The essence of their recommendation was that legislation should be considered, which would deal with:

• "The circumstances in which it would be lawful for a medical practitioner to cease or authorise the cessation of all further life-sustaining treatment of a patient whose life functions are being maintained artificially while the person has no spontaneous respiratory and circulatory functions or his or her brainstem does not register any impulse.
• The right of a mentally competent person to refuse any life-sustaining treatment with regard to any specific illness from which he or she may be suffering, even though such refusal may cause the death or hasten the death of such a person.
• The right of a medical practitioner responsible for the treatment of a terminally ill patient to alleviate pain and distress in accordance with responsible medical practice, by increasing the dosage of medication to be given to the patient, with the object of relieving the pain and distress of the patient and with no intention to kill, even if the secondary effect of this action may be to shorten the patient's life.
• Whether it would be lawful for a medical practitioner to give effect to the well-informed considered request of a terminally ill, but mentally competent, patient to make an end to the patient's unbearable suffering or to enable the patient to make an end to his or her unbearable suffering by administering or providing a lethal agent.
• The recognition of a written directive regarding the cessation of medical treatment in cases of terminal illness.
• Recognition of a power of attorney authorising a person to make decisions concerning the medical treatment of the principal in the event of his terminal illness. The continuing validity of a power of attorney after the principal has become mentally incompetent.
• Those instances in which the chief medical practitioner of a hospital or clinic may, in the absence of a directive of the patient or his agent decide to discontinue the treatment of the terminally ill patient.
• The circumstances in which a court may order the cessation of medical treatment or the performance of any medical procedure which would have the effect of terminating a patient's life."

While not yet accepted by government or translated into legislation, this report was greeted with dismay by pro-life groups, who felt, for example, that it threatened the "basic right to life of frail aged, chronically sick and handicapped" people (Life News, 20 August 1999). As with the 1997 Choice on Termination of Pregnancy Act, it also raised the issue of the rights of pharmacists who might be called upon to dispense or supply the medication that would be used to end a patient’s life, or stand by when a lethal dose was prescribed, or accede to a patient being denied access to life-prolonging medication.

SAAHIP’s approach is informed by the principles of the practice philosophy of Pharmaceutical Care. Accordingly, pharmacists are understood to enjoy a covenantal relationship with their patients. Their actions should always be designed to ensure that the desired patient outcomes are attained whenever pharmacotherapeutic agents are employed. However, they are also informed by the basic tenets of medical ethics, amongst which is the principle of respect for patient autonomy.

In the SAAHIP Position Paper on the Pharmacist’s Role in Termination of Pregnancy, it was noted that this topic represented "a conflict between two apparently irreconcilable viewpoints". The issue of assisted suicide presents just such a conundrum. A Task Force of the American Society of Health-System Pharmacists (ASHP) has considered this issue in depth. In June 1999, the Society decided "to remain neutral on the issue of health professional participation in assisted suicide of patients who are terminally ill; further, to offer guidance to health-system pharmacists who practice in states in which suicide is legal". The task force chose to expand on the meaning of this position of neutrality (Am J Health-Syst Pharm 1999; 56: 1672-3). They explained that neutrality is "a position that does not take an active part with either contending side on an issue", but that it was "different from taking no position". While having no position could be regarded as avoiding the issue, neutrality was "impartial or non-partisan".

The ASHP Statement on Pharmacist Decision-making on Assisted Suicide (Am J Health-Syst Pharm 1999; 56: 1661-4), is built on the following principles:

• The basic tenet of the pharmacy profession is to provide care and affirm health. Pharmacists should therefore "serve as advocates for the patient throughout the continuum of care".
• Pharmacists should ensure the rights of competent patients to access to all legally available treatment options.
• Pharmacists must respect the confidentiality of all patient information, "regardless of whether they agree with the values underlying the patient’s choice of treatment or decision to forgo any particular treatment".
• Patients’ ability to make decisions and exercise their legal and ethical rights relies on pharmacists providing full information on the options available.
• Pharmacists must collaborate with other members of the health care team.
• While pharmacists have the right to conscientious objection, when confronted with choices on whether or not to participate in "morally, religiously, or ethically troubling therapies", they should not impede patient access to legal therapy options.

It was this last principle, seeking to accommodate a collision of rights, which informed the SAAHIP Position Paper on the Pharmacist’s Role in Termination of Pregnancy.

Crucially, the ASHP statement also identified real barriers to adequate end-of-life care. These were:

• "inadequate knowledge and use of pain- and symptom-management therapies
• the paucity of published data related to the ingestion of lethal drugs and the outcomes thereof
• insufficient education of health care professionals about end-of-life and palliative care issues
• inadequate recognition that end-of-life care is the responsibility of the entire health care team
• legal and regulatory issues that deter appropriate provision of pain and symptom management".

In developing this policy paper, SAAHIP also took note of the fact that the issue was, at present, of a speculative nature. The Bill envisaged by the Law Commission Report has yet to be tabled, in that or any other form. However, it acknowledged the fears of its members, who saw in this report the sign of an impending policy change, ‘slippery slope’ against which they looked to their Association for guidance and support.

SAAHIP reaffirms the basic principle underlying the SAAHIP Position Paper on the Pharmacist’s Role in Termination of Pregnancy, in that it recognises the pharmacist’s right to conscientious objection to involvement in actions that offend her/his moral, religious or ethical views. However, in recognition of the primacy of patient rights, it supports the establishment of systems that protect the patient’s access to legally prescribed treatments, while reasonably accommodating the pharmacist’s right of conscientious objection. Furthermore, it urges all members to work towards overcoming the barriers to adequate end-of-life care identified by the ASHP.

On the substantive matter of assisted suicide, SAAHIP is guided by the decision of our American colleagues, and adopts a position of informed neutrality.

This position paper was drafted by Andy Gray, and was amended
and approved by the National Executive as an official position paper of the Association.

February 2000