Assisted Dying

Assisted dying: retrogressive, not progressive; nihilism, not liberalism

On September 11, the Second Reading of the Assisted Dying (AD) Bill takes place in the House of Commons. This would allow a terminally ill adult in England or Wales to have a lethal prescription for self-administration, supervised by ‘an attending health professional’ (doctor or nurse). The key prerequisite is a life expectancy of less than six months; the patient does not have to be in physical or mental distress.

      The Bill is not about long-term progressive conditions such as multiple sclerosis or dementia. Nor does it extend to incurable conditions such as post-stroke ‘Locked-in’ syndrome (e.g. Tony Nicklinson) or major disability caused by a road traffic accident (e.g. Paul Lamb).

      Opinion polls indicate that 60–80% of the public favour AD. In contrast, 80–90% of palliative care doctors are against. Why?

Self-determination (individual autonomy)

The main justification for such a fundamental change in the law is the right to self-determination: people should have the right to choose the time and mode of their death. Supporting arguments centre on the limits of palliative care and compassion (‘it’s compassionate to assist someone to die who is suffering unbearably; it’s cruel to force them to continue to suffer’).

      However, despite upsetting ‘horror stories’ (possibly some in your own family), palliative care does not (at least, should not) leave patients to suffer unbearably. As a ‘last resort’ option in extreme situations, it is permissible for a doctor to progressively increase the dose of symptom relief drugs even if this results in reduced consciousness and thus indirectly hastens death.

      The most appropriate response to horror stories is to increase the availability of specialist palliative care, not change the law. Interestingly, Lord Falconer has said that the primary reason for wanting to change the law is not uncontrolled pain but loss of independence and being reliant on other people.

      Restrictions on self-determination are legitimate if other people are likely to be endangered. Thus, the debate about AD centres on the question: can a law be devised which would allow terminally ill people to end their lives (should they wish to) without endangering others (who do not want to)? Advocates for AD claim that it should be possible, whereas others (including most palliative care doctors and nurses) claim that a change in the law would cause more harm than good.

      Already some people fear (and refuse) palliative care because they fear they will be ‘done away with’ – and suffer as a result. This number would surely increase if AD became lawful, enhancing the perception of doctors and nurses as potential killers.

Mutually exclusive philosophies

Although both sides claim compassion as a major motivation, palliative care and AD are essentially mutually exclusive philosophies. Palliative care is based on the belief that life has meaning and purpose up to the moment of death, whereas AD is essentially nihilistic. Expecting health professionals to deliver both palliative care and AD – to face in two directions simultaneously – is simply too big an ask.

      Sir Christopher Woodhead, former chief inspector of schools and an AD activist, died a few weeks ago. He suffered from motor neurone disease and cancer. Despite this, he earlier told a friend:

‘The only way you can deal with [terminal illness] is to live from day to day… The more limited your world, the richer it can become… There are benefits. You can be brought closer to people who love you. This has brought me closer to [my wife]. That is something to be grateful for.’

These sentiments reflect well the ethos of palliative care.

Desire to hasten death

The common denominator in patients who desire to hasten death is despair – a sense of hopelessness, helplessness and lack of control – related to actual (present) or anticipated (future) severe pain or other distressing symptom, loss of independence, and becoming a burden. The wish to hasten death is generally not constant unless the patient has a depressive illness, which normally responds to treatment. In practice, almost all patients change their minds when in receipt of high-quality palliative care. In fact, an expressed wish by a terminally ill person to hasten death does not mean they want AD; they want to be heard, to express their frustrations and fears, to be understood.

Prognosis

As noted above, the key criterion in the upcoming Bill is a life expectancy of less than six months. This is also the case in those States in the USA where ‘physician-assisted suicide’ is legal. Oregon has records going back 17 years, accessible on the internet (Oregon Public Health Division: Death with Dignity Act annual reports). These show that, after receiving their lethal prescription, more than 10% live longer than the mandated six months, some for 2–3 years.

      Indeed, in medical practice generally, instances of wildly inaccurate prognosis are not uncommon: some patients have outlived their initial prognosis by as much as 10–20 years.

Coercion

There is also risk of coercion: both doctor-on-patient and family-on-doctor. A Dutch doctor commented:

‘In the past, if I suggested euthanasia [a lethal injection administered by a doctor], nine times out of ten the patient would choose euthanasia; now when I suggest palliative care, they choose palliative care’.

In Belgium after 13 years of euthanasia, families much more consider dying as undignified, useless, and meaningless, even when it is peaceful. Demands for fast active interventions, particularly in relation to elderly parents, are increasingly direct.

‘Mission creep’

Once the barrier of legislation is passed, AD seems to take on a dynamic of its own. Last year, Professor Theo Boer, a member of a Regional Euthanasia Review Committee in the Netherlands, wrote:

‘Whereas the law sees assisted suicide and euthanasia as an exception, public opinion is shifting towards considering them rights, with corresponding duties on doctors to act… Don’t go there.’

Here in the UK, the law at present provides a clear boundary. It may occasionally be crossed by doctors (and others) but it is unambiguous. Indeed, it is perfectly consistent to argue that AD is ethically legitimate in some extreme cases but that it is wrong to change the law. As now, it could be better to allow hard cases to be taken care of by various expedients than to introduce new legislation which would inevitably become too permissive.

 

Robert Twycross is a retired palliative care specialist.

August 2015

 

Address for correspondence: robert.twycross@palliativedrugs.com

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