BGS Position Statement on Assisted Dying (Physician Assisted Suicide and Voluntary Active Euthanasia)
Position statement
A position paper is a thing which tells you what position to take on a thing. A position paper is a thing which tells you what position to take on a thing. A position paper is a thing which tells you what position to take on a thing. A position paper is a thing which tells you what position to take on a thing.
Date Published:
30 October 2024
Last updated:
30 October 2024 This statement sets out the BGS position on assisted dying, our priorities for end of life care, and our concerns that effective legal safeguards cannot be created to protect older people from unwarranted harms.
Introduction
This statement sets out the BGS position on assisted dying (AD), our priorities for end of life care, and our concerns that effective legal safeguards cannot be created to protect older people from unwarranted harms.
We urge government caution in proceeding with legalisation and assert our expectation to contribute meaningfully to the development of any future law on assisted dying.
We have supported our statement with detail on rationale, clarifying our use of terminology, our stake holding, how we developed our position and setting out the results of a member survey on assisted dying. We have also set out our views on the importance of personalised care, alternatives to assisted dying, de-medicalisation of dying, conscientious objection, respect for patient autonomy and medical paternalism.
The BGS position on Assisted Dying
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Health and social care context
BGS priorities for end of life care
In developing this position statement on Assisted Dying, the BGS has identified the following priorities for end-of-life care in the UK which should be addressed before a change in the law is considered:
- Allowing death due to natural causes at the right time, instead of continuing unwanted interventions aiming to prolong life. This is distinct ethically from the intentional ending of life, even when life is unquestionably coming to an end.
- Improving timely recognition of terminal decline due to underlying disease processes including multimorbidity, advanced dementia and severe frailty. This is consistent with national guidance advocating the timely identification of patients approaching the last 12 months of life to tailor their care according to their individual preferences and wishes.9
- Deploying effective health communication systems to share information regarding individual preferences, including advance care plans incorporating advance decisions to refuse treatment and preferred place of death, also shared with individuals with valid powers of attorney for health and welfare.
- Enabling holistic, multidisciplinary care services to deliver Comprehensive Geriatric Assessment focused on multimorbidity, dementia and frailty, with recognition these conditions cannot always be ameliorated.
- Providing universally accessible, high-quality supportive and palliative care services making provision for those whose terminal decline is due to multimorbidity, dementia and/or frailty which enable individuals to enjoy naturally enduring life by ameliorating unpleasant physical, psychological and existential symptoms which otherwise cause end of life to be distressing and burdensome.
- Shifting societal attitudes to de-medicalise death and supporting wider societal care provision to alleviate distress in terminal disease.
Safeguards for older people
Many BGS members are concerned that effective legal safeguards to protect older people from unwarranted harms cannot be developed. NHS England defines patient safeguarding as, “protecting a citizen’s health, wellbeing and human rights; enabling them to live free from harm, abuse and neglect”, with those receiving care in their own home and people with physical, sensory and mental impairments in need of most protection. 10 This recognises the patient group of primary concern to us, namely older people, as being among the most vulnerable in society. For these reasons alone the BGS has significant stake in contributing to the debate on Assisted Dying and the development of workable safeguards if AD is legalised in the UK and Crown Dependencies.
Our review of international patient safeguarding precedents in jurisdictions currently permitting AD (most notably in Canada) has identified a rapid erosion of safeguards with a shift in eligibility criteria to include conditions without natural death being foreseeable.11 By contrast, the Netherlands is considered to have appropriate safeguards and an established review board. Despite this, 0.1% of deaths in 2022 and 0.05% of deaths in 2023 occurring as part of their AD program were deemed to have occurred without fulfilment of due care criteria, meaning relevant safeguards were not observed.12,13
Our assessment is that the risk for safeguard failure is at least moderate in a modern, well-run AD service which we find to be unacceptable when considering the needs of older people. Notwithstanding the range of ethical stances presented by our members, the BGS therefore expects to contribute meaningfully to inform the development of any future law on Assisted Dying, particularly with respect to developing and implementing meaningful and workable safeguards.
Supporting statements, methodology and rationale
Terminology
Multiple contested terms are used in the Assisted Dying debate. For the avoidance of doubt, the BGS uses the umbrella term Assisted Dying (AD) to refer to health care professionals’ involvement in activities intended to end a patient’s life (adapted from the British Medical Association14), specifically:
- Physician Assisted Suicide (PAS): where healthcare professionals prescribe lethal drugs within defined criteria at the voluntary request of an adult patient with mental capacity to make this request, to enable them to self-administer the drugs to end their own life; and
- Voluntary Active Euthanasia (VAE): where healthcare professionals administer lethal drugs within defined eligibility criteria at the voluntary request of an adult patient with mental capacity to make this request with the intention of ending that patient’s life.
Note: Current proposed Assisted Dying legislation in the UK and Crown Dependencies makes no provisions for patients who lack capacity or for advance decision making.
How we developed our position statement
Background
The BGS’s previous position statement on AD was published in July 2015 and was opposed to the legalisation of Assisted Dying in the UK.15 In 2024, considering advancing debates and proposed UK legislative changes, the BGS reviewed its position statement. Professor Martin Vernon and Dr Andrew Stanners, Co-chairs of the BGS Ethics and Law Special Interest Group, convened a working group (WG) to review current evidence and draft a new position statement.
All BGS members were invited to participate in contributing to the new position statement and the WG was formed from those submitting formal expressions of interest to join. The group comprised colleagues from a range of professional backgrounds including geriatric medicine, clinical academia, general practice, nursing, allied health professions and BGS policy development. There was at least one representative from each of the four UK nations. Within the group there was a diversity of declared professional opinion and positions on AD. However, the WG committed to open collaboration and a shared aim to produce a position statement that was rigorous, informed by evidence and sensitive to the diversity of views existing within the BGS membership.
Timeline
| 10 May 2024 | 13 June 2024 | 11 July 2024 | 2 September 2024 | 23 September 2024 | 24 October 2024 |
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Survey
Surveys conducted by the Royal College of Physicians (2019) and British Medical Association (2020) identified that physicians working in Geriatric Medicine were more likely to be opposed to a change in the law on Assisted Dying.16,17 However, the last time the BGS membership was surveyed on the issue was over twenty years ago.18 BGS WG consensus was that historical data from surveys conducted by other organisations, while informative, could not be utilised to reflect adequately the diverse, multi-professional views of current BGS membership, and that a BGS survey should be developed to inform the new position statement with the following aims:
- Establish the professional views of respondent BGS Members on the legalisation of Assisted Dying.
- Understand the views of respondent BGS members on what position BGS should take on the legalisation of Assisted Dying.
- Understand whether respondent BGS members would be willing to engage professionally in the processes of Assisted Dying for eligible individuals in the event of a change in UK law.
- Understand the level of confidence among respondent BGS members that effective safeguards could be developed to protect the interests of older people in the event of a change in UK law on Assisted Dying.
Survey design, administration and utilisation
The BGS-hosted survey was distributed to all members for anonymised response and utilised a pragmatic design to sample respondent views on specific key thematic issues identified by the WG. Time and resource constraints limited the scope and scale of the exercise which was intended to be informative but not exhaustive. Specifically, the survey was not intended as a membership referendum on the legalisation of Assisted Dying, nor was it intended to be a research exercise. The necessary and intentional limitations of its content and methodology are acknowledged by the WG and drew additional, helpful free-text responses from members which have been considered carefully when drafting the new position statement.
One issue raised by members related to question 9 of the survey, which asked the following:
‘What should the British Geriatrics Society's position be (supportive or opposed) on a change in UK law on Assisted Dying for eligible individuals?’
The question permitted only a binary response and was intentionally included in that format, after careful consideration by the WG, on the basis that proposed legislation is itself binary (to permit or prevent activities) and there can be no ‘neutral’ legal position on the matter of Assisted Dying.
The WG were in consensus in wanting to understand specifically respondents’ answers to the question of whether the BGS should be supportive or opposed to legalisation of Assisted Dying to gauge the level of support or objection. It is fully accepted that this approach is contentious and lacks nuance, a point raised vigorously by some respondents. The WG understand the view that this approach may be methodologically flawed but nonetheless are in consensus that the survey output remains informative.
With these caveats in mind, the data outputs of the survey have been considered by the WG and utilised descriptively to inform the current BGS position statement. For transparency both the survey and its raw data outputs without interpretation are available from the BGS on request for others to draw their own conclusions.
Survey summary outcomes
The survey was conducted throughout August 2024 with the following summary outcomes:
Demography
- A total of 775 responses were received (15.5% of BGS membership) which is a high response rate for a BGS survey of this kind.
- The majority (74%) were from England
- 63% were female and 35% were male
- 50% were consultant geriatricians
- 86% were independent prescribers
- 46% declared their religion as Christian and 39% declared no religion
- 74% declared their ethnicity as white (English, Welsh, Scottish, Northern Irish or British)
Respondent views on a change in UK law on Assisted Dying (PAS and VAE)
- For PAS, 50% were opposed, 33% were supportive and 17% were undecided on a change in UK law
- For VAE 55% were opposed, 27% were supportive and 18% were undecided on a change in UK law
Respondent views on BGS position on a change in UK law on Assisted Dying (PAS and VAE)
- For PAS 60% responded that BGS should be opposed, and 40% responded that BGS should be supportive of a change in UK law for eligible individuals
- For VAE 66% responded that BGS should be opposed and 34% responded that BGS should be supportive of a change in UK law for eligible individuals
Respondent views on professional engagement with the process of Assisted Dying (PAS and VAE) in the event of a change in the UK law
- For PAS 52% were not willing, 27% were willing and 21% were undecided on professional engagement with the process
- For VAE 60% were not willing, 21% were willing and 19% were undecided on professional engagement with the process
Respondent views on confidence in development of effective safeguards for Assisted Dying (PAS and VAE) in the event of a change in the UK law
- For PAS 50% either disagreed or strongly disagreed, 35% either agreed or strongly agreed and 15% were undecided about effective safeguards
- For VAE 53% either disagreed or strongly disagreed, 30% either agreed or strongly agreed and 17% were undecided about effective safeguards
Evidence of BGS members having a legitimate stake in the assisted dying debate
The BGS’s mission is to realise a society where all older people receive high-quality, personalised care when and where they need it. As an organisation, the BGS has a wealth of multi-professional experience of working with older people living with complex health conditions and their resultant care needs. The BGS advocates for the consideration of the specific needs of older people in all areas of public policy where these can be expected to impact significantly upon them and those providing care and support to them.
Globally, cancer is the most common condition reported by those seeking assisted death. However, there have been increasing requests for assisted death because of multi-morbidity, ‘geriatric [frailty] syndromes’ and dementia.11-13
International data from jurisdictions where Assisted Dying is legalised demonstrate consistently the importance of the issue for older people. In Canada (2022), 85% of medically assisted deaths were in people over the age of 65 with the highest proportions in the age categories 71-75 years (15.7%), 76-80 years (15.7%) and 81-85 years (14.5%).11 In the Netherlands (2023), 90% of medically assisted deaths were for people over the age of 60 with the highest proportion of deaths (34.5%) aged 70-80. 13 In Oregon (2023), 82% of medically assisted deaths were aged over 65 (mean age of 75).19 Similar trends are observed in Australia and New Zealand where the mean age for accessing assisted dying services is 70-79 years.20
Personalised care
The BGS recognises the heterogeneity of population ageing, characterised by increasing prevalence of multi-morbidity, dementia and frailty and the increasing requirement for care personalisation to be adopted widely to meet the complex needs of individuals, including at the end of their life.
Personalised care ensures patients have control and choice in the way their care is planned and delivered, and facilitated by healthcare professionals involving patients in key decisions about their care and outcomes.21 It is widely believed that care tailored to what matters to an individual in the last years and months of life will result in better experiences and outcomes for those involved.22
To achieve this at scale, the wider health and social care system must adapt to focus on key care outcomes for individuals by utilising the core principles of personalised care. Anticipating and timely planning for future deterioration is central to this and must incorporate realistic outcome focused discussions contextualised to everyone’s understanding of their condition, prognosis for recovery and their preferences.
More broadly, the need for AD may be reduced by improving existing palliative and end of life care services. There is already evidence that the UK has led the world in achieving a high quality of death, 23 and the Health and Care Act 2022 has introduced a statutory requirement for Integrated Care Systems (ICSs) to provide palliative care services.24 However, the limited capacity of these services and observation that many people feel uncomfortable talking about their end of their life wishes are currently hindering opportunities for many to receive optimal supportive, palliative and end of life care.23
Alternatives to assisted dying (including better end of life care)
Without access to AD, individuals may feel obliged to endure physical, psychological and existential symptoms accompanying the last stages of the end of their life without alleviation. The BGS recognises these concerns as valid, resonating with the experiences of many members’ professional and personal experience where patients in advanced states of multimorbidity, dementia and/or frailty are subject to unnecessary and burdensome treatments during the last months of their life.
In the current era of sophisticated healthcare aimed at prolonging life, where prognostication for older patients with frailty is difficult, and where clinicians work within fragmented, under-resourced and impersonal health systems, there is often default to active treatment for patients whose prognosis is unknown. It is however insufficient to simply oppose a change in the law that would allow AD unless there are genuine and satisfactory alternatives to current practice and service provision that address both fears of loss of control and of being subjected to unwelcome or burdensome medical treatments during the last months of life.
BGS End of Life Care Special Interest Group (SIG) Consensus on Assisted Dying
Note: The SIG statement has been produced in parallel to the BGS AD WG and reached similar conclusions. It is reproduced here in edited form to augment the BGS position statement.
People living with multimorbidity, dementia and frailty face a great degree of diagnostic and prognostic uncertainty, unpredictability and escalating care needs which do not fit into traditional models of palliative care. For this reason, older people have not been well served by current palliative care services. Older people who cannot access adequate health and social care services are not supported to live well and often feel they are a burden on their families, health and social care services and society, creating a negative view of their own worth.
There is a paucity of evidence around the attitudes of people living, and dying, with complex conditions to assisted dying and what impact the legalisation of AD would have on this group.
In addition, the current argument for AD detracts from ongoing efforts to demystify normal dying, and to improve health and social care provision for older people living with complex conditions to live well until they die.
As a professional group looking after people living with complex needs, the SIG has profound concerns about the impact that ageism, loneliness, social isolation, uncertainty and inequitable and inadequate access to health and social care have on older people in the final years of life.
The SIG’s fundamental concern is that constraints in provision of, and difficulty in accessing, health and social care, will impose an expectation for older people to opt for an assisted death.
Demedicalisation of dying
The medicalisation of death entails at least two considerations, namely the role of clinical staff and the use of medication.
Death should be a natural process. As medical practice has advanced, the available range of effective interventions to sustain life has increased. At the same time, there has been a societal shift disenfranchising and isolating many from the natural process of dying, leading some individuals to not accept or understand the reality of death for themselves or their loved ones. Fear of dying and death may lead to demands for medically futile treatments that risk increasing, rather than relieving, suffering.
Even when death is an inevitable consequence of incurable and progressive disease, requests for continuation of treatments which have become ineffective can lead to significant ethical difficulty for clinicians and distress for patients and their families. Recognising and sensitively communicating treatment futility is crucial despite the difficulties entailed.26 This will transition care from restorative to supportive, ensuring the best possible experience at the end of life.
One argument for the legalisation of AD is that a medicalised death may prolong suffering, however, it must be recognised that high quality supportive and palliative care may achieve a comfortable death as an alternative.25 A component of this argument focuses on medically sustained life causing suffering but paradoxically includes an expectation that clinicians would prescribe the desired medications to bring about death and if necessary administer them.26 Arguably this simply replaces one medical intervention with another.
Additionally, it is often assumed that AD should be embedded in healthcare systems, which is not the case in all jurisdictions.26 For example, in Switzerland, AD is a civil act and not a medical act. Similarly, in Austria, doctors review cases but do not participate further.26 There are at least four separate stages where medical input could be required:
- Assessing and prescribing
- Administrating
- Certifying death
- Reviewing the process.
Alongside the BGS’s membership survey on AD, other UK surveys have indicated many healthcare professionals would be unwilling to take part in AD. Surveys have also highlighted that AD presents a risk of moral injury and distress in healthcare professionals.27 However, the implementation of AD does not have to involve clinicians actively, with some jurisdictions using machines or non-clinical staff.26 While it is feasible to remove the need for a clinician at the end of a patient’s life, healthcare professionals remain vital in advocating for patients and providing oversight. Therefore, the BGS asserts strongly the need for their continued participation in the AD debate, and in the development of proposed future legislation.
Conscientious objection
For jurisdictions permitting AD, it is common practice for healthcare professionals to opt out of participating on the grounds of conscientious objection. Arguably, and by comparison, the legal position on conscientious objection has shifted since the 1967 Abortion Act, because of the rights of healthcare practitioners to object to their participation in activities choosing between life and death on grounds of conscience being eroded.28
International evidence suggests that safeguards for medical and nursing staff is crucial to maintain legal, professional and emotional protection for healthcare professionals. In particular, the right to conscientious objection based on moral, religious or ethical grounds is crucial. This includes protections for staff in training: in jurisdictions where AD is permitted, concerns about the impact on career progression have been raised for those with peripheral involvement who are not afforded adequate protection for conscientious objection.29
Some healthcare professionals may object to participation in AD because of conflicts with their personal beliefs or values, or because of the emotional impact. Evidence suggests that healthcare professionals participating in AD can experience conscience-based emotions of ‘moral shudder’ and moral distress.30
The BGS AD survey found that the majority of respondents were both not supportive of the legalisation of AD in the UK, and not willing to professionally engage in the process of AD. The BGS strongly recommends that any future UK law legalising AD should support explicitly healthcare professionals who object conscientiously to direct participation in AD.
Autonomy
Respect for patient autonomy, and the attendant rights this affords people to make their own decisions, is fundamental to the delivery of effective health care. No decision is more profound than whether a person wishes to continue living.
People may choose that they would no longer wish to continue living for medical reasons, such as distressing symptoms, or following acceptance that the end of natural life is close. Alternatively, their reasons may be psychosocial or financial, for example, not wanting to be dependent, or a burden on family or friends, and being unable to do things that they once enjoyed.
Autonomy is complicated. We are not autonomous only as individuals, but as family and social units. Decisions can affect more than one individual and important decisions need safeguards. We must ensure that decisions are free and not coerced, even implicitly, and that they are not driven by untreated illness, such as depression, or unrelieved symptoms. We must also ensure that decisions to seek an assisted death are serious, enduring, and that proper, legally robust procedures have been followed.
For people dying with cognitive impairment, many will lack mental capacity to decide on assisted dying, and the ability to self-administer medication. AD would therefore take place either because of an advance directive or following a request by a legal proxy. The circumstances of a request would require careful legal specification, and the creation of additional safeguards against coercion or exploitation.
Clinical paternalism
The BGS acknowledges the potential for challenge of their current position on AD as being paternalistic by imposing a professional view which restricts the right of an individual to make their own choice.
AD may be regarded as the ultimate expression of individual autonomy, giving individuals a right to determine the point at which their life has reached its end. There is evidence to suggest that in jurisdictions where AD is legalised, autonomy and control (rather than unbearable suffering) are leading reasons for the request of an assisted death.20,31-33
Nonetheless, in taking our current position on AD, the BGS brings a wealth of expertise and experience of working with older people. This includes facilitating and advocating the rights of individuals to make choices regarding their care and treatment through care personalisation while focused on safeguarding the rights of older adults with vulnerabilities. The BGS therefore urges caution when considering legislation to permit AD based entirely on the principle of respect for autonomy, for the following reasons:
- There is a fundamental difficulty in defining a minimum legal and clinically applicable standard for autonomous choice within current UK consent law.
- There is a risk that the autonomous choices of some to end their life may impinge on the rights of others, and justice principles already require some individual societal freedoms to be curtailed to protect the wider interests of others.
- Accepting the high likelihood of professional conscientious objection in the event of AD being legalised, adherence to ethical principlism focused solely on respect for autonomy risks undermining the professional relationships which exist between patients and their health care professionals.
Acknowledgements
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The position statement has been created by a BGS working group comprising the following members:
- Professor Martin Vernon (Co-chair), Consultant Geriatrician and Associate Medical Director, Tameside and Glossop Integrated NHS Foundation Trust and Honorary Professor, University of Chester.
- Dr Andrew Stanners (Co-chair), Consultant in Geriatric Medicine, Mid Yorkshire Teaching NHS Trust and Inter-Disciplinary Ethics Applied Centre, University of Leeds.
- Dr Esther Clift, Consultant Physiotherapist in Acute Frailty, Isle of Wight NHS Trust
- Dr Liz Davis, Acting Frailty Consultant, Liverpool University Hospitals NHS Foundation Trust.
- Dr Sarah Evans, Consultant Geriatrician, Whittington Health NHS Trust.
- Professor Rowan Harwood, Professor of Palliative and End of Life Care, University of Nottingham and Honorary Consultant Geriatrician, Nottingham University Hospitals (dissents from the conclusions of the statement).
- Shireen Ismail, Registered Osteopath, Verdure Clinic.
- Mrs Gabrielle Jenkinson, Advanced Clinical Practitioner, The Princess Alexandra Hospital NHS Trust.
- Dr Eva Kalmus, GP with Extended Role in Frailty
- Dr Katherine Patterson, Consultant Geriatrician, Belfast Health and Social Care Trust.
- Dr Louis Savage, GP with Special Interest/ Specialty Doctor in Geriatric Medicine, Gloucestershire Hospitals NHS Foundation Trust.
- Professor David G Smithard, Consultant in Acute Frailty, Lewisham and Greenwich NHS Trust, and Visiting Professor, University of Greenwich.
- Dr Joanna M. Ulley, Consultant in Geriatrics and General Medicine, The Rotherham NHS Foundation Trust.
- Dr Stephanie Wells, Consultant Geriatrician, University Hospital of Wales.
References
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Appendix
The raw anonymised data collected from the BGS member survey on assisted dying is available on request. Please email Lucy Aldridge, BGS Policy Coordinator, at l [dot] aldridge [at] bgs [dot] org [dot] uk to request this information as a Microsoft Excel document.