Suppose assisted dying were legalised in Britain tomorrow. How would we measure if that was a successful move or not? Would a low take-up justify having changed the law? Or a high one?
And what if the number of terminally ill people who sought recourse to assisted dying were to increase over time? Would that be a cause for concern? Or would it vindicate the legislation, simply showing that people were exercising rights previously denied to them?
These are the kind of critical questions MPs failed to ask in last week’s debate on assisted dying – the first in four years. Any serious consideration of the way legalisation could transform our whole culture in relation to ageing, chronic illness and dying was sorely missing.
The ethical nightmare we won't confront
Instead, MPs lined up to explain why they had dropped their previous opposition to assisted dying. From Nick Boles to Sir Vince Cable, one by one they registered their volte-face on the subject. And by doing so they abdicated their responsibility as leaders: to paint a vivid picture of possible future scenarios. They repeatedly refused to accept the invitation – one offered by Lyn Brown for example – to foresee the difference such a monumental step could make; indeed, even to acknowledge it would be a monumental step.
Assisted dying is a highly emotive and deeply distressing issue. I cannot begin to imagine the acute pain, profound fear and bewildering loss of control that is said to come with motor-neurone disease or the late stages of cancer. That suffering, those stories, must not be left out of deliberation. Nor should we dismiss the strength of such unwell patients’ desire for control over the manner and timing of their deaths.
But nor should we ignore the wider effects that a change to the law might have on society; how it would transform the experience of ageing, the dynamics of the family and the practice of medicine.
In his revealing speech to the House, Crispin Blunt invoked what he clearly viewed as the spectre of an ageing society: “By 2040 nearly one in seven people will be 75 or over,” he said. “More of us will have to grapple with surviving with the pain and indignity of crippling progressive infirmity later in life.” The solution to this? Care will only ever be one part. Providing an “escape from pain and indignity” through assisted dying will be necessary, he said.
Blunt insisted the vast majority would not take this route. But if assisted dying were being sold as a viable alternative to social or hospital care, that would surely normalise it, making it par for the course for an ageing society. Premature death could well become a cultural expectation.
Can we be trusted with euthanasia?
True, many of the MPs involved in the debate emphasised the restrictive conditions under which euthanasia might be legalised. Only terminally ill patients with six months to live would be eligible.
But, again, the politicians’ unwillingness to consider the consequences was breath-taking in its naivety. The fundamental logic of assisted dying – that I should have control over my death as I have had over my life – fundamentally clashes with this restriction. If we enshrine in law the principle that I should have control over the manner and timing of my death, why should that not be extended to the terminally ill patient with seven months to live? Or the person suffering from devastating mental rather than physical ill-health? Or someone simply tired of life? Do they not have an equal right to autonomy?
Indeed, at one point Steve McCabe voiced this very challenge to the six-month criteria. “Life expectancy in itself,” he said, “does not tell us anything about suffering.” Rather, if someone is given the right to choose, that right should extend to “a stage where he has no quality of life”. The six-month restriction is wholly arbitrary, McCabe was rightly saying. Thus, within the course of the debate itself, a member of the house, unnoticed, was sliding down the slippery slope from tight to lax restrictions.
The second massive transformation the legalisation of assisted dying would enact would be on the dynamics of the family.
Nick Boles assured the House that any assistance would require an independent assessment of the state of mind of the patient. Doctors and a High Court Judge would have to be absolutely persuaded that the person wanting to die did not “show any signs of coming to a decision under pressure or because they felt they were a burden”.
Boles was confident abuse would show up this way, refusing to countenance a picture of the future informed by the real-life contexts in which end-of-life decisions occur today. When we look unflinchingly at what happens when life draws to a close, we see complexity, dilemma and sometimes even abuse. Wills, inheritances, care costs – arguing over these do not always bring the best out of us.
So let’s fast-forward to a world in which assisted dying is now an option. An 85-year-old grandmother, no longer able to look after herself, has received a diagnosis that she is terminally ill and has only a few months to live. Does she go into a fiendishly expensive nursing home which will exhaust her lifetime’s savings? Or does she bow out? No one in the family has said a word to her. Yet she feels a pressure – her decisions have been complicated by the possibility of assisted dying.
Eventually, she settles on assisted dying. She’s not escorted to the clinic with a son holding a gun to her head. No grandchild has attempted to manipulate her. No one has said anything to her, in fact, so no independent assessment panel will pick up on overt coercion.
And yet, who’s to say that what’s really going on is a grandmother choosing to die prematurely because she feels she has become a burden? Are we really okay with that?
Who wants to live forever?
Finally, and most unsettling, is how the introduction of the law would transform medical practice. Again, no one in the debate mentioned this.
Answering the question of what had changed to justify reopening the assisted dying question, Nick Boles appealed to the Royal College of Physicians (RCP)’s decision in February to shift its stance from opposition to a neutral position on assisted dying.
Now, crucially, this only happened because a cabal at the top of the RCP changed their rules on how they determined their stance – as Fiona Bruce pointed out in the debate (another ignored intervention). Previously it was straightforward. The institution’s leadership adopted the most favoured option of their members – which is opposition to assisted dying. But this time it was decided that the College would default to neutral unless opposition secured a supermajority of 63%. So, extraordinarily, the leadership of the Institution no longer represents the dominant view of its members.
This move has masked the real attitude of most doctors, which is that getting into the business of assisting people’s deaths fundamentally changes the practice and also perception of the profession. According to the Hippocratic oath, the first duty of the doctor is not to harm (primum non nocere). And the distinction between intentional killing (administering barbiturates) versus letting die (turning off the life-support machine) protects doctors from becoming anything other than the helping profession.
If this distinction were to collapse, what would the country look like in 40 years time? Hospitals could be transformed from places of healing and care, to places of last resort, haunted by mistrust and fear.
The virtue of prudence involves making a good judgment about the present based on a sober assessment of the future. It is the virtue we expect from statesmen. Which is why we were let down last week. Instead of imagining future scenarios – not indulging in speculative fancy, but making predictions informed by a sense of history, by a sense of how things tend to go in the world – most MPs buried their heads in the sand. They should be ashamed of themselves.