Caring for patients “from cradle to grave” was the founding principle of the NHS. It was a solid mantra – so solid, in fact, that it continues to guide today’s healthcare professionals above all else. 

But times have changed and so has the meaning of patient care. Although life expectancy has increased dramatically since the NHS was established in 1948 – from 63 to 83 years for females in England today – these final years are not necessarily being lived in good health. This has made quality of life a more important issue than ever for healthcare professionals. Does patient care mean allowing terminally ill patients to battle on in pain until the bitter end? Or is it kinder to offer relief in the form of euthanasia, despite the ethical and legal complexities involved?

These are the questions currently being debated in the Scottish Parliament, where MSPs are deciding whether to adopt an assisted suicide bill. Under the proposals, doctors and pharmacists could prescribe and dispense lethal drugs to terminally ill patients deemed eligible for assisted suicide. The issue has also made its way further south – in England, the House of Lords is tackling assisted dying legislation. 

The outcomes will potentially be the most significant in healthcare legislation in recent years. With dedicated campaigners on both sides of the euthanasia debate, any decision will provoke strong reaction – and could change what it means to provide patient care for doctors and pharmacists alike. 

---

Euthanasia laws around the world

● The Netherlands was the first country to legalise euthanasia in 2002. There are strict rules that doctors must adhere to – they must be satisfied that the patient’s request for euthanasia is voluntary and well-considered, and that the suffering is unbearable with no prospect of improvement. 

● Belgium became the second country to legalise euthanasia in 2002. Doctors can help patients end their lives when they freely express a wish to die – however, the doctor has to be present at the patient's bedside when the wish is expressed. Last year, Belgium became the first country to legalise euthanasia for children. There is no age limit, but they need the consent of their parents and must be suffering and close to death. 

● In the US, the stance on euthanasia varies. In five states, doctors can legally prescribe lethal doses of medicine. Assisted dying has been legal in Oregon since 1997, but it is estimated that fewer than 50 people a year have used the law to end their lives. 

● Switzerland allows assisted suicide within certain circumstances, as long as it is in the interest of the patient. Swiss law has also allowed the creation of organisations such as Dignitas and Exit, which attract visitors from overseas wishing to end their lives. 

● In the UK, euthanasia is still regarded as manslaughter or murder and is punishable with a prison sentence. 

---

A humanitarian argument

Charities and campaign groups have long called for assisted dying to be legalised in the UK as in the Netherlands and Belgium (see Euthanasia laws around the world, above). The humanitarian argument is well-known. Dignity in Dying, a charity that supports the legalisation of assisted suicide, firmly believes a change in law would lessen the suffering of people with long-term illnesses. 

But the charity's chief executive Sarah Wootton points out it would also keep people safer. Due to the forbidden nature of euthanasia, people often obtain illegal drugs from overseas to take control of their own death, she explains. 

“This is unregulated and dangerous – a person who takes this drastic measure has no idea if they may be left in more pain afterwards,” Ms Wootton says. “It is clear that a safeguarded and transparent law that involves healthcare professionals is the right way forward.” 

The British Humanist Association echoes the argument. “So long as there are strict safeguards, it is our moral duty as a society to give assistance to mentally competent adults who are suffering incurably and have made a clear and informed decision to end their life,” says Pavan Dhaliwal, the charity’s director of public affairs and campaigns. 

Unintended consequences

It's hard to argue against the basic principle. But anti-euthanasia groups believe a change in law could have unintended consequences. Care Not Killing is one of these groups. The UK-based charity campaigns for better palliative care rather than the legalisation of assisted suicide, which it believes could result in abuse of the system – putting pressure on vulnerable people to end their lives. It is clearly not alone in its views. Care Not Killing has organised a petition urging MSPs to vote against the assisted suicide bill, which has garnered 10,000 signatures so far. 

These potential pitfalls are being carefully considered by those in government. Last July, a debate around assisted suicide split the House of Lords and attracted many protesters across the political spectrum. 

Baroness Campbell of Surbiton, who chairs the British Council of Disabled People and has spent her life campaigning for their rights, said the bill “frightened her” due to its potential for abuse. Any new law would apply only to someone who had made an informed choice driven by their own interests, rather than pressure from others. But Lord Howarth of Newport, a Labour peer, raised a valid question over whether health professionals could tell whether a patient was being coerced into assisted dying. 

---

What C+D readers think

---

The healthcare viewpoint

There are clearly strong feelings on both sides of the argument. The campaigners and MPs may have the power to sway the debate one way or the other but, ultimately, the success of any change in law will lie in the hands of healthcare professionals. 

They will have the power to decide whether to perform assisted suicide – even vocal support groups such as Dignity in Dying and the British Humanist Association believe healthcare professionals should have the power to opt out if they wish.

So far, there has been a mixed reaction to the proposals among the healthcare community. Doctors have strong concerns over helping patients die, if representative body the British Medical Association (BMA) is anything to go by. “The BMA is opposed to all forms of assisted suicide and euthanasia, a policy that has been formed through democratic process,” says Peter Bennie, chair of BMA Scotland.

The pharmacy community, on the other hand, has taken a far less rigid view. The Royal Pharmaceutical Society (RPS) Scotland has so far remained neutral on the Scottish Parliament’s assisted suicide bill. It has simply stressed that, by dispensing prescriptions for lethal medicines, pharmacists would play an important role in the process. 

“We want to ensure politicians understand that the pharmacist’s role reaches far beyond supply, and that the pharmacist would need to work in partnership with medical colleagues,” RPS Scotland says. 

“As healthcare professionals, the concept of dispensing a prescription that would end someone’s life is quite outside the realm of routine pharmacy practice and raises many ethical and practical questions.” 

This neutral stance perhaps stems from the general uncertainty among pharmacists on the issue. A C+D poll of 231 readers earlier this year revealed 34 per cent would assist in
a legal suicide, while 48 per cent were against it and 18 per cent wanted more details. Speaking to pharmacists, it appears that views on the subject are largely formed by personal experience. 

Stephen Eggleston, community pharmacist working in Worcestershire, has witnessed patients suffer due to terminal illness. These experiences have led him to support assisted suicide. "We have all seen patients decline – from being robustly healthy in their early 70s to frail and possibly bed-bound old people, who die often without a shred of dignity. I have found it incredibly difficult to watch patients endure the humiliation this level of dependence imposes,” he tells C+D.

Mr Eggleston points out that, unlike humans, animals are put to sleep if they are suffering without hope of recovery. “It has been said many times that if we treated our pets the way we are forced to treat our family, we would be arrested and charged with cruelty,” he says. 

Locum dispenser Benjamin D’Montigny agrees assisted suicide is “the hardest kindness”. “I am of the opinion that allowing someone to suffer against their will is morally unacceptable,” Mr D’Montigny says. “I believe that our personal feelings should not stand in the way of clinical judgement.”

---

The Scottish proposals

● Only those suffering from a terminal or life-shortening condition are eligible for assisted suicide.

● Interest in assisted suicide must be stated at least a week before a patient can formally request to end their life. 

● The formal request must be backed-up by two doctors, and followed by a 14-day ‘cooling-off’ period.

●  If the request is agreed, a ‘facilitator’ – unknown to the patient – will give them a medicine that has been dispensed by a pharmacist who has opted into the process. 

● The pharmacist will be included in the planning process to ensure the safe and timely dispensing of any prescriptions as well as ensuring that all legal requirements have been fulfilled.

● If the prescription is not used within two weeks, it is returned to the pharmacy where it was dispensed. 

Source: Assisted Suicide (Scotland) bill

 

---

Doubt is in the detail

Perhaps the doubt that remains in many pharmacists’ minds is how the system would work in practice. Mr D’Montigny stresses there must be “a robust safeguarding system in place” to ensure patients are capable of making the decision, and a cooling-off period. The Scottish bill does specify that patients must wait at least three weeks before their initial request for assisted suicide is acted upon (see The Scottish proposals, above), but there remain some questions over whether patients could be coerced into ending their own lives.

Locum pharmacist Alisdair Jones makes the point that there needs to be “adequate provisions in law” to prevent abuse of the system and clear details on how it would work in practice, including the role of the pharmacist. If these elements were clarified, he would be in support of legalising assisted suicide. “I think that – especially in instances where patients are terminal and perhaps in severe pain – it would seem the kinder course of action to facilitate the patient’s decision to end their own life,” Mr Jones says. 

Fiona McElrea, owner of Whithorn Pharmacy in Wigtownshire, Scotland, stresses that the issue raises a number of questions. She feels she needs to look at the Scottish bill in more detail before making a decision, but says there is an emotional distinction between “end-of-life care” and “assisted suicide”. “The wording – assisted suicide – is very hard-hitting and evocative,” Ms McElrea explains. “Are you helping someone die or are you giving them dignity and allowing them to pass away pain-free?” 

Ultimately, she believes the issue comes down to patient choice – and therefore supports the bill in principle. “If the patient has a terminal illness and has stipulated that they want to die at home, everyone makes sure that is done. So, should a patient decide when they want to die?” Ms McElrea points out. “I would much prefer to be involved than wash my hands and say no. We do have a responsibility to help patients at the end of their life.” 

Whether you agree or not, pharmacists should prepare to take a stance on the issue. This year has already heralded landmark changes to medical law – just last month, the UK became the first country to allow the creation of three-parent babies. Although this law focuses on the beginning of life, it seems inevitable that one focusing on the end of life is fast approaching. As Sarah Wootton of Dignity in Dying says, the only thing preventing a change in law is time. And, in time, healthcare professionals will need to decide exactly what patient care means to them.