Opinion: Assisted dying

LilyThe Assisted Dying Bill returns to the House of Lords this week following high-profile interventions by the Archbishop of Canterbury, Justin Welby [£], and his predecessor-but-one, George Carey.

While the bill may receive a second reading in the Lords, it stands little chance of progressing in the Commons. This is because key MPs, including David Cameron and Nick Clegg, are firmly against it. I respect the sincerity of Cameron and Clegg’s concerns, but I also believe their stated views show that they have not approached the issue in the right way. It is vital that any debate in the commons is open and honest, and not skewed by prejudice or emotion. MPs could do worse than begin the debate by considering the views of the two archbishops, which actually advanced the quality of the public discourse quite significantly.

There are two groups of vulnerable people who would be affected by a change in the law – those who want help to die without excessive suffering and those who might feel under pressure to end their lives early because they feel they are a burden. In this situation, the correct approach is not to absolutise the rights of one group over the other – it is to balance their competing needs in the fairest possible way. Justin Welby argued that those who support assisted dying defend the rights of the terminally ill without thought for those vulnerable to pressure. Here he seems to be arguing for balance. But then he seems to return to a more one-sided way of thinking- he asserts that a change in the law would be ‘too dangerous’ for the vulnerable, but offers no argument as to why this should outweigh the harm and suffering facing the terminally ill. We can see that the temptation to absolutise on the side with which we feel most natural sympathy is strong. But this is obviously the wrong approach.

So what is the right balance – can a law with strong safeguards be justified if it spares some terminally ill people a desperately painful death? I believe that it can. It is important to remember that both affected groups of people are vulnerable. But there is a strong case to make that the terminally ill group are much more vulnerable. Indeed, vulnerable is not quite the right word – those who the bill aims to help face the near certainty of intolerable suffering. The strength of George Carey’s article in the Daily Mail was that he appreciated this. These people are directly in the firing line. They are also being asked to give up more of their autonomy over matters relating to their own bodies and their own suffering. At least members of the other group have a choice in principle and will often retain a fair measure of control, even though some might feel intense pressure.  It is true that there are more people in the ‘pressure risk’ group. But pure numbers are, it seems to me, countered by the greater degree of risk to the terminally ill group and the greater threat to their autonomy.

This is not enough to win the argument – clearly any new law must include rigorous safeguards if it is to be justified. But this is the point- there is a fine judgement call to make about whether any proposed safeguards can be enough to tip the balance in favour of a change in the law. It’s certainly not clear that they cannot and we must not rush to this conclusion.

Here, the right approach is to look at the evidence from countries which already have an assisted dying law. As Professor Raymond Tallis points out, in Oregon the slope has ‘refused to become slippery’. Numbers of deaths have levelled out at 0.02% of total deaths per year, and the Oregon Hospice Association initially opposed assisted dying, withdrew its opposition after eight years of the law, finding that there was “no evidence that assisted dying undermined Oregon’s end-of-life care or harmed the interests of vulnerable people”. The ‘intolerable pressure’ argument appears much weaker when we look at the empirical evidence. And of course, we are considering the argument in the context of very strong reasons in favour of allowing the other vulnerable group the control over their own death that they wish for.

Ethical judgements like this are never an exact science. Once we have set out the arguments clearly and fully on both sides, we need to come to a decision. But we must set out the arguments clearly, and we must recognise that this is a balancing act like any other policy involving competing rights or interests.  In this case, I believe it is clear that the decision should be in favour of an assisted dying law, providing the safeguards are properly worked out.

Our politicians may disagree, perhaps for good reasons. But if so, I want to hear them engage with the evidence, argue over the safeguards, and explain why the balance should tip the other way. I do not want to hear woolly arguments about the sanctity of life, one-sided judgements based on personal experience, or speculative doom-laden predictions made without looking at the evidence. These kinds of responses let down the vulnerable people in our society who so desperately seek a small measure of control over the nature of their own death.

 

* James Harper works for a Liberal Democrat MP specialising in Asylum and Immigration casework. The views expressed are his own.

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17 Comments

  • If government has one job it’s to protect us from being killed by other people. Killing must remain illegal, even if it is dressed up in dishonest terms like ‘assisted suicide’.

  • James Harper 15th Jul '14 - 4:44pm

    Don’t think that’s quite right- the government should protect us from being -unjustly- killed by other people. In any case, this is not euthanasia- the patient would be required to take the medication themselves.

  • R Uduwerage-Perera 15th Jul '14 - 5:12pm

    Dear Colleagues,

    As a Buddhist the entire issue of assisted deaths is one that causes me great anxiety, but I do not have a right to impose my beliefs on someone who finds themselves in a position whereby life itself is a punishment/torture.

    If my mind had not already been made up, it certainly was yesterday when the Guardian reported the words of Desmond Tutu who is calling for “mind shift” in the right to die debate:

    “I have been fortunate to spend my life working for dignity for the living. Now I wish to apply my mind to the issue of dignity for the dying. I revere the sanctity of life – but not at any cost.”

    Desmond Tutu further added and I agree with:

    “I can see I would probably incline towards the quality of life argument, whereas others will be more comfortable with palliative care. Yes, I think a lot of people would be upset if I said I wanted assisted dying. I would say I wouldn’t mind, actually.”

    My mind has been changed, and I suspect that many others will have as well and personally hopefully this will bring those suffering some hope for the future.

    Ruwan Uduwerage-Perera

    Liberal Democrat English Party Diversity Champion
    Ethnic Minority Liberal Democrat (EMLD) – Vice Chair

  • matt (Bristol) 15th Jul '14 - 5:33pm

    I would look at this proposal more charitably if I could be completely assured of a less target-led appraoch to paitent care, more adequate staffing, more training, and clear understanding of the existing legisaliton around capacity assessment, best-interests decision-making etc among GPs, senior nurses, and all staff on geriatric wards in NHS hospitals.

    I have met people who do not understand that their parents’s wishes are legally required to be consulted in advances respect of whether her resucitation treatment is to be witheld or withdrawn in the event of a terminal condition rapidly developing, and have conspired with the GP to withold details of the degree of the condition from someone who had no cognitive impairment on the grounds it would distress them. This is illegal. This is not understood. Don’t give people any more power they can inadvertently abuse, until the current system is working more like it should.

  • Peter Hayes 15th Jul '14 - 6:38pm

    Both of my parents died at the age of 90. My father had a stroke and had to move away from my mother into a not for profit care home. He made his own decision after over a year there and just gave up refusing food. My mother had several month in hospital becoming more confused as she was moved from ward to ward and then a cottage hospital for discharge assessment. The assessment just told me she had enough money to be moved out into a private home with 24 nursing cover. It took some time to start to arrange this, power of attorney etc. and she died before the move, I do not know if telling her made her give up or if the doctor who told me she would not live the night knew the morphine level they were administering but she was ready to go. If I was in their position my request would be very clear, if there is a conflict between pain relief and length of life let me go quietly.

  • Helen Tedcastle 15th Jul '14 - 7:30pm

    The article tries very hard to be balanced and it is commendable for that reason.

    However, I do not share the optimism regarding George Carey’s intervention nor the intervention from South Africa from Desmond Tutu. I do not share the cast iron safeguard argument of the supporters of the Falconer Bill, that Oregon’s example is a solid basis for protection of the weak.

    Here’s why. George Carey stated that his reason for changing his mind on assisted dying for the terminally ill was because of the Tony Nicklinson case. However, Tony Nicklinson was not terminally ill. He was asking for the introduction of Voluntary Euthanasia as practised in the low countries, where there has been a huge rise in cases of euthanasia for the elderly, the disabled and people who can find a doctor willing enough to kill them.

    So at once, his argument rested on a confused understanding of what is in the Falconer Bill and an emotional reaction to a very sad ‘hard case.’

    On Desmond Tutu – his argument rested on the case of Nelson Mandela and the fact that he was kept alive long after he should perhaps have been allowed to die. Tutu’s reaction to this is to suggest that assisted suicide is another choice but the real choice was for the family – not to insist that the doctors keep Mandela alive long after he should have been allowed to pass away peacefully. There is a difference between killing and letting die.

    Tutu does not seem to grasp this but as he said himself, he had not given the issue much thought until recently.

    The key issue for me is this: Is the law’s purpose to protect the weakest and most vulnerable members of society from unscrupulous carers and relatives? Is it there to protect/prevent the weakest from the subtle coercion of those same close relatives who suggest/hint that it is their responsibility to die? Is freedom of choice for terminally ill people really free if coercion is involved?

    Or Is it there to grant a few strong-minded people who have the will to commit suicide and will do so only if a doctor gives them the lethal drugs?

    If a culture of ‘normalisation’ of suicide for weaker groups takes hold, then the reasons for requests for assisted suicide will run along the lines of ‘being tired of life’ and ‘fear of being a burden.’

    In Oregon, only a third of patients stated ‘unbearable pain’ was the reason for requesting assisted suicide. Other reasons are the very existential ones noted earlier. As Lord Falconer’s bill is based on Oregon, it seems to me that the ‘safeguards’ are too weak and ambiguous to prevent a vulnerable person dying because of depression or another existential reason.

    After all, one the drugs are taken, there is come back – it’s a one way street.

    A liberal society must protect and prioritise the needs of the weakest and most vulnerable and for this reason, I am opposed to assisted suicide and any moves towards Voluntary Euthanasia.

  • Helen Tedcastle 15th Jul '14 - 7:34pm

    Correction to previous comment: After all, once the drugs are taken, there is no come back – it’s a one way street.

  • Jayne Mansfield 15th Jul '14 - 9:39pm

    @ Once ore I a gree with you Helen.

    It is important not to conflate palliative care and assisted euthanasia.

    Even before the hospice movement spread across the country, old style doctors had a saying,
    ‘ Thou shalt not kill and nor should thy strive , officiously to keep alive’.
    In the days when death took place at home, I remember front parlours where we as children sat and chatted whilst someone was dying in a bed that had been brought downstairs. I was never frightened because pain was adequately controlled by the family doctor who was not fearful of prescribing too much morphine when someone was terminally ill.
    They were not Harold Shipman, they were trusted doctors who used their judgment in accordance with the needs of the patient and without the fear of being struck off,

    Assisted euthanasia is a completely different matter. Already some disabled people are expressing their concern . The individual might ‘choose’ to die and take the drug themselves, but what pressure do they feel under because they feel or are made to feel a burden by their immediate careers or society at large?

  • Richard Church 15th Jul '14 - 10:46pm

    Helen, people living in extreme pain and disability are very weak and very vulnerable. You talk of subtle coercion, but there is nothing subtle about the coercion you impose on these people. You require them to stay alive against their will, in pain and suffering.

    The reason you give is that other people may be coerced into death against their will. No-one wants to see that, so suggest how better the legislation can be drafted to ensure that doesn’t happen. Maybe you have another reason, based upon a religious view aroung the sanctity of life, if so, then say so.

  • Helen Tedcastle 15th Jul '14 - 10:50pm

    @ Jayne Mansfield: Hi Jayne. Yes we seem to be losing as a society, our ability to deal with the end of life. My Grandmother’s generation were more matter of fact and the deceased family member was viewed by children and all the family.

    Now schools can actually fine families if children are taken out of school to even attend the funeral of an aunt or uncle. Another of Gove’s legacies to families.

    Assisted suicide elevates ‘free choice’ to the highest value and narrows the definition of compassion to ‘autonomy’.

    Personally, I think compassion has got to be wider than that when it comes to setting the law, and take into account the certain unintended consequences of taking away the full protection of parliament through prohibition.

  • Helen Tedcastle 15th Jul '14 - 11:03pm

    @ Richard Church. I have given my view and explained the key principles. You seem to think that sanctity of life is the only argument against assisted suicide. It isn’t. There are many key ethical reasons why this bill and euthanasia in general is positively harmful to society. I subscribe to them.

    I’m sorry but no one is coercing anyone to stay alive. Being alive is the natural state and everyone has the ability to die at any moment.

    In my area, several people a year jump off a local bridge and commit suicide. This is regarded as a social evil but in fact it was it was their choice. Should it be regarded as a social good?

    Now, those who advocate assisted suicide argue it is right to elevate to the highest value, the principle of free choice, even though all the evidence shows that most euthanasia and suicides among the elderly and sick are done out of fear of being a burden. Even in Oregon, only a third cite ‘unbearable pain’ as a reason for requesting assisted suicide.

    Also no psychiatric tests are carried out on these people before the doctors pronounce their verdict – why? Surely mental health and depression is the first thing to check – but no, not in Oregon. And Falconer says the safeguards are watertight.

    No they are not.

  • Richard Church 16th Jul '14 - 8:32am

    @ Helen Tedcastle. “Being alive is the natural state”. I am not sure what you mean by that. Many, maybe most of us have or will have our lives saved and prolonged by ‘un-natural’ medical intervention. Dying is also a perfectly ‘natural’ phenomenon which without ‘un-natural’ medical intervention can be slow and painful. Death is an equally natural state.

    Suicide is no longer illegal, as it was once. You or I can go and jump off a bridge if we want, but you will only permit people in the last stages of their life to kill themselves by the slow and horrible method of refusing food and water. I see neither the logic or the compassion in that.

  • Jayne Mansfield 16th Jul '14 - 9:07am

    I worry that the focus will move from palliative care and I do not believe that there are enough safeguards to prevent a move towards decisions that are made on behalf of the weak and vulnerable because they are too weak and vulnerable to make the decision themselves.

    I would be interested to know what doctors’ professional bodies have to say on this because it is they and not people like myself who will be expected to comply with any new law.

  • matt (Bristol) 16th Jul '14 - 10:00am

    Let’s put the funding into the NHS to ensure adequate training and staffing, and then we can have this debate. Whilst there is a risk that the culture that caused Mid-Staff Hospital to be investigated and prosecuted is still around, assisted dying is too much power in the hands of the untrained and overstressed.

  • Jayne Mansfield 16th Jul '14 - 10:18am

    @ Matt ( Bristol )
    I agree.

    Also, just managed to answer my own question, The Royal Colleges of Physicians and of. GPS oppose the bill.

    There seems to be so misunderstanding amongst the general public. The sad case of the late Tony Niichlinson is used as a reason for supporting the bill, but cases like his would not be covered by the bill.

  • Jayne Mansfield 16th Jul '14 - 10:21am

    Nicklinson

  • Helen Tedcastle 16th Jul '14 - 11:30am

    @ Richard Church: No side in this debate has the monopoly on compassion and mercy for the sick, so I’m not sure this statement is fair,

    ” …you will only permit people in the last stages of their life to kill themselves by the slow and horrible method of refusing food and water.”

    There is a distinct difference between killing and letting die.

    Most terminally ill people at the very last stage of illness are sedated or at least made comfortable. In the case of Tony Nicklinson, who requested Voluntary Euthanasia, he did I believe refuse to eat but Falconer does not cover his request, as he was not terminally ill. The bill would have to amended to cover the disabled and then we are into the realm of full-blown euthanasia.

    Perhaps Nicklinson could have been spared suffering if doctors and family had simply let him die when he had his terrible accident, rather than bringing him back from the brink. To me, that would have been the most compassionate approach.

    I repeat Richard, that changing the law to allow doctors to kill (by lethal drugs given to patients), is a rubicon I do not think we should be crossing as a society, because of the immense dangers to the most frail and vulnerable – which outweigh any benefit (in my view) to the strong.

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