The British Geriatrics Society’s position on assisted dying

Abstract

Key Points

• The British Geriatrics Society (BGS) is currently opposed to the legalisation of Assisted Dying (AD) in the UK and Crown Dependencies.

• Shortcomings in health and social care for older people with complex needs, including high-quality palliative and end-of-life care, should be addressed when considering legalisation of AD.

• Many BGS members are not confident that effective safeguards could be developed to protect vulnerable older people with complex needs from harm.

• The BGS acknowledges that a significant minority of members are supportive of legalisation of AD in the UK, many members are undecided and attitudes may change. Given this diversity of views, the BGS urges caution and offers advice in proceeding with potential legalisation of AD.

• The BGS recommends that any future UK legislation should include a conscience clause for professionals who object to direct participation in AD.

Commentary

The British Geriatrics Society (BGS) has reached a current position that opposes the legalisation of Assisted Dying (AD) in the UK. This reflects its wealth of multiprofessional experience with older people living with complex health and care needs and its advocacy for high-quality, timely, personalised care. AD is highly relevant to older people with complex needs since there have been increasing requests for it due to multimorbidity, ‘geriatric [frailty] syndromes’ and dementia [3, 4, 5]. Furthermore, international data from jurisdictions where AD is legalised demonstrate the importance of the issue for older people. In Canada (2022), 85% of medically assisted deaths were for people >65 with the highest proportions in those aged 71–75 (15.7%), 76–80 (15.7%) and 81–85 (14.5%) [3]. In the Netherlands (2023), 90% of medically assisted deaths were for people >60 with the highest proportion (34.5%) aged 70–80 [4]. In Oregon (2023), 82% of medically assisted deaths were for people >65 (mean 75) [5]. Similar trends are observed in Australia and New Zealand where the mean age for accessing AD is 70–79 [6].

Health and care context is highly relevant to personalised decision-making and choice [7, 8], and this is no different when considering AD. The current state of care services for older people and wider societal attitudes and behaviours towards them can therefore be expected to impact on a person’s decision-making. Notwithstanding some exemplary services providing care for older people, the overall picture is one of under-resourcing of health and social care, including palliative care [9, 10]. Lack of resources has led to neglectful care in some settings. Furthermore, attitudes towards older people may be negative [11], some may be abused [12] and many are socially isolated. These factors may influence older peoples’ decision-making and choice, especially towards the end of their lives, by contributing to feelings of low self-worth and fear of being a burden on families, services and society. This may also be in ways that are difficult to identify [13], such as through imposing an expectation that an older person should consider AD. The BGS is concerned therefore that older people may be directly, indirectly or tacitly influenced to choose AD because of adverse factors remediable through positive changes in attitudes, culture and health and care provision.

There is evidence to suggest that in jurisdictions where AD is legalised, autonomy and loss of agency (rather than unbearable suffering) are leading reasons for the request of an assisted death [6, 14]. Whilst the BGS recognises the importance of respect for autonomy, especially in end-of-life decisions, many BGS members are concerned that legal safeguards to protect older people from harm would not be sufficient. There is some evidence raising concerns about safeguarding in relation to AD, and it is also unclear how safeguarding methods can properly identify and respond to people who have been indirectly or tacitly influenced to choose AD in the adverse healthcare and social context described above. A review of patient safeguarding in jurisdictions currently permitting AD (notably Canada) has identified a rapid erosion of safeguards with a shift in eligibility criteria to include conditions without natural death being foreseeable [3]. 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 programme were deemed to have occurred without fulfilment of due care criteria, meaning relevant safeguards were not observed [15, 4].

The BGS acknowledges the potential for challenge of their opposition to legalisation of AD as being paternalistic by imposing a professional view which restricts the right of an individual to make their own choices about the end of their life. However, since there are risks of safeguard failure in existing AD services, the right to autonomous choices for some to end their life may impinge on the rights of others not to be harmed, and a just society arguably must curtail some individual freedoms in order to protect the wider interests of others.

Surveys previously conducted by the Royal College of Physicians (2019) and British Medical Association (2020) identified that Geriatricians were more likely to be opposed to a change in the law on AD [16, 17]. To capture contemporaneous membership views to support the Society’s current position, a new survey was therefore undertaken. This identified that for Physician Assisted Suicide (and Voluntary Active Euthanasia), 50% (55%) were opposed, 33% (27%) were supportive and 17% (18%) were undecided on a change in UK law. Sixty percent (66%) responded that BGS should be opposed and 40% (34%) responded that BGS should be supportive of a change in UK law. Fifty percent (53%) either disagreed or strongly disagreed, 35% (30%) either agreed or strongly agreed and 15% (17%) were undecided about the effectiveness of potential safeguards in the event of legalisation. Fifty-two percent (60%) were also not willing, 27% (21%) were willing and 21% (19%) were undecided on their own professional engagement with AD [2]. Other UK surveys have also highlighted that AD presents a risk of moral injury and distress in healthcare professionals [16]. Because of this risk, although they remain vital in advocating for patients and providing oversight, the BGS asserts the need for a right to conscientious objection for healthcare professionals in any proposed future legislation.

In support of its position, the BGS identifies the following priorities for end-of-life care which should be addressed before legalisation of AD is implemented. Person-centred, multidisciplinary care services should be enabled to deliver Comprehensive Geriatric Assessments focused on multimorbidity, dementia and frailty, with a recognition that these states are often part of a terminal decline at the end of life. This is important because older people living with multimorbidity, dementia and frailty face diagnostic and prognostic uncertainty and escalating care needs which do not fit into traditional models of palliative and end-of-life care. Care must be tailored according to the individual’s preferences [17] and inappropriate interventions aiming to prolong life discontinued, thereby providing improved experiences [18] and supporting non-medicalised death. The clear intent is to provide timely, inclusive, specific, accessible, high-quality multidisciplinary support to relieve burdensome physical and psychological symptoms.

The BGS brings expertise and experience of working with older people, including facilitating and advocating their rights to make choices regarding personalised care whilst safeguarding their rights not to be exposed to unwarranted harms. In the current adverse health and social care context, the position of the BGS is that the potential harms to some older people of legalising AD outweigh the potential benefits to others. It therefore currently opposes a change in UK law, instead advocating for improved access to and positive outcomes from personalised holistic care at the end of life.

Acknowledgements:

The Working Group wishes to acknowledge valuable support from Lucy Aldridge, Policy Co-ordinator at the BGS.

Declaration of Conflicts of Interest:

None declared.

Declaration of Sources of Funding:

None declared.

References