Professor Penney Lewis:

In regard to doctors who do not want to participate, all of the regimes that I have explored either have an explicit or implicit conscientious objection provision. I am not aware of any regime where there is an obligation on a doctor to provide assisted dying. Indeed, there is quite a lot of empirical evidence that in most jurisdictions there is a group of doctors who refuse to participate; a group that participate, but only in certain circumstances; and a group who are willing to do it, but that does not mean they accede to every request. There is quite a good body of evidence about requests that are granted versus requests that are not granted and the reasons doctors refuse to grant requests. Some refusals are because the individual doctors never grant requests, or for example because they do not agree with euthanasia in psychiatric cases. Doctors can object to certain kinds of euthanasia as well. It is possible to create a regime where doctors are making their own choice about whether to participate.

In that regard, it is interesting to look at the Canadian experience, because assisted dying is very new in Canada. There was some concern, in part because access to health care in Canada is sometimes very difficult in regions of the country that are very sparsely populated and have a huge land area. We still need more data, but it seems that there are enough doctors who are willing to provide assisted dying. There may be areas of the country where it is more challenging but the initial forecast that no or hardly any doctors would want to do this does not seem to be borne out in the Canadian experience.

The question of a protracted process was raised. The balance has to be struck between what the literature calls "prospective scrutiny", that is, scrutiny in advance of the provision of assisted dying, and "retrospective scrutiny". The Dutch have struck that balance quite well. They have trained a cohort of doctors to provide specialised advice and consultation in euthanasia cases. These doctors are very familiar with the legal criteria and with how to assess capacity, suffering, voluntariness etc. They also have a lot of experience in providing euthanasia, in consulting on it and in its alternatives. That provides a kind of prospective scrutiny. It is perfectly common in the Netherlands for a doctor to call in a consulting doctor who then says that the patient does not meet a certain criterion. That is the end of the case, although obviously the patient still receives care. There is then a process of reporting to the regional review committees, which review every single case. They publish a very detailed annual report and individual judgments in many of the cases.

It is certainly possible to shift that balance. The English debate at the moment is very fixated on the consent of a High Court judge. My feeling is that this is an extremely burdensome thing to expect a very ill patient to go through. The vast majority of euthanasia or assisted dying cases involve patients who are in their last weeks or months of life. That does not mean it should be restricted to those patients, but nonetheless that is the reality. They are mainly end-of-life cancer patients and that consent is a significant burden. Yes, by all means, some kind of prospective scrutiny is appropriate. Peer review, through involving another doctor, is desirable.

There are other models. The Colombians are trying a model of hospital review committees. It does not seem to be working in Colombia but that is probably because there is a lot of opposition to the legalisation, which was imposed by the courts. However, that is another possibility. That can also be quite a burden to a very unwell patient but it depends on how it is implemented. I am in favour of some kind of prospective review but also a reporting obligation and a rigorous assessment of the cases, with doctors being aware that if they do not comply with the criteria, legal and professional consequences are perfectly possible.