3.3 Tratamiento Antirretroviral
3.4.3 Esquema de Tercera Línea
In January 2004, Lord Joffe introduced a second Private Member’s Bill, the Assisted
Dying for the Terminally Ill Bill 2004 (‘ADTI Bill 2004’)361 in the House of Lords.The
Bill would have enabled a competent adult who is suffering unbearably from a terminal
illness to receive medical assistance to die at their own request.‘Medical assistance to
die’ referred to providing the patient with the means to end life, or ending that life if the
patient is physically unable to do so.362The ADTI Bill 2004 included a requirement for
the option of palliative care363 to be discussed with patients before assisting their
deaths.364
The ADTI Bill 2004 was given a Second Reading in March 2004. The Select
Committee conducted an exhaustive examination of the Bill, including studies on public opinion and a comparison of the Bill to the laws of four jurisdictions (Switzerland, the
Netherlands, Belgium, and Oregon(US))365 where assisted death has already been
legalised in some form.366 The Select Committee published the 2004 HL Select
Committee Report in April 2005 which presented the ethical and practical issues
surrounding the Bill, and the arguments for and against a change in the English law.367
Although the Select Committee failed to reach a consensus on the acceptability or 360 PAD Bill 2003 (n352). 361 ADTI Bill 2004 (ch1 n48). 362 ibid cl 1(2). 363 See section 3.4.3. 364 ADTI Bill 2004 (ch1 n48) cl 3(1). 365 See ch 5. 366
2004 HL Select Committee Report Vol I (ch1 n49) paras2-7.
367
otherwise of the ADTI Bill 2004, it did make recommendations for future legislation.368 Some of the issues highlighted by the report were:
i) The ADTI Bill 2004 sought to legalise not only medical assistance with suicide but also, in cases where self-administration of lethal medication is not possible,
voluntary euthanasia.369 The Select Committee recommended that any future Bill
should be clear in distinguishing between assisted suicide and voluntary euthanasia and to address these two courses of action separately, as the considerations involved
in each are very different.370
The Select Committee visited two jurisdictions with very different assisted death
laws Oregon, where only physician-assisted suicide is legal, and the Netherlands,
where both physician-assisted suicide and euthanasia by physicians are legal. These showed very different annual rates of assisted deaths. The Select Committee found that whilst less than one in 700 deaths in Oregon was attributable to assisted death, that figure was more than one in 40 in the Netherlands. Of those deaths in the Netherlands, less than 10% were from assisted suicide, while over 90% were the
result of euthanasia.371 The Select Committee concluded that the inclusion of
euthanasia in the law on assisted death had led to a significantly higher rate of assisted deaths. The Select Committee was also of the view that assisted suicide, with its emphasis on the individual taking responsibility for the final stage of ending their life, has the effect of making those who are minded to end their lives think
more carefully before taking action to give effect to their wishes.372
The Select Committee considered that any new Bill should be narrower in scope than the ADTI Bill 2004. It found that while some physicians supported a change in the law, the medical profession as a whole was at best ambivalent about legalising
assisted death and in many cases opposed.373 It considered that there would be less
opposition to a law which was restricted to physician-assisted suicide. The Select Committee heard evidence from Oregon that any proposal to extend Oregon’s Death
368
2004 HL Select Committee Report Vol I (ch1 n49) para7.
369 ADTI Bill 2004 (ch1 n48) cl 1(2). See also 2004 HL Select Committee Report Vol I (ch1 n49) para243.
‘Voluntary euthanasia’ is explained in ch1 n7.
370
ibid para 246.
371
ibid para 243.
372
ibid para 244. See also section 3.3.4.
373
with Dignity Act (‘DDA’)374 to also legalise euthanasia was expected to encounter
much greater opposition from the medical profession.375 The Select Committee also
noted that a blurring of the line between voluntary and involuntary assisted dying is
more likely to occur by legalising voluntary euthanasia376 than by legalising assisted
suicide.377 It emphasised a belief that the key issue with assisted death is that
responsibility for the ultimate act should rest with the patient.378
It is submitted that the Select Committee’s view that there would be less opposition from the medical profession for a law on assisted death that did not include
euthanasia by physicians is no longer supported in England and Wales today. This is demonstrated by recent studies that found almost equal support for physician-
assisted suicide and euthanasia by physicians in the UK. The first is Seale’s 2007–
2008 survey of doctors’ attitudes (as referred to previously),that showed 35.2% of
doctors surveyed supported physician-assisted suicide for the terminally ill, whilst
34% thought that doctors should be able to perform euthanasia for such patients.379
The second study on doctors’ attitudes was by McCormack et al in 2011. This study too found almost equal support for physician-assisted suicide and euthanasia but the level of support for both was lower than in Seale’s earlier study. Whilst 24.9% of doctors were willing to perform physician-assisted suicide, 22.7% were willing to
perform voluntary euthanasia.380
ii) ‘Terminal illness’ was defined by the ADTI Bill 2004 as an inevitably progressive illness which cannot be reversed by treatment, and which will likely result in death
within a few months at most.381 The Select Committee heard evidence that an
accurate prognosis is not possible beyond 8–12 weeks.382The Royal College of
Physicians (‘RCP’) gave evidence that prognosis of terminal illness was ‘a
probabilistic art’ and that ‘prognosticating may be better when somebody is within the last two or three weeks of their life’ but that, ‘when they are six or eight months
374
See section 5.7.2.
375
2004 HL Select Committee Report Vol I (ch1 n49) para245.
376
‘Voluntary euthanasia’ (ch1 n7).
377
2004 HL Select Committee Report Vol I (ch1 n49) para245. Although no support for this specific concern is found by this thesis in ch6.
378 ibid para 246. 379
Seale (n173).
380
R McCormack et al, ‘Attitudes of UK doctors towards euthanasia and physician-assisted suicide: a systematic literature review’ (2012)26(1) Palliative Medicine 23.
381
ADTI Bill 2004 (ch1 n48) cl 1(2).
382
away from it, it is pretty desperately hopeless as an accurate factor’.383Similarly, the Royal College of General Practitioners stated that ‘it is possible to make reasonably accurate prognoses of death within minutes, hours or a few days. When this
stretches to months, then the scope for error can extend into years’.384These
statements are supported by data from the Oregon Public Health Division’s (‘OPHD’) annual reports, where some terminally ill people who had been given lethal drugs by physicians pursuant to the DDA, on the basis of a prognosis of six months or less had gone on to live longer, sometimes much longer, before either
using the drugs to commit suicide or dying of natural causes.385The Select
Committee recommended that, ‘if a future [B]ill should include terminal illness as a qualifying condition, this should be defined in such a way as to reflect the realities
of clinical practice as regards accurate prognosis’.386
iii) ‘Unbearable suffering’ was defined by the ADTI Bill 2004 as suffering, resulting from the patient’s terminal illness, which the patient finds so severe as to be
unacceptable.387 The Select Committee heard evidence that suffering is a subjective
experience, which cannot be assessed objectively by clinical methods, or reliably
attributed to the underlying condition.388The Select Committee recommended
changing the phrase ‘unbearable suffering’ to ‘unrelievable suffering’,to require
that efforts be made to relieve any suffering, and restrict assisted dying to only those
whose pain cannot be alleviated by palliative care.389 Thus, a more objective medical
assessment is made of the patient’s suffering which ensures that all available steps
have been taken to relieve distress.390
iv) The ADTI Bill 2004 provided that only if a physician believed that their patient is not competent, were they to refer the patient to a psychiatrist to confirm that the patient was not suffering from a psychiatric or psychological disorder causing
impaired judgement.391 However, the experience of Oregon’s law on physician-
assisted suicide was that referrals under similar provisions in the DDA were rare.392
383
2004 HL Select Committee Report Vol I (ch1 n49) para118.
384
ibid.
385 OPHD, Oregon’s Death with Dignity Act: The Second Year’s Experience (Second Annual Report) 12; OPHD,
Sixth Annual Report on Oregon’s Death with Dignity Act 4. See section 5.7.2.
386
2004 HL Select Committee Report Vol I (ch1 n49) para269(c)(iii).
387
ADTI Bill 2004 (ch1 n48) cl 1(2).
388
2004 HL Select Committee Report Vol I (ch1 n49) paras 127–130.
389
J Keown, ‘Debate Physician-Assisted Suicide: Lord Joffe’s Slippery Bill’ (2007)15 Med.L.Rev 126.
390
ibid.
391
ADTI Bill 2004 (ch1 n48) cl 8.
392
The Select Committee recommended that a patient requesting assisted dying should be given a psychiatric assessment by default, to confirm that the request is based on a reasoned decision free from external pressure, and that the applicant is not
suffering from a psychiatric or psychological disorder causing impaired judgement. v) The ADTI Bill 2004 required a specialist in palliative care to have discussed the
option of palliative care with the patient.393 However, the Select Committee stated
that:
if a future [B]ill is to claim with credibility that it is offering assistance with suicide…as complementary rather than alternative to palliative care, it should consider how patients seeking to end their lives might
experience such care before taking a final decision.394
It recommended that patients should actually experience palliative care rather than
merely be informed of such care as an option.395
The Select Committee drew attention to evidence from a UK charity for hospice care, Help the Hospices, that ‘experience of pain control is radically different from the promise of pain control,
and cessation is almost unimaginable if symptom control has been poor’.396 It
concluded that patients seeking assistance to die without having experienced good
symptom control could not be deemed fully informed.397
vi) The GMC gave evidence to the Select Committee that:
A…law [on] physician-assisted dying would have profound implications for the role and responsibilities of doctors and their relationships with
patients.398 Acting with the primary intention to hasten a patient’s death
would be difficult to reconcile with the medical ethical principles of
beneficence and non-maleficence.399
393
ADTI Bill 2004 (ch1 n48) cl 3(1).
394
2004 HL Select Committee Report Vol I (ch1 n49) para269(c)(vi).
395 MA Branthwaite, ‘Taking the Final Step: Changing the Law on Euthanasia and Physician Assisted Suicide’ (2005)
331 BMJ 681.
396
2004 HL Select Committee Report Vol I (ch1 n49) para258.
397
ibid.
398 See section 3.3.3. 399
Select Committee on the Assisted Dying for the Terminally Ill Bill, Assisted Dying for the Terminally Ill Bill [HL]
A similar observation was made by Finlay et al in their 2011 article on a reappraisal needed of safeguards for an assisted dying law. They argued that the underlying ethics of medicine is at variance with the ethics of assisted death, as the role of doctors is to treat illness or, where that is not possible, to relieve its symptoms and
thereby improve quality of life.400 The Select Committee considered that the issue
was whether a reformed law on assisted dying should encompass ‘therapeutic killing’, or whether the therapeutic option of a physician giving a patient a lethal overdose crosses a ‘Rubicon’ that would radically alter the way every physician
practices medicine.401 With particular reference to implications for palliative care,
Finlay argued in 2005, that once the option of a lethal overdose enters the arena, a paradigm shift occurs in medical decision-making. Assisted suicide and euthanasia become treatment options that would have to be presented to all terminally ill people
who are believed to be in the last months of life.402This potential conflict between a
physician’s traditional role and responsibilities towards a patient, and physician- assisted death, was later emphasised in 2010 in the DPP’s Policy which states that a factor in favour of prosecuting an assisted suicide is whether or not it is perpetrated by ‘a medical doctor, nurse or other healthcare professional’ and whether the
deceased had been ‘in his or her care’.403