Some people say the Crown Prosecution Service (CPS) should publish guidelines to indicate under what circumstances it will prosecute assistance with suicide and when it won't. Wouldn't such clarity be helpful?
I've heard it said that some doctors are already practising euthanasia against the law in order to help dying patients out of their suffering? Is this true? And, if it is, wouldn't it be safer for all patients if Parliament regulated the practice by making a law to control it?
Another commonly-heard statement is that doctors are administering overdoses of analgesics to dying people in order to kill their pain but knowing that it will result in their deaths? Is this true? And, if it is, what is the difference between this and euthanasia?
Patients have the right to refuse or halt treatments, even if they are told by their doctors that they will probably die as a result. So why can't they have a right to ask their doctors to bring their lives to an end?
But doctors can withhold or withdraw life-sustaining treatment without a patient's consent. Isn't that just passive euthanasia? And, if a doctor can withdraw such treatment without consent, surely he should be able to administer euthanasia at the patient's request?
Pro-euthanasia campaigners say they support good palliative care and that, where assisted dying has been legalised, palliative care services have improved. Doesn't that suggest that palliative care and assisted dying can exist side by side?
Palliative care in Britain may be of outstanding quality, but not everyone has access to it – there's something of a postcode lottery. Doesn't this strengthen the argument for legalised assisted dying as an alternative for dying people who are suffering?
Assisted Dying Overseas
I've heard it said that in countries where assisted dying has been legalised has proved beneficial, with more open discussions of dying between doctors and patients and with no evidence of abuse. Is this true?
Assisted Dying and Religion
But why can't people with personal moral objections to assisted dying stand back and let others who don't share their views have this facility? Why should they be allowed to impose their views on others?
Answers to Above Questions
Euthanasia may be defined as the intentional killing by act or omission of a person whose life is not thought to be worth living. It may be:
Voluntary – where the person concerned requests it
Involuntary – where the person has not requested it
Non-voluntary – where a person is not in a position to request it (eg he or she is in a coma or suffering from dementia)
Traditionally, euthanasia is associated with distressing medical conditions. However, with rapid advances in the science of pain relief and palliative care generally in recent years, there has been a shift in the case made by its advocates for its legalisation (see below under 'Assisted Dying').
Physician-assisted suicide (PAS) is where a doctor prescribes lethal drugs, at a patient's request, for the patient to take himself.
Euthanasia and PAS together are often referred to by the portmanteau term 'assisted dying'. That is the term used in this FAQ Brief to refer to both practices: where we refer to one or the other individually, we use 'euthanasia' or 'PAS' as appropriate.
Assisted Dying is illegal in Britain and in most other countries in the world Euthanasia is legal only in The Netherlands, Belgium and Luxembourg, while PAS is legal in The Netherlands and the US States of Oregon and Washington. Assisted suicide has been legal in Switzerland since 1942 but not as part of the health care system or specifically within the context of serious illness
In Britain euthanasia is indictable as murder and carries a maximum penalty, on conviction, of life imprisonment. Assistance with suicide is illegal under the Suicide Act 1961, which decriminalised suicide itself (meaning that charges are no longer brought against those who attempt to kill themselves) but retained the prohibition of assistance with suicide, the maximum penalty for which, on conviction, is 14 years imprisonment.
Suicide was decriminalised, not because it was regarded as acceptable, but as an act of compassion after the event. There was a recognition that anyone who attempted to take his or her own life was in distress of one sort or another and that it was inhuman to add to this by the bringing of charges against those who survived. However, society has maintained its abhorrence at and disapproval of suicide. This is shown in, for example, the support given to the strenuous efforts made to resuscitate those who have attempted suicide and to the regimes, such as 'suicide watches', which are put in place where individuals are considered to be at risk of taking such action.
The continued prohibition of assistance with suicide also recognises that assistance with suicide may be given for non-altruistic reasons – for example, to be rid of a care burden of an elderly relative or to expedite an inheritance – and that, without the protection of the law, vulnerable people would be at risk. The European Court of Human Rights recognised this need in 2002 when, in refusing an Appeal from the House of Lords to allow assistance with suicide in a particular case, it commented that 'the [UK] law which criminalised assisted suicide was designed to safeguard life by protecting the weak and vulnerable…against acts intended to end life or to assist in ending life' .
The law is there to deter crime as well as to punish it. Its absolute prohibition of euthanasia and assisted suicide, together with the maximum penalties available on conviction, means that anyone contemplating these actions has to think very carefully and to understand that a serious breach of the law is involved. This deterrent effect is almost certainly a factor of the low incidence of these crimes in Britain.
However, though the law itself is absolute, its administration has enough flexibility to allow compassion to be shown to really 'hard cases' while at the same time awarding more severe penalties to cases of clear abuse. The sentences allowed are expressed as maxima, and it is not uncommon for people convicted of euthanasia or assisted suicide to receive lesser penalties, or indeed not to be prosecuted at all, if the circumstances of the offence are such as to warrant it. Pro-euthanasia campaigners are fond of telling us that decisions not to prosecute or to award lesser penalties mean that 'the law isn't working'. In fact, the law is working exactly as it should – it is using a stern face to deter breaches and a compassionate heart in dealing with deserving cases. Because of the law's deterrent effect, the cases which hit the headlines are often the really 'hard cases' where compassionate treatment is considered appropriate. They are no guide as to the cases we might see if these actions were to be legalised.
Experience shows that, when exceptions are made to laws, the conditions laid down soon become extended and exploited for other purposes than those originally intended. The 1967 Abortion Act is a good example. Safeguards may sound reassuring in principle, but the ones we have seen in recent 'assisted dying' bills are not robust enough to stand up to the rough and tumble of the real world – the personal stresses which surround terminally ill people and the everyday pressures on clinical practice. The safest course is the one we have now – to ban these actions outright (which makes people think very seriously before contemplating them) and to deal on their merits with any breaches that occur. After all, we wouldn't seriously consider making laws to allow stealing or injuring in prescribed circumstances. So why should we consider doing so in the case of killing or assisting with suicide?
Q. Some people say the Crown Prosecution Service (CPS) should publish guidelines to indicate under what circumstances it will prosecute assistance with suicide and when it won't. Wouldn't such clarity be helpful?
Again, this sounds reasonable in principle, but consider what it would mean in practice. We have a law that forbids assistance with suicide but the CPS has discretion not to prosecute in certain circumstances – for example, if there isn't enough evidence to sustain a prosecution or if it is felt that it is not in the public interest to do so. These decisions, however, can only be taken after the event, when a crime has been committed and the precise circumstances are known. To expect the CPS to publish advance guidelines would, in effect, be turning it into a consultancy service for intending law-breakers. Should the CPS be asked to tell us how much we can steal before being charged with theft or how much injury we can inflict without being charged with assault? Of course not! In any case, no guidelines could cover every situation or remove the need for investigation after the event of whether, for example, coercion had been involved in individual cases.
The case for assisted dying has undergone something of a shift of emphasis in recent years. 20 years ago or more there was little pressure for it, but what there was was focused on the relief of pain and other distressing symptoms of the dying process. In the last 20 years, however, there have been remarkable advances in medicines and techniques for pain control and in palliative care more generally. Dying in pain or with other symptomatic distress is now much rarer than it was and there is no reason nowadays why anyone, given expert palliative care, should not die peacefully and with dignity. Where we hear of 'bad deaths', it is usually because the spread of palliative care, both around the country and within the health service, hasn't kept pace with the remarkable advances that have taken place in quality.
Ironically, the advances which have been made in palliative care have been accompanied by an increase in the stridency of demands for legalisation of assisted dying. The reason for this is that the campaigners are now basing their case on different arguments. Recognising that modern palliative care has largely dealt with the old problem of pain and other symptomatic distress, they are now arguing that assisted dying should be available as another end-of-life choice for people whose distress is existential rather than clinical. The main pressure group, Dignity in Dying (formerly the Voluntary Euthanasia Society) recently stated that 'no amount of good palliative care can address some patients' concerns regarding their loss of autonomy, loss of dignity and loss of control'. Pro-euthanasia campaigners say that they support investment in good palliative care, which they see as the answer for the majority of terminally ill people. Their case for assisted dying is now that a minority of terminally ill people who want, instead of or in addition to palliative care, control over when and how they die should have 'the right to have an assisted death'. In other words, as medical science has advanced, the case for legalising assisted dying has changed. It is now centred on the promotion of personal autonomy and control rather than on symptom relief.
Sound law-making has to balance intended benefits against potential harms. This 'balance of harms' issue is seen in other laws. For example, some people say they would feel safer if they were allowed to have personal firearms. But they aren't allowed to do so on the basis that, while carrying guns may help some people to feel safer on the streets, the end result would be more hazardous for the rest of us. 'Knife crime' is another example.
The same principle applies here. There is a small minority of people who are resolved and clear in their minds that, when their time comes, they want to go quickly and, if necessary, by their own hand. Indeed, a lot of people make statements of this sort when they are healthy and there is no serious prospect of death. But those who work day in and day out with the dying know that this isn't a representative picture of terminally ill people as a whole. While a few people who say they want assisted dying are serious, in most cases there is something else behind their question. This may be physical - a distressing symptom that needs palliation; or psychosocial - they may want an honest discussion with their family; or emotional – they may be depressed or in despair; or spiritual - wanting answers to questions such as 'Why me?' and 'Why now?' Depression is particularly common in terminally ill patients and often leads to suicidal thoughts; and yet in most cases it can be effectively treated. Terminally ill people often have undisclosed concerns about the care burden they are placing on their families or about consuming funds in nursing care which they want to leave to their children. Some of them raise the subject of assisted dying with their doctors – which they can do safely in the knowledge that, because it is illegal, they won't be taken at their word. Almost invariably, these moods pass and those concerned go on to die natural and peaceful deaths.
But consider what would happen if the door to assisted dying were to be opened by a change in the law. A minority of self-reliant people might welcome this, but the great majority of terminally ill people would lose the protection which the law now gives them. They would feel less happy about talking frankly with their doctors, for fear that their thoughts might be taken at face value, and they could well be tempted to embark on a course of action which they would not otherwise have contemplated but which they were choosing for the sake of others rather than themselves. And this is to say nothing of the scope for external coercion which could be brought to bear, however subtly, by friends or relatives who wanted to get a sick relative off their hands or were looking to expedite a useful inheritance.
In other words, changing the law would provide a facility for a determined few, but at the cost of exposing much larger numbers of vulnerable people to harm. These concerns were recognised by a Parliamentary Select Committee on Medical Ethics in 1994, which had this to say after examining whether assisted dying should be legalised:
'We concluded that it was virtually impossible to ensure that all acts of euthanasia were truly voluntary and that any liberalisation of the law in the United Kingdom could not be abused. We were also concerned that vulnerable people - the elderly, lonely, sick or distressed - would feel pressure, whether real or imagined, to request early death.'
This unanimous conclusion has been endorsed by Parliament every time the issue of legalising assisted dying has been raised since then. Parliament has taken the view that priority must be given to protecting the vulnerable, and it is hard to see how this conclusion can be faulted, especially now that we have high-quality palliative care.
Safeguards may sound reassuring, but we have to ask ourselves the question – would they be effective in practice? Let's look at some of the 'safeguards' we've seen in recent assisted dying bills. An applicant would have to have mental capacity. Does that include freedom from depression, a very common condition among terminally ill people? It's perfectly possible to be depressed and yet to be fully compos mentis. Do we want assisted dying for people who are suffering from transient depression? Even if people with depression are ruled out, could its existence be spotted by doctors? Oregon's experience suggests not. A recent independent survey of the working of the Death with Dignity Act there, which allows PAS, has revealed that as many as one in six of those who have taken their own lives with lethal drugs supplied by their doctors were suffering from treatable depression which their doctors had failed to detect when assessing them. Though assisted dying bills usually prescribe that, in cases of doubt, an applicant should be referred for psychiatric evaluation, this rarely happens in Oregon in practice – only in about one in ten cases; and yet it's clear that it should be happening. Then there is freedom from coercion. A doctor may be able to spot obvious external coercion by relatives, though that's far from certain. But could he be sure of detecting internalised feelings of guilt at being a burden on the family? Assessments like this go beyond a doctor's clinical competence. But conditions like this are as common among terminally ill people as they are difficult to spot.
These are just a few examples. Others include the difficulty of estimating how long an applicant has to live, and even whether or not someone is really terminally ill. According to the Royal College of Pathologists, one in twenty post mortems reveals inaccurate diagnosis, including whether the person concerned was terminally ill. Medicine is far from being the exact science that the general public thinks it is.
On the face of it, that may appear to be so. Comparison of death rates in the few countries which have legalised the one or the other indicate that fewer people are prepared to resort to it.
However, while PAS might be regarded as the safer of the two options in terms of the take-up rate, its legalisation nonetheless poses serious risks. For example, where does PAS leave people who are incapacitated to the point that they cannot self-administer lethal drugs? Legalising PAS would lead quickly to demands for legalising euthanasia in such cases. Even among patients who are capable of self-administration, what assurance could there be that this had in fact taken place. In Oregon, where patients who qualify for PAS are given a prescription to use as, when and where they see fit, there is no way of knowing whether those who take the prescribed drugs have done so themselves or have been helped – perhaps encouraged or even coerced – by others. And what happens if ingestion is followed by medical complications: this sometimes happens in Holland and doctors then find themselves in the position of having to 'finish off' the patient with euthanasia.
In any case, from an ethical point of view there is no difference between PAS and euthanasia: in both cases the intention of the doctor is to end the life of the patient. PAS is simply 'euthanasia one step back'. And it is seen by the pro-euthanasia movement simply as a first stage in the process of legalising euthanasia.
Let's begin by defining what we mean by this term. The 'slippery slope' is a metaphor. The argument is that, just as it can often be difficult to get a firm foothold once you have embarked on an icy surface, so it is difficult to enact assisted dying legislation which will apply in limited conditions without it spreading, once the principle has been conceded, into unintended areas. Is there any evidence that this has happened. Yes, there is.
In Holland, the 2002 law which legalised voluntary euthanasia and which was effectively a codification of existing practice has already been extended, via the Groningen Protocol (see below under Assisted Dying Overseas) to encompass involuntary euthanasia for seriously-ill new-born children. The Dutch Euthanasia Society is pressing for further extension of the law to include people with dementia, and there is even talk among Dutch campaigners of legalising an 'end-of-life pill' to be available from pharmacists. A similar process is happening in Belgium following legalisation of euthanasia there. It is also the case that legalisation has failed to stamp out illegal euthanasia in Holland. There are estimated to be considerable numbers of illegal acts over and above those declared under the law.
Though the formal position of the pro-euthanasia movement in England and Wales is to limit assisted dying to the terminally ill, campaigners are also supporting suggestions that chronically ill people who want to commit suicide in Switzerland should be told how far their friends and relatives can go in assisting them to do so without being prosecuted. And in Scotland we have seen proposals by the MSP Margo MacDonald for euthanasia not only for the terminally ill but for people with degenerative illnesses, for those who have become incapacitated and for anyone 'who finds their life intolerable'. The suggestion has also been made, by Baroness Warnock, a supporter of legalising assisted dying, that people with dementia are wasting the lives of others and the resources of the NHS and ought to consider whether they should remove the burden they are creating by ending their lives.
Introducing his second assisted dying bill to Parliament in 2004, Lord Joffe candidly told a select committee that he and the campaigners saw it as a 'first stage'. It would be foolish not to heed his words.
Assisted dying is contrary to the Hippocratic Oath, which includes the undertaking that 'I will give no deadly medicine to anyone if asked'; and its condemnation by the World Medical Association was reaffirmed in 2005. Here in Britain, all the Medical Royal Colleges and the British Medical Association have declared their opposition to a change in the law. Their objections reflect concerns over the contradiction between assisted dying and sound medical ethics and over the dangers that legalisation would create for vulnerable patients. Nor is this simply a case of the 'top brass' losing touch with the grass roots. Opinion polls among doctors in the field show substantial opposition to a change in the law to allow assisted dying. Opposition is strongest (over 90%) among doctors who work closely with dying patients and are most familiar with the modern treatments available. These results are hardly surprising. Doctors have everything to lose and nothing to gain from the legalisation of assisted dying. It is they who would be charged with doing the assessing and prescribing (or administering) of lethal drugs, and it is they who could find themselves in front of the General Medical Council or even the Courts if they got it wrong – and, as observed above, some of the judgements they would be required to make go beyond a doctor's normal clinical competence.
Q. I've heard it said that some doctors are already practising euthanasia against the law in order to help dying patients out of their suffering? Is this true? And, if it is, wouldn't it be safer for all patients if Parliament regulated the practice by making a law to control it?
There is no hard evidence to support allegations of this nature. What evidence there is consists of anonymous surveys of doctors, some of which suggest that there may be a very small element of euthanasia taking place. One of the most recent of these surveys was conducted by Brunel University and it compared estimates of illegal action by doctors in Britain with similar action in other countries, including countries (like Holland and Belgium) which have legalised euthanasia. The Brunel survey found no incidence of physician assisted suicide in Britain at all and a rate of illegal euthanasia which was described in its report as 'extremely low' – a small fraction of one percent of all deaths. The survey also concluded that the rate of illegal action by doctors in Britain was lower than in most other countries of Europe, and much lower – interestingly - than in those countries which had legalised assisted dying. In other words, where euthanasia has been legalised, illegal action by doctors is greater than in Britain, where it remains illegal. These conclusions contradict the claims of pro-euthanasia campaigners that, if the practice were to be legalised and regulated, whatever illegal activity there is would cease.
A parliamentary select committee, which examined this question recently and on which both advocates and opponents of euthanasia sat, came to much the same conclusion. It accepted that 'human experience shows that all laws are flouted to a greater or lesser extent' but it pointed to various factors – for example, the prevalence of team-work in clinical practice and the increasing tendency of people to litigate if they suspect malpractice – which discouraged law-breaking by doctors. The select committee's conclusion was that covert euthanasia was not a common phenomenon in Britain. So, don't worry! It's safe to go into hospital or to be treated by your GP!
Q. Another commonly-heard statement is that doctors are administering overdoses of analgesics to dying people in order to kill their pain but knowing that it will result in their deaths? Is this true? And, if it is, what is the difference between this and euthanasia?
This is a common misconception. Very rarely, when strong doses of analgesics, such as morphine, are given to patients who are close to death, they may have the secondary effect of shortening life - although with modern palliative care this occurs in less than one case in a thousand. It is known as the principle of 'double effect' - when an action is taken for a good purpose (in this case to relieve pain) but has a bad effect as well (hastening death) The 'double effect' principle can be seen in other areas of clinical practice, apart from pain-relief in people who are close to death. Chemotherapy, for example, can sometimes have harmful as well as beneficial effects, and surgery can occasionally result in the death of a seriously ill patient. The intention, however, is not to do harm but to deal with the patient's condition. And intention is all-important in ethics. If a patient dies as a result of 'double effect', there has been no breach of medical ethics or of the law. Assisted dying, on the other hand, is designed deliberately to bring the patient's life to an end and, for that reason, it is both unethical and illegal.
It is important not to get this matter out of proportion. 'Double effect' is a very rare occurrence indeed these days. If pain is being appropriately treated with analgesics, the toxic dose (ie the dose capable of killing the patient) is virtually always very much higher than the therapeutic dose (the dose sufficient to relieve pain or other distressing symptoms). It is almost always possible therefore for a skilled palliative care physician to kill the pain without any risk at all to the patient's life. On very rare occasions, when a dying patient is close to death, it may be necessary to sedate him or her in order to relieve the pain adequately, but even here it is the disease process which kills the patient, not the treatment. It is important not to make the elementary mistake of assuming that, because one action follows another, it has been caused by it. There will always be a last dose of any drug for a dying patient, just as there will always be a last cup of tea. But we should not jump to the unfounded conclusion that the patient has died because of the drug, any more than that the drink has caused his death.
Q. Patients have the right to refuse or halt treatments, even if they are told by their doctors that they will probably die as a result. So why can't they have a right to ask their doctors to bring their lives to an end?
A patient's right to refuse treatment exists in order to ensure that he or she is not subjected to unwanted treatments: for a doctor to administer treatment without a patient's consent would constitute assault. But patients don't have the right to demand specific treatments. In good clinical practice a doctor will take account of a patient's wishes as regards specific treatments, but in the last analysis treatment decisions have to be based of a professional assessment of the resultant benefits and risks to the patient. To base them solely on the patient's wishes would change the nature of the doctor-patient relationship fundamentally. It would turn it into a simple commercial relationship between a customer and a supplier, in which the patient's wishes are paramount, and it would remove from clinical practice what the General Medical Council has called 'the principle of beneficence and non-maleficence' – meaning that a doctor has a duty to protect a patient, even from the patient himself if necessary.
In any case, it is necessary to look at the reasons why a patient might refuse life-sustaining treatment or ask for it to be halted. It may not be in order to die. Patients who ask for treatment to be halted, more often than not do so simply because they are finding the treatment too burdensome: they may accept that they will probably die as a result but that isn't why they ask for the treatment to be halted. And, even if a patient does halt treatment because he wants to die, that's not the same thing as the patient ending his life. It's the illness which is doing that; the patient is simply accepting that it should take its natural course. If a patient dies after asking for treatment to be halted or after refusing treatment, that doesn't constitute suicide in either law or ethics. By contrast, assisted dying involves a decision to end life ahead of its natural course, and it is therefore both illegal and unethical.
Q. But doctors can withhold or withdraw life-sustaining treatment without a patient's consent. Isn't that just passive euthanasia? And, if a doctor can withdraw such treatment without consent, surely he should be able to administer euthanasia at the patient's request?
There is no such thing as 'passive euthanasia'. Euthanasia – or, for that matter, assisted suicide – involves a deliberate intention to end someone's life. It is an active process with the defined objective of bringing a life to an end. Withholding or discontinuing treatment, on the other hand, usually has different objectives. Often it is because it is considered that a treatment would be futile or dangerous for the patient or because, having been tried, the treatment has proved ineffective. Every surgeon has encountered patients who demand operations which would do no good or could even be dangerous for them: such requests have to be refused. If a patient dies after treatment being withheld or withdrawn, this isn't euthanasia unless it was the doctor's explicit intention to end the patient's life. If the doctor's intention was not to kill the patient: but the act was simply an acceptance that further treatment was futile, burdensome or dangerous, and that there was nothing further that could be done to stop the illness taking its natural course, this is good medical practice and not euthanasia.
In any case, it is not unknown for treatment to be halted and for patients to survive, and in a few cases even recover. At the end of the day it is the illness, not the physician, that kills the patient. Doctors aren't magicians: they cannot always save their patients' lives and they cannot predict with complete certainty what will be the effect of a decision to withhold or withdraw futile treatment. What is important is that they should save lives where they can rather than bring them deliberately to an end.
As observed above, the relationship between a doctor and a patient is more than just a commercial relationship between a customer and a supplier. It involves what the General Medical Council has called 'the principles of beneficence and non-maleficence'. In simple language, this means that a doctor must always act in what he perceives to be the patient's best interests, even if those interests aren't apparent to the patient at the time. It is this relationship which enables patients to place complete trust in their doctors.
Pro-euthanasia campaigners tell us that, where assisted dying has been legalised, patients continue to trust their doctors – indeed, we are told, they trust them more because they can discuss assisted dying with them as a legal option. This argument doesn't stand up to close scrutiny. Of course people say they trust their doctors in countries which have legalised assisted dying. They have no realistic alternative but to trust the doctors they have. The question is not whether they do, but whether they can, trust their doctors. We are not saying they can't, we are saying that simple statements that they do prove nothing.
Moreover, as observed above (see under Assisted Dying), patients who live in countries where assisted dying is illegal are able to raise the subject with their doctors secure in the knowledge that they will not be taken at their word. This is an important safeguard for those terminally ill people – the majority – who raise the subject with their doctors, not in order to secure assisted dying, but as a means of seeking reassurance about their prospects or of dealing with other issues of importance to them. Legalising assisted dying may encourage a franker exchange of views between doctors and a small minority of patients who are serious about ending their lives – but it is an inhibiting factor for the majority.
Palliative care is a relatively recent branch of health care. Its origins go back to the foundation, by the late Dame Cicely Saunders in the late 1960s, of the modern hospice movement and her recognition of the need to treat 'total pain' – physiological, psychological, spiritual and social – in people who are dying. There have been huge advances since then, and especially in the last 20 years, in the knowledge that physicians specialising in palliative medicine have of how pain-relieving drugs work and of the techniques for using them. As a result of these break-throughs, it is now possible for specialists in palliative care to tailor pain-relief programmes to the needs of individual patients and to ensure that relief from pain is constant rather than intermittent.
Palliative medicine is, however, just one component, albeit a major one, in the overall discipline of palliative care, which includes specialists in many other fields with knowledge and skills to help relieve suffering. Specialist palliative care teams often include, for example, physiotherapists, social workers, psychologists and chaplains as well as specialist doctors and nurses. This joint-working recognises that the suffering which many terminally ill people experience is multi-faceted and not limited to pain and other symptomatic distress. Palliative care teams from time to time encounter requests for assisted dying, but almost invariably these disappear once effective symptom control has been achieved and those concerned come to appreciate the empowerment which good palliative care can give them over the remainder of their lives.
It is important not to make the mistake of viewing palliative care in Britain as just a 'death-bed science'. It is much more than that. More than half of all patients admitted to hospital palliative care units or hospices for symptom control and other support services return home, with their conditions stabilised, and are able to live normal or near-normal lives for months, sometimes even years.
Though palliative care is generally associated with the treatment of terminally ill people, it is also available for the much larger numbers of people who are not dying – in the sense of having a terminal prognosis – but are suffering from illnesses which, though not immediately life-threatening, cannot be cured and are likely to cause lasting discomfort or other distress – for example, multiple sclerosis, heart and lung disease, Parkinson's disease. Many palliative care treatments available to dying people are able also to help chronically ill people to cope with their conditions.
Q. Pro-euthanasia campaigners say they support good palliative care and that, where assisted dying has been legalised, palliative care services have improved. Doesn't that suggest that palliative care and assisted dying can exist side by side?
Of course the pro-euthanasia movement supports palliative care: it would be difficult for anyone to say they didn't. They see palliative care as the answer to the suffering of the majority of dying people, but they want to have assisted dying for a minority of people who may or may not want palliative care but want, above all, to control the manner and timing of their deaths (see above under 'Assisted Dying').
The claims that legalising assisted dying has led to an improvement in palliative care services in other countries should not be taken at their face value. In the first place, the standard of palliative care has improved in most developed countries over the last 10 years or so, simply as a natural consequence of advances in clinical knowledge and practice generally. But that doesn't mean the improvement stems from the legalisation of assisted dying. Secondly, it is necessary to recognise that what many other countries mean by 'palliative care' is not what is meant by the term in Britain. Take, for example, the US State of Oregon, where PAS was legalised in 1997. We are told that palliative care here has improved over the last 10 years and that most dying people in Oregon are enrolled in hospice programmes. What we are not told is that Oregon does not have in-patient specialist palliative care beds in hospitals or the intensive four-year palliative care training programme for practitioners that we have in Britain. To many Oregon doctors palliative care is little more than a personal and part-time interest. The statement about hospice enrolments is also potentially misleading. Most hospice care in Oregon is of the 'hospice at home' variety, with patients being visited by doctors and district nurses with a knowledge of palliative care. While we have similar programmes in Britain, they are supplemented here by a network of in-patient hospices staffed by specialist palliative care practitioners. Moreover, a patient who wishes to be funded for hospice care in Oregon has to renounce a right to curative therapy and to accept that care will be limited to palliation. Palliative care in Oregon is also largely limited to end-of-life care, whereas in Britain it is a specialty applicable to chronic as well as terminal illness.
There is simply no comparison between such a system and palliative care in Britain. Indeed, a recent report by Brunel University (see above under 'Medical Ethics') concluded that in the UK there was 'a culture of medical decision-making informed by a palliative care philosophy'.
Q. Palliative care in Britain may be of outstanding quality, but not everyone has access to it – there's something of a postcode lottery. Doesn't this strengthen the argument for legalised assisted dying as an alternative for dying people who are suffering?
Palliative care has been under-funded. We have to recognise that, with rapid and sometimes expensive advances in most branches of medicine, resource allocation within the NHS involves difficult choices between competing priorities. That said, palliative care is a relatively low-cost form of health care with the potential to benefit tens of thousands of people – after all, we are all going to die one day and many of us will need palliative care. The Government has recently published its Strategy for Care at the End of Life, which has reaffirmed a commitment to increase funding and to improve coordination of clinical, social and other services. One thing that is certainly needed is to ensure that the advanced palliative care knowledge and skills which exist in specialist hospital departments are cascaded among non-specialist health care professionals, such as GPs and District Nurses, who have most contact with terminally and chronically ill people.
Does the resource gap strengthen the case for assisted dying? No, for two main reasons. First and foremost, the campaign to legalise assisted dying in Britain centres around people who either don't want palliative care or want something in addition to it. The main campaigning group, Dignity in Dying, stated in one of its recent publications that 'no amount of good palliative care can address some patients' concerns regarding their loss of autonomy, loss of dignity and loss of control'. The statement continued: 'We therefore believe that patient choice should include the right to a medically assisted death'. The campaign to legalise assisted dying isn't therefore about inadequacies of palliative care. It's about giving a minority of highly self-reliant individuals the right to ask their doctors to help them end their lives at a time and in a manner of their choosing. And, second, if assisted were to be legalised, it could well have an adverse impact on the development of palliative care. Assisted dying provides a bolthole for lazy doctors: it's so much easier and cheaper to end, or help to end, a patient's life than to control what can sometimes seem to be intractable symptoms. The arguments of pro-euthanasia campaigners that palliative care has improved where assisted dying has been legalised are illusory (see above).
Assisted Dying Overseas
Q. I've heard it said that in countries where assisted dying has been legalised has proved beneficial, with more open discussions of dying between doctors and patients and with no evidence of abuse. Is this true?
Let's take an example of legalised PAS and one of legalised euthanasia – Oregon and Holland, respectively. On the face of it, Oregon doesn't look too bad – with PAS accounting for about I in 700 of all deaths. But the figures of deaths from PAS, which are derived from annual reports by the Oregon Health Department, don't tell the whole story. The Department collects statistics on the numbers of PAS deaths reported, but it freely admits that its data rely on voluntary reporting by prescribing. There is no central prescriptions registry in Oregon which could pick up illegal prescribing. In other words, there is no sure way of knowing whether the apparently low numbers of reported physician-assisted suicides are the same as the actual numbers. The Department's reports also show that reported cases of PAS come from a limited number of Oregon physicians writing prescriptions. Most Oregon doctors won't participate in PAS, with the result that patients are 'doctor shopping' and in some cases receiving prescriptions for drugs to end their lives from doctors who have little knowledge of them beyond their case notes. Third, and perhaps most important, evidence has emerged that the conditions for PAS are in some cases not being adhered to as strictly as they should. Recent independent research has shown that as many as one in six of those who took their own lives via PAS were suffering from treatable depression which the prescribing doctors should have detected or at least referred for psychiatric evaluation. Since Oregon's PAS law came into force in 1997 only 1 in 10 applicants for PAS has been referred to a psychiatrist for examination, though depression is a well-known phenomenon of terminal illness.
Now let's look at Holland, where euthanasia and PAS have been legal since 2002. The death rate here is much higher – a UK parliamentary select committee estimated it in 2005 at 1 in 38 of all deaths, most of it from euthanasia as opposed to PAS. Indeed, if estimates of illegal euthanasia are added, the death rate rises to as high as 1 in 32. Illegal euthanasias – ie those without consent or where consent cannot be given – persist in Holland, giving the lie to the often-repeated claim that 'regulating' assisted dying by legalising it brings the practice into the open. As observed above (see under Ethics), a recent evaluation of estimates of illegal assisted dying in Britain and in various other countries has indicated that the incidence of such action in Britain is 'extremely low' while it is much higher in countries, including Holland, which have legalised it. Moreover, in 2005 a legal agreement was reached (the Groningen Protocol) whereby Dutch doctors may end the lives of seriously ill new-born children.
Assisted Dying and Religion
It's perfectly true that people with religious convictions are usually opposed to the legalisation of assisted dying. The practice runs contrary not only to Judeo-Christian beliefs but also other faiths including Islam, Sikhism, Buddhism and Hinduism. But opposition comes from a much wider spectrum of opinion that this. As observed above (see under Ethics), all the Medical Royal Colleges and the BMA are opposed, and opinion polls show that the great majority of doctors and nurses support this stance. Are they all motivated by religion? Of course not. And there are others in all walks of life, with or without a religious faith, who are opposed to assisted dying on grounds of either human ethics or public safety. The suggestion that opponents of assisted dying are just religious zealots is simply an attempt by pro-euthanasia campaigners to marginalise the opposition.
Q. But why can't people with personal moral objections to assisted dying stand back and let others who don't share their views have this facility? Why should they be allowed to impose their views on others?
They are not imposing their views on anyone. They are saying that they think it's morally wrong and arguing that it shouldn't be done. They have no power to insist that they are listened to. In any case, if you believe that something is wrong, for whatever reason, you surely have a civic duty to warn others against it. To do otherwise would be socially irresponsible: it's called passing by on the other side. If we are to have a civilised debate on assisted dying, there must be no muzzling of opinions. No one suggests that support for assisted dying comes mainly from secularists and humanists and that their views should be discounted because of their beliefs. The same treatment should be extended to people with moral objections to assisted dying, whether these are based on religious beliefs or not.
Q. How do you counter the claim that, according to opinion polls, four out of five people say they favour a change in the law to allow assisted dying?
Many polls of this nature are based on answers to Yes/No or Either/Or questions with no explanatory context and without other options - eg good quality palliative care - being offered. The language used can also be misleading. If people are asked whether there should be 'medical help to die' for those who are 'suffering unbearably', many of them will picture patients wracked by agonising pain which is not being relieved and they will tend to agree with the proposition. But, as explained above (see under Palliative Care and Assisted Dying), the reality is very different. The symptomatic suffering of terminal illness can be controlled with modern medicines and skills; and the suffering for which legalisation is being sought is in most cases the existential suffering consequent on loss of personal mobility and independence. While such distress is undoubtedly real, it is not what most people understand by the phrase 'unbearable suffering': yet this latter term continues to be used by campaigners.
Even where polls do not use misleading language, we do not know how many of those who say they would favour a change in the law are expressing a committed view based on careful thought and how many are simply giving the answer that sounds the most appropriate. Assisted dying is a highly complex subject on which there is widespread ignorance. How many people, for example, are aware of what modern palliative care can do or have thought through carefully and balanced the risks to most terminally ill patients of changing the law against its benefits to a few who want assisted dying? Similar opinion poll results can be obtained on other subjects – such as capital punishment, the European Union or immigration – about which people often feel strongly but know little. Parliament has not allowed itself to be stampeded by opinion polls into legislating on these issues: it should continue to do the same with assisted dying and to concentrate on the facts rather than the spin.