Should physician-assisted suicide (PAS) be legalised in the UK? An innovative workshop exploring medical students’ perspectives

ABSTRACT

This workshop aimed to investigate students’ perspectives on physician-assisted suicide (PAS) and its potential legalisation. A two-pronged strategy was used – a goldfish bowl roleplay simulation and a facilitated group discussion. The roleplay enabled students to engage with practical and emotional challenges related to responding to a PAS request, while the discussion encouraged open dialogue on the ethical complexities of legalising PAS. Students showed nuanced changes in perspectives on PAS by actively participating in roleplay and discussions, demonstrating the potential for these approaches to promote deeper understanding.

KEYWORDS:

• Physician-assisted suicide
• ethics
• medical education
• role-play
• medical student

Background

Currently there is great public interest in the legalisation of Physician Assisted Suicide in the UK. A recent report, Assisted dying/Assisted suicide, from a Commons Health and Social Care Select Committee was published in 2024 [1]. In March 2024, Liam MacArthur MSP presented an Assisted Dying for Terminally Ill Adults (Scotland) Bill to the Holyrood parliament [2]. Six separate Bills to legalise Physician Assisted Suicide (PAS) and/or Euthanasia (E) have been debated and rejected in the UK parliaments in the past twenty years [3].

There is a dearth of studies researching the views of medical students in the UK [4]. Studies based on online questionnaires, indicate that overall the majority of students oppose PAS and their opposition increases as they progress through their training [4–7]. Identifying medical students’ opinions and encouraging students to widen their views is particularly important now, with increasing numbers of countries legalising PAS, such as Spain, Western Australia and New Zealand [8]. If PAS is to be legalised within the UK, there will be a direct impact on the future medical practice of current medical students.

The terminology in these debates is often misleading. We need to be clear about definitions:

Physician Assisted Suicide (PAS): Doctors prescribing lethal drugs at voluntary request of an adult with capacity to enable the patient to self-administer the drugs to end their life.

Euthanasia (E): Doctors prescribing and administering lethal drugs at voluntary request of an adult with capacity, with the intention of ending the patient’s life.

Both these activities may be included in the term Assisted Dying (AD).

In this paper we describe an innovative workshop designed to explore the students’ views on legalising PAS, with graduate-entry medical students in a newly opened medical school. This workshop provided an opportunity for a diverse group of international and home medical students to reflect on their attitudes towards a sensitive topic.

Learning outcomes

By the end of the workshop, participants had an opportunity to:

• Identify difficult communication issues surrounding the request for PAS.

• Gain confidence in listening and responding to a request for physician-assisted suicide.

• Participate in a group discussion to identify reasons both for and against legalising PAS.

The workshop

Ground rules, Responding to a request for PAS, The consultation, Key messages from the goldfish bowl, Group discussion on legalising physician assisted suicide

Three students and the facilitator planned the session and discussed the roleplay of a patient and a GP in a Goldfish bowl [9]. None of the students had used this form of role play previously. Forty students sat in a large circle, the ‘patient’ and the ‘GP’ in the centre, with monitor screens at each end and a large whiteboard. The session was led by a facilitator and three students. The group began by agreeing the following ground rules to promote a safe environment for discussion.

Ground rules

• Confidentiality

• Time out

• Honesty

• Positive critique

• Open to possibility

• Respect

• Don’t take yourself so seriously

Responding to a request for PAS

The facilitator introduced the principles of a goldfish bowl technique. All the students in the circle were involved in the role play as it is their task to supply the ‘GP’ with the dialogue in response to the ‘patient’s’ comments or questions when the facilitator stops the role play. The ‘GP’ enacted various suggestions and the students saw how the patient reacted to the dialogue they had supplied.

The case history was read out to all the students.

Case history

Esme, a 42-year-old teacher, has advanced pancreatic cancer with liver metastases. She is weak, jaundiced, in pain, nauseated, depressed, and confined to bed. She was discharged home from hospital two weeks ago as there were no further active treatments. Her discharge letter states that Esme and her husband Peter, an engineer, know her disease is terminal. Peter requests a home visit from her GP, Dr Broadway, “Esme is extremely distressed, in pain and vomiting her medication”.

Her two children Gareth 15, and Sheena 13, are at home on school holidays.

The consultation

One student assumed the role of Esme, the ‘patient’, while another student played Dr Broadway, the ‘GP’. The GP started by asking Esme how she was feeling and began to explore her concerns regarding her pain, when she interrupted him abruptly by asking, ‘Please doctor, will you help me to die?’

The facilitator paused the role play and opened the discussion to all the students to ask for their responses. Some students felt this was a difficult question and were uncertain what to say, others suggested saying that they were not permitted to do this, but after discussion, there was general agreement that the best way forward was to acknowledge that this was a difficult, yet important question and that time would be needed to explore exactly what Esme was asking for. Esme clarified that she wanted Dr Broadway to prescribe something that she could take to end her life. The role play was paused, and the students had a chance to discuss various strategies to help Esme and Dr Broadway. The consensus among the suggestions was for Dr Broadway to say that although he could not do that, perhaps a way forward was to look at what he and the primary care team could do to help her situation. Dr Broadway asked Esme what her main reasons for her request were. Esme explained that she could not face the pain and did not want to be a burden to Stuart and her children. The role play paused again, and there was a discussion as the students had a clearer idea of Esme’s concerns. Suggestions were made about improving her pain control and vomiting by using a syringe driver, providing extra support from the community nursing team and the local hospice community team. Regarding her feeling of being a burden, a student suggested that Dr Broadway asks Esme what she would feel if roles were reversed, if Stuart was the patient in her situation. Esme responded, ‘Of course I would want to look after him at home’. Dr Broadway suggested that this was exactly how Stuart and her children felt about her care.

The discussion moved on to practical ways of supporting Esme at home and ensuring that her symptoms were controlled. This concluded the role play and the students playing Esme and Dr Broadway were de-roled and rejoined the group.

Key messages from the goldfish bowl

• The exercise provided an insight into the complexity of discussing challenging topics such as PAS.

• Students learned some new approaches to responding to a patient’s request that they were unable to meet.

• Patients may have underlying hidden concerns which take time and mutual trust to uncover.

• Engaging in roleplaying within a classroom setting provided an enriching educational experience for all participants, as it facilitated the exploration of a realistic scenario in a safe environment.

Group discussion on legalising physician assisted suicide

The group took part in a discussion on PAS led by the facilitator. Firstly, participants were asked where they stood in relation to the legalisation of physician assisted suicide in the UK. They were directed to stand in a straight line according to their views, with those who were for physician assisted suicide at one end of the line, and those who were against at the opposite end. The space in between was occupied by those who were not sure. Participants were asked to think about the reasons behind their decision to stand where they chose. It was clear that before the discussion there was a range of views across the room.

The reasons for legalising PAS

The students were asked to consider why legalisation would be a good idea, no matter what position they took. This resulted in an open conversation rather than the usual polarised debate. Among the reasons they gave were:

• Autonomy – it&s my choice

• Fear of future

• Burden to others

• Suffering – prolonged dying

• Able to be open about suicidal ideas

• Dignity-maintaining a positive perspective of self

• Avoid travelling to Switzerland

• Cost

• Stimulate better healthcare

The reasons against legalising PAS

The students were then asked to suggest reasons against legalising assisted suicide. Among the reasons given were:

• Irreversible

• Slippery slope argument

• People and circumstances might change

• Loss of trust in doctors

• Depression/mental illness

• Emotional toll on doctors

• Vulnerable people at risk-pressure on people with disabilities

• Coercion

• Sanctity of life

Each of the suggestions was recorded by a student and discussed in the group. This gives just a flavour of the rich conversation where everyone had to reflect on both sides of the argument, but it is beyond the scope of this article to go into the details.

Student opinion survey

An online survey was conducted after the workshop to ascertain whether there was any trend in the students’ views as a result of their discussions in the workshop. A small majority were in favour of legalisation of PAS before the workshop (55%), 30% were against PAS and 15% were unsure. After the workshop almost 25% of students said they had a change of view. Of those whose views had changed from supporting PAS, 10 of the 11 students showed a trend towards being unsure or against PAS.

Workshop evaluation

Following the session, students were asked to complete a written evaluation. Responses were generally positive, with students reporting that the session was ‘interesting’, ‘thought-provoking’ and ‘insightful’. Feedback about the format of the discussion was also positive, ‘Very interactive and laid back, made the session very engaging’, ‘Brilliant session and really enjoyed the fishbowl’. Others included constructive feedback, ‘Would be great to share opinions anonymously’ and ‘Not enough time for debate’. Overall, students expressed positive attitudes about future workshops on different subject matters.

Discussion

The workshop gave students the opportunity to explore a wide range of views on both practical and moral issues involved in the legalisation of PAS. Students gained an awareness of how to approach difficult questions from patients when they could not accede to their request. They had an experience of goldfish bowl role play, where no patients get hurt and students felt safe to express their views and try out a variety of communication strategies. The activity provided real world relevance with the scenario being a real-life scenario. The participants could experience the practical application of their skill set and management techniques which connected them to both physical and emotional elements of care. They also had an opportunity to observe the varying perspectives from peers who differ in viewpoints, including analysing nuances they may have missed.

Whilst there are limitations of the methods used in this workshop such as a lack of contribution by less confident students to freely express their views, there are still benefits to be obtained. Moreover, such workshops can be replicated in discussions in other topics of great debate in the UK such as abortion, healthcare funding, privatisation, and mental health.

Conclusion

The use of an interactive workshop to explore the views about legalising PAS of medical students proved to be an effective way to stimulate discussion. The goldfish bowl exercise gave students the opportunity to immerse themselves in a simulated doctor-patient consultation on a request for PAS. This was followed by a facilitated group discussion that explored the different perspectives and concerns raised by the students. After the workshop, a number of students reported that their views had altered, with majority reporting a shift towards opposing the legalisation of PAS. These interactive methods can stimulate reflection and result in a change of opinion.

Acknowledgments

We would like to thank all the first-year graduate medical students at the Three Counties Medical School, University of Worcester for their contributions to the success of workshop and for their enthusiasm. David Jeffrey would like to thank the Winston Churchill Trust for the award of a Churchill Fellowship in 2006 to study PAS in Oregon, USA.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.