‘Assisted dying’ is a Rubicon we must not cross

Dr James Haslam

On 14 September, the British Medical Association (BMA) Annual Representative Meeting 2021 will debate motion 70:

‘That this meeting believes, in order to represent the diversity of opinion demonstrated in the survey of its membership, the British Medical Association should move to a position of neutrality on assisted dying including physician assisted dying.’

First, full disclosure: I am an unpaid member of the steering group for a campaign called Our Duty of Care (ODOC), [1] a branch of Care Not Killing for healthcare professionals, which opposes physician-assisted suicide (PAS) and euthanasia. Please don’t let this prevent you from hearing me out; as you’ll discover, my involvement in this debate comes from fresh and powerful experience – I volunteer because I passionately believe in this cause.

 

May I begin by disentangling a little terminology. ‘Assisted dying’ is a euphemism encompassing (and, I believe, employed to mask) the practices of PAS and euthanasia – the former describes the prescribing and dispensing of a lethal cocktail for a patient to self-administer; the latter describes the prescribing and administering by the doctor of an injection intended to kill. Does the Hippocratic Oath ring any bells?

‘Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course.’

It is worth noting that encouraging or assisting another’s suicide remains a criminal offence. [2]

Proponents of ‘assisted dying’, such as Dignity in Dying (previously known as the Voluntary Euthanasia Society), argue legalisation is necessary on the basis of three main arguments: control, comfort and compassion. Each of these arguments are problematic. There are limits to autonomy and the control we can exert over our lives; especially when the autonomy of a vocal few infringes upon the security of the many other vulnerable lives. [3]  As a consultant anaesthetist and intensivist who has managed the symptoms of many dying patients, I can honestly say I have never encountered an actively dying patient whose physical pain I have not been able to address. As to the compassion argument, that ‘we would never treat our pets like this’, I would say that compassion means caring for our patients, not killing them.

The BMA survey

Although ‘assisted dying’ would be introduced for those deemed to be in their last six months of life (you know as well as I do how poor we are at prognosticating that),4 this stipulation will inevitably and incrementally be extended to many other groups of patients – those with chronic illness, disability, even children. Not to do so would be seen as discriminatory.

It is interesting that in the survey that the BMA motion refers to,[5] the doctors most closely involved in the care of dying patients (palliative care physicians, GPs, oncologists, geriatricians) are some of the most opposed to ‘assisted dying’ – they know first-hand it is unnecessary, unethical and unregulatable. Despite half of those polled endorsing PAS, only a minority would be prepared to actively participate (‘OK, but someone else can do it’?).[6] There was no majority for euthanasia, neither in principle nor practice.

And PAS inevitably leads to euthanasia: it is actually quite hard to kill people who are not already actively dying. There are some patients who just won’t die even when they self-administer a lethal cocktail – some require a physician to finish them off. Why do you think prisoners on death row have a doctor on hand for the occasions when even the lethal injection fails?

Seventy-five years ago this month, the BMA held an international medical conference where the medical war crimes uncovered at the Nuremberg trials were discussed, including all kinds of ‘mercy killing’ – the natural nadir of the slippery slope that happens when doctors assent to the ideology that some lives are not worth living. The upshot was a statement submitted to the World Medical Association the following year:[7]

‘Although there have been many changes in Medicine, the spirit of the Hippocratic Oath cannot change and can be reaffirmed by the profession.
It enjoins:
The brotherhood of medical men.
The motives of service for the good of patients.
The duty of curing, the greatest crime being co-operation in the destruction of life by murder, suicide…’

The World Medical Association recently reaffirmed its opposition to both PAS and euthanasia.[8] ‘Assisted dying’ is not progressive, a moving with the times. It is regressive and goes against the grain of thousands of years of Western medical culture.

‘The consequences would be grave’

Proponents for ‘assisted dying’ argue that there will be conscience clauses for objectors. In other jurisdictions, and even with other controversial practices in the UK, these have proven to be weak. Already the proposed conscience clauses mandate ‘effective referral’. Be in no doubt, this would fundamentally alter the fabric of our profession, there would be no patient nor doctor untouched by, even complicit with, this ‘new’ practice – the consequences of its implementation would be grave indeed.

Do we want to live in a society where families subtly coerce their elderly relatives to ‘do the right thing’? Where patients fear presenting to their doctor with a worrying symptom in case the diagnosis entails discussion, even urging (we both know there are doctors who will), to take the ‘easy way out’ (next level ‘protect the NHS’)? Where parents are stopped in the street and questioned as to why they have not already euthanised their disabled child? Or where doctors are no longer troubled by their conscience after their umpteenth ‘assisted death’? I certainly don’t. The only viable safeguard against abuse of the vulnerable and the coarsening of medical conscience is the current status quo: prohibition of assisting suicide. This is a Rubicon we must not cross.

Perhaps I could finish with a story. Greg was 62 years of age when he was told by his doctor he had early onset Alzheimer’s dementia. He was still working, but retired the day after his diagnosis. He had been well off and highly intelligent, reading two to three books a week for his entire adult life, and authoring various books of his own. With a background, diagnosis and prognosis like this, one might think Greg was a prime candidate to take matters into his own hands and arrange a trip to Dignitas. On the contrary, with the diligent care of his wife Ruth and support from the wider family, and latterly with assistance from professional carers, Greg bravely faced five-and-a-half years of living, ultimately dying, with dementia.

This story is true. Greg and Ruth are my parents and, as I write this, my precious father Greg died a few weeks ago. Only 2 days before his death, with eyes sparkling, he gave my mother a last kiss. He died in my parents’ living room and, along with my family, I was there for his passing. He received high-quality palliative care, along with wonderful Marie Curie nursing during those last couple of difficult nights. I can assure you he was dignified until the end. The trauma of watching him die would only have been worsened by watching him expire prematurely, us having intentionally ushered death into that living room, rather than let nature take its course.

The antidote to ‘assisted dying’ – to the fear of loss of autonomy, of indignity and being a burden at the end of life – is empowerment of patients and their families with high-quality health, social and palliative care. Let’s campaign to properly resource that.

So then, my medical comrades, please take heed. The legalisation of ‘assisted dying’ is not inevitable. As the well-known aphorism says: the only thing necessary for the triumph of evil is for good [wo]men to do nothing. Please let your BMA Representatives know you wish them to vote down motion 70. Write to your MP and ask them to vote against Baroness Meacher’s ‘Assisted Dying Bill’ when it is debated in the House of Commons. And please sign ODOC’s letter to the Secretary of State for Health and Social Care, the Rt Hon Sajid Javid MP, endorsing the ‘spirit of the Hippocratic Oath’ in the World Medical Association’s opposition to physician-assisted suicide and euthanasia.[1]

Dr James Haslam is a Consultant in Anaesthesia and Intensive Care Medicine at Salisbury NHS Foundation Trust.

Footnotes

1. Our Duty of Care. Available at: https://ourdutyofcare.org.uk

2. Legislation.gov.uk. Suicide Act 1961, Section 2. Available at: https://www.legislation.gov.uk/ukpga/Eliz2/9-10/60/section/2.
Accessed September 2021

3. Fewer than one GB resident a week travels to Dignitas: http://www.dignitas.ch/images/stories/pdf/statistik-ftb-jahrwohnsitz-1998-2020.pdf
There are over half a million UK deaths annually: https://www.ons.gov.uk/aboutus/transparencyandgovernance/freedomofinformationfoi/deathsintheukfrom1990to2020

4. White N, Reid F et al. A systematic review of predictions of survival in palliative care: how accurate are clinicians and who are the experts?
PLoS ONE 2016;11:e0161407 [full text]

5. British Medical Association. Physician-assisted dying survey.  Available at: https://www.bma.org.uk/advice-andsupport/ethics/end-of-life/physician-assisted-dying/physicianassisted-dying-survey

6. Author’s note: This is a little like those people who would be prepared to receive a transplant organ but aren’t prepared join the organ donation register, only the context here is ending life not saving life.

7. Supplement to the British Medical Journal. British Medical Journal 1947;1:S127 [full text](subscription required).
Author’s note: Methods of ‘mercy killing’: gas, benzene injections, cremation of semimoribund individuals before death, etc.

8. World Medical Association. WMA declaration on euthanasia and physician-assisted suicide, 13 November 2019. Available at: https://www.wma.net/policies-post/declaration-on-euthanasia-andphysician-assisted-suicide/

 

This article was first published as an Opinions Blog 09/09/2021, at https://www.doctors.net.uk/blog/opinions/2021/09/09/assisted-dying-is-a-rubicon-we-must-not-cross

 

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