Guidelines for Physician-assisted Suicide

Guidelines for Physician-assisted Suicide 2024 (PAS)

?Raphael Cohen-Almagor

As the British Parliament is considering legislating physician-assisted suicide, here are the guidelines I devised following research in The Netherlands, Belgium, Switzerland, the United Kingdom, the United States, Canada, Australia, New Zealand and Israel during the past 34 years.

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Guidelines for Physician-assisted Suicide 2024 (PAS)

Raphael Cohen-Almagor

§? A patient may request and lawfully be provided with?assistance to end his or her own life. This is provided that:

(a)? The patient suffers from an intractable, incurable, irreversible condition that cannot be reversed or remedied and the prognosis is that his/her life expectancy, even if receiving medical treatment, will not expected to exceed six months

(b)? The diagnosis was confirmed by at least one more expert for the condition from which the patient suffers

(c)? The patient is aged 17 or over[1]?????????????????????????????????????????????????

(d)? ?The patient expressly wishes to end his or her life and has made a signed declaration to that effect, as is required in Belgium[2] and as is proposed by Lord Falconer (the Oregon statute requires both oral and written declaration)

(e)? The patient has been ordinarily resident in England and Wales for at least one year.

§? The expressed wish to die should be voluntary, made in a sound mind, and signed in the presence of a witness who is not related to the patient’s family nor to the medical team that treats him/her.[3]

§? The decision should not be made by the patient’s family or as a result of family pressures. Some families can make the decision to end life because they feel overwhelmed by the patient’s illness.[4] Many people cannot cope with the fact that their loved one is dying. For these reasons, the PAS decision has to be reached without any pressures.

§? PAS should not be rushed. The patient should state this wish repeatedly over a period of time. It is suggested that a period of not less than 14 days has to elapse since the day on?which the person’s declaration took effect. This recommendation is similar to the one invoked in laws and guidelines in Oregon (15 days), Belgium (one month) and as is proposed by Lord Falconer (14 days).

§? Social workers need to confirm that the request to die is voluntary, free as much as possible from external pressures.

§? Second opinion: An expert should examine the patient’s medical files, confirm the diagnosis and verify that the patient’s desire to die is genuine and voluntary, and that the attending physician was correct in the diagnosis that s/he made that the patient is, indeed, suffering from an incurable and irreversible disease. The Oregon Death with Dignity Act requires that a consulting physician shall examine the patient and her relevant medical records and subsequently confirm, in writing, the attending physician’s diagnosis that “the patient is suffering from a terminal disease.” Furthermore, the consulting physician must verify that the patient is capable, is acting voluntarily, and has made an informed decision.[5]

§? It is advisable that the identity of the consultant be determined by a committee of specialists who will review the request for physician-assisted suicide. Such is the case in the Netherlands.[6]

§? The attending physician and the independent consultant are required to agree that the patient is dying.

§? Palliative care: Requests to die might be influenced by pain and suffering, physical and mental; therefore, palliative care is mandatory prior to physician-assisted suicide.[7] A palliative care specialist will inform the patient about relevant measures to help the patient cope with pain and suffering, including comfort care, hospice care and pain control. The Oregon statute requires that the attending physician explores, together with the patient, all feasible alternatives for treatment, including comfort care, hospice care and pain control. The Australian Northern Territory law held that a medical practitioner shall not assist a patient if there are palliative care options to alleviate suffering to levels acceptable to the patient. The Israeli Dying Patient Law stipulates that the responsible physician will make sure that everything possible is done in order to alleviate the patient’s pain and suffering, all in accordance with the principles of palliative care. The proposed British Assisted Dying Bill (2014), prepared by Lord Falconer of Thoroton, requires that the patient “has been fully informed of the palliative, hospice and other care which is available to that person”.[8]

§? The patient must be informed of his or her situation, the limited prognosis for recovery, the expected escalation of his/her disease, and the degree of suffering that may be involved. There must be an exchange of information between physicians and patients. The laws in Belgium and Oregon contain these provisions.

§? Requests for PAS should be initiated by the patient. Such a sensitive request should not be initiated by the medical team as such initiative is likely to compromise the voluntariness of the decision.

§? The decision-making process should include the patient, his/her loved ones (family and/or close friends), physicians, a psychologist and a social worker. Perhaps a lawyer should be consulted as well. Section 2 of the Oregon Act requires that the written request for medication to end one’s life be signed and dated by the patient and witnessed by at least two individuals who, in the presence of the patient, attest to the best of their knowledge and belief that the patient is capable, is acting voluntarily, and is not being coerced to sign the request.[9]

§? Shortly before PAS is performed, the attending physician and a psychiatrist should visit the patient to confirm that the patient wishes to go ahead with the procedure. They should make it clear to the patient that s/he has the right to forfeit the request without any problems. The law of the Northern Territory in Australia and the laws of Oregon and Belgium explicitly accentuate this point. The revocation need not be in writing. Verbal declaration is sufficient.

§? Only physicians should perform PAS.[10]

§? Nurses are not allowed to perform PAS.[11]

§? The practice of terminal sedation, sedating patients until death without their and their beloved people’s consent, should not be allowed.[12]

§? It is emphasized that physician-assisted suicide will be conducted as a last resort, after exhausting all treatment options that could potentially bring the patient some relief and reduce his/her suffering.

§? Physicians will be allowed to use only the lethal medications authorized by the Ministry of Health.

§? The physician who performs PAS should not receive a special fee. This in order to rule out incentives for PAS at the expense of other procedures.

§? The decision-making process leading to death should be documented fully and the happenings on the day of the procedure should be recorded in detail.

§? As a control mechanism, pharmacists should be required to file a report every time lethal medications are sold. Then it would be possible to track down the medication to the physician, and keep track of how many times physician-assisted suicide was performed.?

§? Physicians should not be coerced into taking actions that conflict with their conscience. No coercion should be involved in the process. Conscientious objection should be respected as is stipulated in Israeli law and as is proposed by Lord Falconer.

§? Physicians who provide aid-in-dying as specified above should not be guilty of an offence.

§? A Monitoring and Control Committee should be established to review all PAS cases and see that they were performed in accordance with the said guidelines.

§? Annual Reports: Data about all PAS cases will be made public and published annually. In the Netherlands, the Termination of Life on Request and Assisted Suicide (Review Procedures) Act requires that the regional review committees submit annual reports.[13] The reports should be made available to the public. Discussions and debates about their findings should be promoted and encouraged.

[1] R. Cohen-Almagor, “Should the Euthanasia Act in Belgium Include Minors?”, Perspectives in Biology and Medicine, 61(2) (Spring 2018): 230-248.

[2] Belgian Act on Euthanasia, Chapter II, Section 3, no. 1, https://www.ethical-perspectives.be/viewpic.php?LAN=E&TABLE=EP&ID=59

[3] R. Cohen-Almagor, “First Do No Harm: Euthanasia of Patients with Dementia in Belgium”, Journal of Medicine and Philosophy, 41(1) (2016): 74-89.

[4] John Hardwig, “Families and Futility: Forestalling Demands for Futile Treatment”, J. of Clinical Ethics 16(4) (2005): 328-337; R. Cohen-Almagor, “Fatal Choices and Flawed Decisions at the End-of-Life: Lessons from Israel”, Perspectives in Biology and Medicine 54(4) (2011): 578-594; Lara Pivodic, Lieve Van den Block, Koen Pardon et al., “Burden on Family Carers and Care-related Financial Strain at the End of Life: a cross-national population-based study”, European Journal of Public Health 24(5) (October 2014): 819-826.

[5] Oregon Death with Dignity Act, https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Pages/ors.aspx

[6] M.C. Jansen-van der Weide, B.D. Onwuteaka-Philipsen, and G. Van der Wal, “Implementation of the Project Support and Consultation on Euthanasia in The Netherlands (SCEN)”, Health Policy 69(3) (2004): 365–373; R. Cohen-Almagor, Euthanasia in the Netherlands; KNMG, The Role of the Physician in the Voluntary Termination of Life (Amsterdam: Koninklijke Nederlandsche Maatschappij tot bevordering der Geneeskunst [KNMG], 2011); Marianne K. Dees et al., “Perspectives of Decision-making in Requests for Euthanasia: A qualitative research among patients, relatives and treating physicians in the Netherlands”, Palliative Medicine 27(1) (2012): 27–37. See also Steun en Consultatie bij Euthanasie in Nederland (Support and Consultation for Euthanasia in the Netherlands) is a programme organised by The Royal Dutch Medical Association (KNMG). SCEN physicians are specially trained and certified by the KNMG. In Belgium, a specialist committee (LEIF) exists only in Flanders, not in Wallonia. Consequently, the euthanasia act does not prescribe that the consultant must be a LEIF physician. Cohen et al argue for improving the present consultation system in Belgium. J. Cohen, Y. Van Wesemael, T. Smets et al., “Nationwide survey to evaluate the decision-making process in euthanasia requests in Belgium: do specifically trained 2nd physicians improve quality of consultation?”, BMC Health Services Research, 14 (2014): 307.

[7] M. Laporte Matzo, Witt Sherman, D., Palliative Care Nursing - Quality Care to the End of Life (Dordrecht: Springer-Kluwer, 2001); Arif H.?Kamal,?Thomas W.?LeBlanc,?and Diane E.?Meier,?“Better Palliative Care for All-Improving the Lived Experience with Cancer”, JAMA (31 May 2016); Final report on the SAMS funding programme 2014–2018, Research in Palliative Care (Swiss Academy of Medical Sciences, 2020).

[8] Assisted Dying Bill (2014), Section 3 “Declarations”.

[9] Oregon Death with Dignity Act (1997).

[10] In Switzerland, aid in dying is commonly provided by lay persons. The law does not insist that only physicians do this. See Meinrad Schaer, “The Practice of Assisted Suicide in Switzerland,” EXIT Report, 2010 https://www.finalexit.org/dr_schaer_switzerland_1996-97_report.html; Samia Hurst and Alex Mauron, “Assisted Suicide and Euthanasia in Switzerland: allowing a role for nonphysicians”, BMJ 326 (2003): 271-273; Marc-Antoine Berthod et al, “Assisted Suicide in Switzerland: the advent of a ‘pattern for misconduct’”, Swiss J. of Sociology, 46 (2020): 1-17.

[11] In the Netherlands and in Belgium, there were cases where nurses performed euthanasia. See R. Cohen-Almagor, Euthanasia in the Netherlands; G.G. van Bruchem-van de Scheur,?A.J. van der Arend, H. Huijer Abu-Saad et al, “Euthanasia and Assisted Suicide in Dutch Hospitals: the role of nurses”, J. Clin Nurs 17(12) (2008): 1618-1626; Els Inghelbrecht, J. Bilsen, F. Mortier, L. Deliens, “The Role of Nurses in Physician-assisted Deaths in Belgium”,?Canadian Medical Association Journal (2010); J. Bilsen, L. Robijn, K. Chambaere et al, “Nurses’ Involvement in Physician-assisted Dying under the Euthanasia Law in Belgium”, International Journal of Nursing Studies (2014).

[12] Raphael Cohen-Almagor and E. Wesley Ely, “Euthanasia and Palliative Sedation in Belgium”, BMJ Supportive and Palliative Care, 8(3) (2018): 307-313, https://spcare.bmj.com/content/8/3/307?ijkey=OTelnqlPkW1VJBe&keytype=ref

[13] In Belgium, the Federal Control and Evaluation Commission is required to submit a report every two years. However, the Chair of this Commission is an ardent proponent of euthanasia. The reports are very positive about the existing practice.