‘Do we listen if a patient tells us she can’t go on?’

The event comes as a leading journal appeared to back the case for doctors being allowed to help hasten the death of the terminally ill, when patients indicate it is their wish.

Last report last week the report, in The Journal of Medical Ethics, examined statistics relating to assisted dying schemes in Oregon in the US and in the Netherlands, and reported that there was no evidence for common concerns around legalised physician assisted suicide (PAS) or voluntary euthanasia.

There was no justification, they said, for fears that the elderly, physically disabled, the uninsured, or people with psychiatric illnesses and other potentially vulnerable groups were disproportionately likely to take the decision to end their lives.

Claims that such groups might be subjected to pressure to opt for PAS, or that it was a "slippery slope" were therefore unfounded, the University of Utah study concluded.

Recently the British Medical Association (BMA) has reversed its position on the issue several times, reflecting a split in opinion amongst doctors.

Meanwhile, a series of high-profile cases where doctors have been charged with misconduct, or patients have sought assistance in ending their lives - often overseas - has kept the issue in the headlines. The RCP symposium will bring together physicians, lawyers and ethicists to discuss the current position and potential change.

Last year a bid in the House of Lords to introduce a PAS law was blocked, and MSP Jeremy Purvis failed in a recent bid to introduce similar legislation in Scotland.

Fernie, a former medical advisor to the Medical and Dental Defence Union of Scotland (MDDUS), and a member of the BMA Scottish Council, says doctors are worried about the potential for professional repercussions and even criminal cases against them if any future law is in any way ambiguous.

"Should the law change, I would anticipate that the regulatory bodies will have a marked increase in workload. There are big judgments to be made in terms of who decides when life is unacceptable.

"Acts of Parliament are not always as clear as we'd like. Down the line, doctors might be less apprehensive but, to begin with, some of this would be established by case law - and I wouldn't fancy being the doctor involved in that."

Regardless of the law, for many doctors it remains an intensely personal issue of ethics, Fernie adds, and one which the MDDUS often receives calls about. "We get doctors phoning us and saying this is the situation I'm in and what should I do? The answer essentially is to follow what guidelines there are and ask yourself whether you are satisfied that if asked to account for your actions, you could do that."

The wider question equally requires a very personal response, he suggests. "A doctor has a caring relationship with a patient and can be under a great deal of pressure. Should I bring a life to an end? Will it spare the relatives? Doctors are essentially in a profession that wants to help.

"The question is do we respect a patient's autonomy to the ultimate degree? Do we listen if they say my life is intolerable. I can't go on and I want assistance to end my life'? Or do we say that humans are different from cats or dogs, they can't be put down'?"

Campaigners point to the safeguards in place in Oregon and the Netherlands, where assisted dying is legal, and Fernie acknowledges this.

However, he says ethical considerations would still mean that many doctors would be unwilling to play a part in carrying out the wishes of a patient requesting PAS.

Indeed, this may extend to other health service staff, too. In 1988 a medical secretary in Salford refused to type a letter of referral for an abortion on grounds of conscience. The House of Lords eventually ruled against her in a subsequent industrial tribunal case, but Fernie says there would certainly have to be provision for conscientious objection in any future law.

He said the difference with abortion law was that doctors were being asked to end a life that would otherwise continue. In the case of someone who is terminally ill, that is not the case. "People acknowledge that you can't always make people better.

"The contrary argument is that if you have proper modern palliative care, a patient shouldn't suffer unduly." But, realistically, he adds: "You can't always achieve that."

There are other complications, Fernie will tell the conference. By the time patients are receiving palliative care, they may have been ill for some time. "That means they have potentially modified their normal decision-making processes with diseases. Cancer patients may have brain secondaries. Are they thinking clearly with that? If you have breathing problems, are you getting enough oxygen to the brain?"

Scotland starts from a good base, however, with the robust protections included in the Adults with Incapacity Act, Fernie says.

Dr Michael Irwin, of the Glasgow-based group Friends at the End (Fate), says there is no contradiction between the Hippocratic oath and assisted dying. Doctors no longer take the 2000-year-old oath anyway he says, but its principle of "first do no harm" still applies. "That is right. You shouldn't kill patients, obviously, but if they are dying anyway, all you are doing is speeding up the dying process."

An outspoken campaigner for the "right to die", Irwin says he has accompanied people three times to Switzerland to end their lives. He has been interviewed twice by police in relation to such cases.

However, he argues that laws with proper safeguards work in Oregon and the Netherlands and there is no reason why they shouldn't work here.

Irwin discriminates between a system whereby a doctor prescribes legal medication with which someone can end their own life, and voluntary euthanasia, where a doctor actively administers a lethal injection to a patient. The former is generally more popular among doctors who express a preference, and is the system used in Oregon, while the Netherlands permits both practises. There should be an element of proof that a request is voluntary, he says, and a cooling-off period with the request repeated after two or three weeks. Two doctors should be involved, in order to certify that someone is definitely terminally ill. Under such laws only 50-60 people opt for an assisted suicide in Oregon each year, he says, and this was the basis for the proposals Jeremy Purvis MSP put to Holyrood in 2005.

Not least of Irwin's arguments is that many doctors already do this. The problem is that it goes on behind closed doors. As a result it is not subject to such stringent safeguards, of course, but, from Irwin's point of view, this is unsatisfactory because a patient might be unlucky with their doctor: "It is Russian roulette. Do you have a doctor who is willing to help you?"

John Griffiths, medical advisor to the RCPE, says the issue of PAS arises every time a case comes before the general Medical Council (GMC), such as that of consultant anaesthetist Ann David, who faced a GMC hearing over her decision to withdraw treatment from a comatose patient in 2000. She left the profession before the case could be heard. More recently, Aberdeen consultant Michael Munro was cleared after a misconduct hearing that found he had not hastened the deaths of two terminally ill babies.

"Some doctors would support it subject to safeguards, others say no way. It is contrary to our ethics and puts us in an impossible position," says Griffiths.

The problem, he says, is that the current situation is riddled with double standards. It is widely accepted that doctors will prescribe for a "double effect" in some cases, notably the care of terminally ill patients.

Morphine prescribed for pain relief may have to be administered in such doses that it becomes life-threatening.

"Many terminally ill cancer patients probably die from the effects of the medicine, which depresses respiration so that they stop breathing. But that drug is justified to alleviate pain."

However, patients with other conditions - such as motor neurone disease (MND) - face a dire prognosis but a convenient drug regimen does not exist to allow a similar approach. "With MND, it isn't justified, because they may not be on a drug," says Griffiths.

The biggest problem could be our unwillingness to confront the problem at all, until it is too late, Griffiths adds. "This event will be raising the issues and forcing people to think about them.

"I think death is still a taboo subject, to quite an extent. People simply don't want to talk about it."

• Visit www.rcpe.ac.uk/education/events/suicide-oct-07.php