Opinion: What are the implications of an Assisted Dying Bill?

I have been following the debate on assisted dying in Scotland for over a decade now. The latest proposal of the Assisted Dying for Terminally Ill Adults (Scotland) (SP Bill 46) was placed before the Scottish Parliament in March.

When the Scottish Parliament conducted its consultation on this Bill in late 2021, it had a record number of respondents (over 14,000). Of those, 78 per cent were strongly in favour of the introduction of assisted dying legislation. When only the public responses were considered, that figure rose to 80 per cent. 

If the consultation response is reflective of the public and political mood, and the Bill passes the Scottish Parliament’s due process to become law, some interesting considerations for the pharmacy profession arise. These can best be summarised under the headings of ethics, supply route and distribution, active pharmaceutical ingredients (APIs), formulation and manufacture.

Conscience clause

Within the Bill there is a conscience clause that would allow healthcare professionals to opt out of participating in assisted dying, and the Royal Pharmaceutical Society has welcomed such an inclusion. 

From a pharmacy perspective, should someone invoke that clause, it could be argued that they will still have to ensure the citizen is informed of where they could access such provision, similar to what happens with other pharmacy services such as emergency hormonal contraception. 

The provision of the API is likely to be a NHS service and with most citizens wanting to experience a pain-free, dignified death at home, I can understand why the community pharmacy supply route will be considered. This is further strengthened by the likelihood of a community pharmacy having been heavily involved in the palliative care of someone with a terminal illness, and that pharmacy will have grown to know them and the support structure around them. 

Some pharmacy teams may therefore see the provision of an API, with a defined outcome, as an extension of care, while others could find such a supply a difficult challenge.

“If the Bill passes the Scottish Parliament’s due process to become law, some interesting considerations for the pharmacy profession will arise”

What has not been decided and is not included in the Bill, rightly so, is the selection of the specific API(s) to be supplied. In the jurisdictions that have enabled assisted dying, the APIs vary greatly – and I know the team and advisers that drafted the Scottish Bill are considering all the available evidence from across the world 
on this matter. 

The common theme, which will come as no surprise to pharmacy registrants, is that controlled substances are used, either as individual APIs or in combination with other POMs. Full compliance with the Misuse of Drugs Act 1971 will therefore be necessary across the entire pharmacy supply chain.

Formulation advice

Turning to formulation, it will, in my opinion, require the citizen to combine the supplied API with a suitable diluent immediately before oral consumption. This will minimise stability issues and allow compliance with the section in the draft Bill that requires self-administration by the consenting citizen. 

Advice on how to do so, including tackling potential swallowing difficulties caused by certain terminal illnesses, would be best provided by pharmacy professionals, who are all trained to advise on appropriate formulation and preparation.

Finally, the sourcing of the API, the quantity involved and the necessity for supply in good time means that the product is likely to be supplied via a pharmaceutical specials manufacturer. The supply chain therefore needs to be robust enough to be able to deliver the API without delay. Advising a citizen, carer or family member of a delayed supply of this nature would be distressing for all. 

As the Bill progresses through the Scottish Parliament, I will monitor progress and report on any further pharmaceutical aspects that arise.