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“Most of the time I don’t have much fun. The rest of the time I don’t have any fun at all” (Woody Allen).

This blog is short of laughs but please read on, for it considers a truly vital question: should the law be changed to allow doctors to prescribe lethal drugs with the aim of ending the life of a patient? It is partly prompted by Rachel Aviv’s excellent but disturbing article “Letter from Belgium: The Death Treatment”  in the June 22 2015 edition of The New Yorker and partly prompted by the Assisted Dying (No 2) Bill which is to be debated in the House of Commons on 11^th September 2015.

Things I’d rather not think about.

“Neither the sun nor death can be looked at with a steady eye”   La Rochefoucauld,  .

Britain in 2015 does not “do” death, dying or grieving very well. Generally they are kept out of sight, out of polite conversation and out of mind until they force themselves upon us. Even top medical specialists who have to deal with these issues regularly find it hard, as I discovered when my Mother was dying of leukaemia in hospital in London and the consultants avoided eye contact and preferred not to acknowledge that her life was ending. Robert Peston became a media story when he flouted convention by speaking about his grief and the clumsiness of his male friends after his wife died^[1].

Another painful subject, that can give grief, death and dying a run for their money is dementia. To watch a loved one gradually being taken away by dementia is to witness a sort of living death. Then there is the fear of losing one’s independence, and fear of the pain that cannot be controlled by drugs and the fear of dying itself. All this against a backdrop of alarming inspection reports by the Care Quality Commission which raise the possibility that though advances in medicine may allow us to live longer, the time gained may turn out to be a fate worse than death. (A paradox nailed by Woody Allen’s insight that “Life is full of misery, loneliness and suffering—and it’s all over much too soon”)

Against this background, it may at first seem unreasonable and uncaring to oppose a change in the law intended to ensure that a competent adult can make up his/her own mind when and how to die, but I want to explain some of the reasons why this is not so, and why the Assisted Dying (No 2) Bill 2015^[2] which aims to amend the law to allow medics to assist people to die would be damaging for society as a whole, and a step too far.  A step we would be wiser not to take.

the bill addresses the wrong problems.

First we should be clear that if the bill is passed it will do nothing to address people’s fears of growing old alone. It will not address fears of increasing dependency or of being at the mercy of inadequate social and health care. It will not help anyone suffering from dementia^[3]. Rather than making it legal for doctors to prescribe lethal drugs as if they were a cure, we should be putting the necessary money and thought into providing reliable and good social, health and palliative care for all who need it regardless of post-code. This would go some way towards removing the fears associated with the end of life and it would do so without the darker consequences of the present bill referred to below. The wider topic of how one provides care for an aging population is the subject of Professor Atul Gawande’s stimulating Reith Lectures^[4] and his well-researched and accessible book “Being Mortal: Medicine and What Matters in the End”^[5] but this is a subject that cannot be considered further in this blog. Instead I shall briefly set out the main reasons I believe the proposed bill should be opposed.

Death is not just an individual matter.

Supporters of the bill present the issues it raises as matters of individual choice. They argue that one should be allowed to choose the time and manner of one’s death but they fail to acknowledge that changing the rules so that doctors can administer lethal drugs with the intention of ending life has implications for society as a whole. It is not just an individual matter. This is one of the reasons why the arguments about what the law should be are so very difficult. One of the many perplexing issues to be faced is, at what point must the autonomy of the individual yield to the greater good of society as a whole? Different people will have different views, depending upon how they perceive the possible risks to society but we should all be able to acknowledge that giving supremacy to the choice for the individual has significant consequences for society as a whole just as we should acknowledge that the law as it now stands gives supremacy to society as a whole and limits individual choice.

allowing doctors to prescribe lethal drugs intending to cause death will change the doctor/patient relationship.

Quite apart from undermining trust between doctor and patient, the doctor who administers lethal drugs is changed by the process.   Anyone doubting this should read “Dancing with Mr D: Notes on Life and Death” which is the memoir of a doctor working for the terminally ill in a nursing home in Holland^[6].

“Always to care, Never to kill” was the title of an article in which thirteen eminent ethicists explained why they believed euthanasia^[7] to be contrary to the faith of Jews and Christians and based on a grave moral error, and why it undermined the medical profession. Though written in 1992 the article remains pertinent and powerful^[8].

Allowing this patient to choose death-by-doctor will affect other patients.

If you permit a doctor and his/her medical team to assist a patient to die by prescribing and supplying poisonous drugs then this will become a ‘treatment option’ in all but name. This has profound ramifications which have not been adequately publicised.

It is surely likely that when lethal drugs become an available ‘treatment’ option the freedom to choose to receive them may subtly become a duty to request assistance in dying. The obligation to choose death will be unspoken but none the less experienced as real by the person concerned. Advances in medicine allow us to live longer and increase the years of life in which we are likely to be dependent upon others. Such dependency, viewed objectively, imposes obligations upon others. An elderly person may (perfectly reasonably) come to feel that they are a burden to others. Such a person may then feel compelled to hasten his/her death because he/she feels an obligation to do something to remove the burden. Can one really say that choosing to die in these circumstances is a truly voluntary choice? I don’t think so.

I would rather err on the side of caution and want to be very sure that we do not create a society in which someone who is vulnerable or dependent feels an obligation to hasten their own death by asking for a lethal drug.

who matters?

To permit assisted suicide to some categories of people is to tiptoe along the path towards becoming a society in which some lives are valued more than others. This raises the possibility that some lives may in time be regarded as ‘lives not worth living?’ Of course nothing could be further from the intention of those who propose the present bill, but it does not make any difference that one’s motive for allowing assisted suicide is merely to give the right of self-determination to the competent adult, nor that one did not intend to imply that some lives were of more value than others.

the arbitrary  restrictions in the bill are not sustainable.

Since the justification for changing the law is the belief that people should be allowed to choose their own fate, it is hard to see how some of the restrictions in the bill will be sustainable in the long term, and hard to see why they were included in the first place (unless they are merely intended to make the bill less controversial in the short term). The bill will only allow someone to be helped to die if he/she is over 18, competent, ‘reasonably expected to die within six months’ from an ‘inevitably progressive condition’ and has been ordinarily resident in England and Wales for not less than a year^[9]. The point is succinctly made in “Always to care, Never to Kill”

“Arguments for euthanasia usually appeal to our supposed right of self-determination and to the desirability of relieving suffering. If a right to euthanasia is grounded in self-determination, it cannot reasonably be limited to the terminally ill. If people have a right to die, why must they wait until they are actually dying before they are permitted to exercise that right? Similarly, if the warrant for euthanasia is to relieve suffering, why should we be able to relieve the suffering only of those who are self-determining and competent to give their consent?”^[10]

It must only be a matter of time before a competent adult who suffers from a disease which he/she finds excessively burdensome and who has a clear and settled intention to die will argue that it is unfair, unjust and unreasonable to deny him a prescribed lethal drug which would be available if only he/she had a terminal illness since his suffering will be greater / last longer than someone with a terminal illness unless he is assisted to die.  It will then be said that it is the arbitrary requirement of the law is forcing him to suffer for an indeterminate period.

summary and Conclusion.

An independent committee: the New York State Task Force on Life reported as follows:

[embeddoc url=”http://www.howshouldibegin.com/wp-content/uploads/2015/08/when-death-is-sought.pdf” download=”all”]

There is also the inconvenient truth that no matter how settled someone’s intention to die appears to be, people change their mind.  Read Alison Davis’s evidence to the House of Lords in the context of an earlier bill to legalise assisted suicide…

Ms Davis: “I have two hats on. I am speaking as an individual today but I do co-ordinate a group for disabled people called No Less Human which is for disabled and terminally ill people, their families and carers. I have spina bifida and hydrocephalus, osteoporosis and emphysema. Nineteen years ago I wanted to die. I have severe spinal pain which is not well-controlled even with morphine. You will excuse me if I am a bit hesitant but I just took morphine 10 minutes ago so I am not quite as altogether as I might be. I have severe pain which cannot be well controlled. When it is at its worse I cannot move, I cannot think, I cannot speak and it can go on for hours; there is no prospect of it getting any better, in fact it is almost certain to get worse. Due to that and a combination of other factors, 19 years ago I decided I wanted to die. It was a settled wish; it lasted 10 years. In the first five of those years I tried to commit suicide several times. They were serious attempts, most of them, and I tried several different methods. I was saved only because my friends arrived in time. My door was never locked at that time and they came in and found I was losing consciousness and they took me to the hospital. At the hospital I was treated several times against my wishes. I told the doctors that I did not want to be treated. They asked for my permission to pump my stomach and I said no. They said, “If we don’t, you will die”. I remember at the time thinking in a very wry way that it was almost funny because that had been my intention; I had wanted to die. So they waited until I lost consciousness and then treated me anyway. Had the form of declaration which this Bill proposes been available at that time I would have signed it with no hesitation whatsoever because my intention was to die and I was suffering then the same pain which is unbearable—except that I have to bear it—that I am now. If the Bill had been law 19 years ago I would not be here speaking with you now. That, in a sense, would give my doctors, who at that time thought I was terminally ill, a very convenient self-fulfilling prophecy because they said I was terminally ill. Actually they were wrong and here I am 19 years later. Had my life been ended by the terms of this Bill nobody would have ever known firstly that my doctors were wrong and secondly that the future held something better for me than would have appeared to be the case 19 years ago. I was saved against my wishes.  I lived on. For 10 years I wanted to die. I note that the Bill has a 14 day waiting period during which the person requesting euthanasia can change their mind. That would not have served me at all: 14 days to change my mind when I wanted to die for 10 years. I think this Bill is extremely dangerous. It sets out supposed safeguards to prevent what is called abuse of what would be the law but I believe that the law itself would be an abuse of sick and disabled people. I sat in at the earlier session and I heard the discussion about people who wanted to commit suicide but cannot and need assistance. By describing safeguards to the Bill in effect we are saying that the sort of people that are specified are right to want to die and should be helped to die, whereas people who are not specified who may well be equally desperate to die and possibly for much the same reason would be considered wrong to want to die and would be helped to live. I think that sends out a very negative message to people like me who suffer on a daily basis and who need help and support to live with dignity. We hear so much about dying with dignity that it almost becomes a slogan or a catchphrase and it suggests that people like me are only dignified when we are dead. …”

For all these reasons the Assisted Dying Bill (No2) 2015 is bad public policy.   That should be enough reason to oppose the bill.

For Christians, there are additional profound and fundamental reasons why assisting someone to kill himself/herself is problematic.  .  As Prof Gilbert Meilander succinctly explained:

“Christians have held that suicide is morally wrong because they have seen in it a contradiction of our nature as creatures, an unwillingness to receive life moment by moment from the hand of God without ever regarding it as simply ‘our’ possession…  We might think of ourselves as characters in a story of which God is the author….characters do not determine the plot of their life’s story, and it is a contradiction of their very being if they attempt to bring the story to its conclusion. We are dependent beings, and to think otherwise—to make independence our project, however sincerely—is to live a lie, to fly in the face of reality.” (“Bioethics, A primer for Christians” 2nd Ed 2005, p 6)

A similar point was made by a group of Jewish and Christian theologians, ethicists, philosophers and scholars in “Always to Care, Never to Kill”

“As Christians and Jews, we have learned to think of human life -our own and that of others- as both gift and trust. We  have been entrusted to one another and are to care for one another. We have not been authorized to make comparative  judgments about the worth of lives or to cut short the years that God gives to us or others. We are to relieve suffering when we can, and to bear with those who suffer, helping them to bear their suffering, when we cannot. We are never to “solve” the problem of suffering by eliminating those who suffer. Euthanasia, once established as an option, will inevitably tempt us to abandon those who suffer. This is especially the case when  we permit ourselves to be persuaded that their lives are a burden to us or to them. The biblical tradition compels us to seek and exercise better  ways to care. We may think that we care when we kill, but killing is never caring. Whatever good intentions we might invoke to excuse it, killing is the rejection of God’s command to care and of his help in caring”

It is heart-rending to see a loved one in pain and suffering.  Rather than legalising death-by-doctor, we need to press our MPs to make available the necessary resources to ensure the provision of reliable social,  health and palliative care.

27/08/2015.

http://www.redonline.co.uk/red-women/interviews/exclusive-robert-peston-on-why-he-feels-bloody-lucky-again ↑

1. http://www.livinganddyingwell.org.uk/publications/parliamentary-business-bills-and-legislation/rob-marris-mps-assisted-dying-no-2-bill . To track the bill see http://services.parliament.uk/bills/2015-16/assisteddyingno2/stages.html ↑
2. Since dementia of itself is not a terminal disease and someone suffering from advanced dementia will not have mental capacity to demand that the doctor provides him/her with a lethal drug. ↑
3. Downloadable from http://www.bbc.co.uk/programmes/b00729d9/episodes/downloads ↑
4. http://www.amazon.co.uk/Being-Mortal-Medicine-What-Matters/dp/0805095152 ↑
5. http://www.amazon.co.uk/Dancing-Mister-Notes-Life-Death/dp/0552996912 (At the time of writing there are 13 used copies available for £0.01 each.) ↑
6. The borderline between ‘euthanasia’ and ‘assisted suicide’ is thin. A doctor who prescribes a lethal tablet assists with suicide. A doctor who puts the tablet on the tongue of a patient practices euthanasia. ↑
7. http://www.amazon.co.uk/Dancing-Mister-Notes-Life-Death/dp/0552996912 ↑
8. Section 2. ↑
9. http://www.firstthings.com/article/1992/02/006-always-to-care-never-to-kill ↑
10. http://www.leaderu.com/ftissues/ft9202/articles/documentation.html ↑