Abstract
If physician-assisted suicide/euthanasia is legalised in the UK, this may be the work of GPs. In the absence of recent or comprehensive evidence about GPs' views on either legalisation or willingness to take part, a questionnaire survey of all Welsh GPs was conducted of whom 1202 (65%) responded. Seven hundred and fifty (62.4% of responders) and 671 (55.8% of responders) said that they did not favour a change in the law to allow physician-assisted suicide/voluntary euthanasia respectively. These data provide a rational basis for determining the position of primary care on this contentious issue.
INTRODUCTION
The possibility of legalised euthanasia in the UK has caused significant debate.1,2,3 The current ‘Assisted Dying for the Terminally Ill Bill’ (House of Lords second reading 12 May 2006) seeks to legalise physician-assisted suicide by prescription, and if necessary, provision of means of self-administration of medication. These practices are already established in other countries; in The Netherlands, euthanasia and physician-assisted suicide became recognised as part of modern health care in 1991, and may be carried out by GPs.4 In Oregon, US, only physician-assisted suicide is legal, and this began in 1997.5 While the proposed law change could fundamentally affect UK GPs, surveys of their views are out of date and do not specify the method of causing death.6,7 The RCGP recently changed from a neutral position to one opposing law change following consultation; the British Medical Association has adopted a neutral stance. Eighty-two per cent of the general public are reported to support a law change to allow people suffering unbearably from a terminal illness to receive medical help to die.6 Conversely, of 2265 doctors from a range of specialties responding to a recent online poll, 1559 (68.8%) stated legal change was unnecessary in view of advances in palliative care (doctors.net.uk on-line poll December 2005). A recent nationwide survey of end-of-life decisions8 showed that UK doctors attending deaths rarely felt UK law inhibited or interfered with their preferred management of patients and did not think new laws were desirable. In order to further inform the current debate, we sought to discover the views of all GPs in Wales.
METHOD
In October 2005, all 1846 GPs listed on the All Wales Primary Care Database were sent a short questionnaire, clearly defining physician-assisted suicide and voluntary euthanasia. It described the drugs recommended for physician-assisted suicide in Oregon [9–10 g of secobarbitol {quinalbarbitone}] and for voluntary euthanasia in The Netherlands [thiopental injection 20 mg/kg to induce a deep coma, followed by injection of pancuronium at 0.27 mg/kg]. We chose to develop our own questions (see Table 1 for questions) rather than replicate those used in previous surveys,5 specifically to illuminate the plausibility of potential law change in the UK, and because the validity and reliability of previously used questions has not been determined. The questionnaires were not anonymous, in order to allow reminders to be sent at 3 and 6 weeks to maximise response.
RESULTS
The 1202 GPs (65.1%) who responded were broadly representative of the sample in terms of geography and RCGP membership. The majority of responders (810; 67.4%) were against legal change for physician-assisted suicide and/or voluntary euthanasia. Seven hundred and fifty (62.4%) and 671 (55.8%) said they did not favour a change in the law to allow physician-assisted suicide/voluntary euthanasia respectively, while 294 (24.5%) and 323 (26.9%) respectively, said that they did. However, 145 (12.1%) and 190 (15.8%) respectively, indicated that they did not know. Two hundred and four (16.9%) were in favour of law change for both physician-assisted suicide and voluntary euthanasia and 611 (50.8%) were against both. Two hundred and thirty-eight (19.8%) were willing to write a prescription for lethal medication, and 147 (12.2%) were willing to carry out voluntary euthanasia, if legalised. A summary of the main findings is shown in Table 1. For physician-assisted suicide, of those that support law change, 14% were not willing to prescribe and 28% were not willing to inject. Conversely, only a very small minority of those against this law change were willing either to prescribe or inject. For voluntary euthanasia there were similar trends. Comments were made by 181 (15.1%) responders; these emphasised the continued need for high quality palliative care. Seventy-two supporters of legalisation commented: 43 stressed the need for stringent safeguards; and 13, who would not conduct the procedures themselves, advocated a specialist service for physician-assisted suicide/voluntary euthanasia. Eighty-six opponents of legalisation commented, many were strongly worded with some concerned that the ethos of clinical practice would be destroyed. In order to determine the potential effects of a non-response bias, an extreme example sensitivity analysis was undertaken to demonstrate the range of responses. This did not alter the overall conclusions or implications from the data.
How this fits in
There is significant debate regarding the possibility of legalised euthanasia/physician-assisted suicide. Up-to-date and accurate data regarding the views of GPs were previously unknown. The majority of GPs are against a law change and are unwilling to carry out these procedures. A minority support a change in the law and are willing to prescribe or inject lethal drugs; these numbers are lower than previous surveys suggest.
DISCUSSION
This is the largest survey of UK GPs to date; the majority of GPs in Wales are against a law change and are unwilling to carry out these procedures. Less GPs are prepared to conduct voluntary euthanasia than reported in both the 1987 survey, which suggested 35% would conduct voluntary euthanasia and a further 10% would consider it,6 and the 1993 report, which found that 46% of NHS doctors would consider taking action to bring about the death of a patient if it was legal to do so.7 However, in each of those surveys the questions were phrased in a less explicit manner than ours, and there is therefore the potential for bias in the way in which we asked our questions. However, it is difficult to predict in what direction this potential bias might operate. The explicit phrasing was designed to differentiate the methods of euthanasia and physician-assisted suicide from good palliative care practices, such as prescription of increasing doses of opiates with the intention of relieving pain, with no intent to cause death. In addition, our questionnaires were not returned anonymously; this may have increased the non-response rate, but the range of views expressed is consistent with previous surveys. Law change does not mean GPs will have to perform euthanasia; but they will be confronted with patients who will want to talk about it. How willing or able they are to do this remains unknown. The proportion of GPs answering ‘don't know’ to the questions was sizeable; this group may need more information to decide, may be genuinely ambivalent or may not have a view. It is unknown why most GPs oppose legal change, yet most of the public appear to hold the opposite view.6 Possibilities include different respective views of many issues including: the place of good palliative care, awareness of the dying process, the ability to refuse treatment or the nature and potential extent of voluntary euthanasia and physician-assisted suicide. This is an important research question, and needs to be addressed. Our findings provide those who argue for a change in the law with evidence that GPs do not seem to be behind them at present, especially as this reflects the views of a representative sample of 1202 practitioners in Wales.
Acknowledgments
Mrs Maggie Hendry for help with the survey, and the GPs in Wales.
Notes
Ethics committee
Ethical approval was not required
Competing interests
Baroness Finlay is a member of the House of Lords and was a member of the Select Committee on the Assisted Dying for the Terminally Ill Bill. All other authors declare no competing interests
- Received March 16, 2006.
- Revision received April 6, 2006.
- Accepted May 2, 2006.
- © British Journal of General Practice, 2006.