when doctors suggest death: an ethical response to clause 5(2)

The amended Terminally Ill Adults (End of Life) Bill has been published ahead of the third reading and House of Commons vote in a few weeks. Contrary to objections – including from some MPs who voted for the Bill with the hope of it being removed in committee – the Bill continues to include Clause 5(2). This clause permits a doctor who deems it ‘appropriate’, to suggest, unsolicited, the idea of ‘assisted dying’ to a patient.

The British Medical Association (BMA) gave strong backing to this controversial clause in their evidence to the parliamentary committee scrutinising the Bill. They referenced a report from Victoria, Australia, which suggested that precluding doctors from initiating conversations meant patients were left unaware of the possibility of an assisted death, particularly impacting those with language barriers, low education, and learning difficulties.

Despite these arguments, we believe that the BMA’s support for this clause is misplaced and short-sighted. It fails to reckon with the ethical and professional consequences of the clause, and with how profoundly it will alter the status of assisted suicide within our healthcare system and wider society. So-called ‘assisted dying’ will become a medical treatment and be rapidly cast as one of a range of options for patients with terminal illness to be offered on an equal basis with all others.

The medical profession will not be a ‘neutral’ player, as the Bill’s proponents contend. The doctor will not be a disinterested facilitator of an autonomous choice. Rather, the mere act of suggesting ‘assisted dying’ implies that a doctor believes it to be in a patient’s best interests – a choice that is worth considering, or is perhaps even preferable. Those professionals inclined to increase uptake will be able to, making use of their influential role in the doctor-patient relationship.

Ludewigs et al recently laid out the ethics of the doctor-patient relationship as one that is bound by fiduciary principles. These principles recognise the presence of a power imbalance; the relationship works because one party (the patient) can trust that the other (the doctor) is working for their benefit. The doctor has other obligations, such as to wider society for the appropriate use of resources, but on balance the patient can still trust that when the doctor advises them, the doctor is using their knowledge of medicine, the clinical state of the patient and of service provisions, to provide a course of action in the patient’s best interest.

The concept of best interests has become synonymous with proxy decision-making when patients lack capacity. But fundamentally, medical ethics dictate that if a treatment causes more harm than good, it is not in that patient’s best interest and therefore is not a treatment option that the doctor should suggest to the patient. There is no justification for offering it, and if pursued, it risks being an assault on the patient. Informed consent is the means by which the patient with capacity has the ability to exert their autonomy as to whether they accept the advice on offer.

One must acknowledge that for a doctor to be allowed to bring up the option of assisted dying unsolicited, medicine has deemed that an assisted death can be a beneficial intervention. In other words, it is to assent to the proposition that some patients are better off dead. Is medical training and broader society ready for this new reality?

The Bill recognises that the doctor will be using their clinical skills to identify specific patients who might benefit. Bringing up the subject signals their judgement that ‘assisted dying’ may be in this patient’s best interests. To gain appropriately informed consent, they must surely explain why they believe assisted death to be a beneficial option, considering elements such as other treatment options being exhausted, end-of-life care being under-resourced, and the prospect that the individual may die a symptomatic death. These reasons will be compelling and potentially coercive.

Though the Bill provides protection for the medic for these doctor-initiated conversations, it does not provide protection for the patient, who may experience multiple doctors, all acting independently, raising the option of an assisted death time and again. However unwittingly, the message they receive has shifted from ‘we will care for you until the end’ to ‘perhaps it would be better if you were no longer here’.

This Bill, including clause 5(2), will undermine the ethical foundations on which medicine is built, and in doing so, will reshape the nature and purpose of the doctor-patient relationship. The doctor will become the gatekeeper of death, offering it not merely as an option, but as a clinical recommendation. We urge politicians, healthcare workers, and the public to carefully reflect on this bill, including clause 5(2), and consider what it will mean for the future of care. It must be rejected because, if passed, this bill will not only change the law, but also the very practice and purpose of medicine itself.