neutral position. Individual nurses are beginning to realise the implications, though, as demonstrated in a recent paper by McCrae and Bloomfield (2013), on the likely impact on mental health nursing.
As a profession, nursing cannot afford to ignore the vocal minority who are striving to dismantle legal protections for the most vulnerable people in our society.
About the author
Steve Fouch is spokesperson for the Care Not Killing Alliance and head of nursing at the Christian Medical Fellowship (CMF). He has a background in community nursing, specialising for several years in HIV and palliative care.