Assisted dying, moral distress, and conscientious objection
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The proposed Assisted Dying for Terminally Ill Adults (Scotland) Bill poses a major challenge for decision making in seriously ill patients and for staff wellbeing.
Despite attempts in law, neither unbearable suffering nor terminal illness can be defined in practice, but these phrases are extremely relevant for defining eligibility. 28·5% of patients admitted to Scottish hospitals are in the last year of life.
Although patients often present to hospital with an acute illness, terminal end-stage organ failure and malignancy are often present. Enacted legislation would add substantially to the moral distress that clinicians already experience when delivering acute services.
Despite the Bill's sponsor's alleged support for clinicians whose ethical position opposes assisted dying, the obligations associated with the Bill's enactment will make conscientious objection impossible to sustain.
The Bill's medical advisory group recommends that there be a duty for all clinicians to refer patients to an alternative practitioner or care navigator service, even if they oppose assisted dying, and that mandatory training for all practitioners be part of the proposed legislation.
These recommendations imply that clinicians will participate obligatorily in what for many is an unethical approach to patient care. Two Hippocratic principles are at stake: “neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course”. Being trained for or participating in a conversation towards assisted dying is to be unequivocally complicit. Advice from the General Medical Council on this matter conflicts with its previous guidelines.
Case law mandates that all reasonable therapeutic options should be offered and discussed with patients (eg, Montgomery vs National Health Service [NHS] Lanarkshire).
Reassurances that the Montgomery ruling will not apply to assisted dying because death is not a treatment are likely to be challenged. Proponents argue that death stands alongside palliative care as an option for the suffering patient.
If death is legitimised as a medical treatment, health professionals would be obliged to offer and explain this therapeutic option as part of their duty of care to eligible patients.
Permissive legislation will reshape decision making far beyond care homes or cancer clinics. The present law protects patients, but also front-line clinicians. The potential for moral distress in relation to assisted dying will add to already exacting pressures.
The Bill's proponents acknowledge the need for safeguards. For NHS staff—the majority of whom do not wish to be agents of assisted dying—conscientious objection requires genuine protection and not just support.