In the NHS, doctors have no financial incentive to over-treat. But according to NHS gerontologist David Jarrett, British medical practitioners are usually driven to use all the means at their disposal to extend the lives of suffering seniors, regardless of the patients’ quality of life, out of fear of litigation. Physicians also fear families. Opponents argue that, if assisted dying were legalised in the UK, greedy families would pressure the elderly to bow out early, just so relatives can get their mitts on the money. The real problem is quite the reverse. Jarrett attests that it’s families who are most guilty of pushing doctors to pull out all the stops to keep loved ones, technically anyway, alive.

When Jarrett chose his specialty in the Eighties, gerontology was a niche field. It’s now the largest medical specialty in the UK. As he wrote in last year’s 33 Meditations on Death, he chose “to practise a branch of medicine where the relief of suffering took precedence over saving life. How wrong I was.” The book is full of anecdotes about elderly patients subjected to intrusive, often painful tests and treatments only to die anyway. That’s hardly the soft-focus sayonara scene we prefer to anticipate, with doting relatives gathered round, the tender saying of last things, and lots of pillows. Although most people poll as preferring to die at home, only one in five Britons do so. Most of us will die in hospitals or care homes.

In my latest novel Should We Stay or Should We Go, published today, I dramatised the hale old age and serene departure we’d all choose if we could. After the book’s central couple make a pact in their fifties to commit joint suicide once they reach the unimaginable age of 80, I spin out a dozen parallel-universe resolutions to this rash vow. In the penultimate chapter, “Once Upon a Time in Lambeth”, the couple reject their pact and in their old age sail gaily on to thriving second careers. They eat loads of vegetables. They exercise. Their sex life blossoms. Younger people revere them. They grow only more physically beautiful, and artists beg to paint their portraits. They never fall ill, and for minor aches there’s always aspirin. When they finally feel a curious sense of “resolution” at the ages of 110 and 111, they stage a huge party at their home, then nod off painlessly in their garden after a few blissful sips of vintage wine. What makes this exercise in positivity interesting? It’s absurd. Of all the outcomes for this couple, including cryogenics and a cure for ageing, in real life this is the one scenario absolutely guaranteed to never happen.

More from this author

Your gym routine is worthless

By Lionel Shriver

The reason most of us devote so little thought to how we want to end our lives is dread, and not merely of death. We’ve good reason to dread falling into the hands of modern medicine, whose practitioners, often with the best of intentions, can artificially drag out the very worst part of our lives. Extended life expectancy doesn’t mean we get to be young longer. We get to be old longer. There are indeed wonderful exceptions — like the extraordinary speculative fiction writer Ursula Le Guin, sharp and enchanting to her very end at 88. But most of us in advanced age will not be, shall we say, at our best.

Humans are not designed to live beyond a certain number of years. Our telomeres continually shorten. Over time, our cells no longer competently reproduce. Moving parts wear out. Yet steadily expanding life expectancy (now 13 years greater than when the NHS was founded) has fostered the unrealistic assumption that this average limit will only keep increasing. Any end point that’s eternally receding needn’t necessarily arrive. Death no longer seems inevitable, but the result of human error: some doctor failed to do his or her job. Death is an affront, over which our families should sue. As many do.

And so two-fifths of the NHS budget is spent on the over-65s. While the service spends an average of £2,000 per capita, for the over-85s that soars to £7,000. But we shouldn’t envy the recipients of such largesse. (How very much nicer to be gifted one of those sleek single-gear bikes with a titanium frame.) Many of us will rack up healthcare costs in the last six months of our lives as high or higher than the cost of our healthcare for all the years previous. In my 2009 novel So Much for That, an oncologist asserts that debilitating cancer treatments had probably provided my protagonist’s wife “a good three months”. “No,” the protagonist differs. “They were not a good three months.”

Suggested reading

The uncomfortable truth about death

By Dr John Lee

To enjoy anywhere near the autonomous, dignified end of days we’d want for ourselves and the people we love, it’s probably a mistake to wait for the medical profession to reform itself. We’ve arrived at a situation no one deliberately designed, and it has a life of its own. The sheer availability of treatments seems ipso facto to justify their employment. Those doctors wanted to replace my father’s heart valves, if only because they could.

Any proactive revolution may have to come from us patients. For young people to mar their precious insouciance by dithering over a distant twilight would be wasteful. But for those of us getting on in years, however unpleasant the prospect (and there will always be a task more terribly pressing), it’s time to devote serious consideration to the circumstances under which we’d prefer life-extending medical treatment be withheld.

This is a family matter. If we discuss with one another, ahead of time, what kind of end of life we’d find intolerable, maybe our families will be less inclined to press doctors to go to extravagant lengths to keep us in a world that holds no more savour.

Surprisingly, although these issues have been a consuming professional concern of late, I’ve never yet sat down with my own elderly father and asked him at what point he might wish to decline life-sustaining care. As he comes closer to death, its very mention starts to feel not only awkward, but like tempting fate. I’m anxious about seeming to indicate that his children want him to throw in the towel prematurely. But there must be a way of approaching the subject out of concern for him and for what he wants to happen, should he decline into a state at such odds with the ferocious man he’s been throughout the rest of his life.

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How France lost her dignity

By Michel Houellebecq

And for those without family — or trustworthy family — to honour our wishes, there are Advance Directives, one of which I just composed on my own behalf. Indeed, rather than dwell on what poems we want read at our memorials, all of us beyond about age-sixty ought to write a personalised record in which we spell out plainly in what circumstances we’d decline further medical treatment — even flu jabs and blood pressure medication, much less intubation or bone marrow transplants. Me, I’d call time with dementia, unrelievable pain, or a terminal diagnosis whose further odious treatment would only slightly delay the inevitable.

As children, we entertain what we want to be when we grow up. In late adolescence, we begin to choose a trade or career. In adulthood, we accept this job and decline that one, marry this person and not that one, settle in this town rather than another. Our plans are often frustrated, but at every stage most of us approach our futures with a degree of intention. The very last stage deserves the same purposive determination we’ve applied to all the others.

Granted, it’s difficult to foresee how our future selves will feel. But I’ve more confidence in the judgment of my younger self than in the presumably reduced version that might make any Faustian bargain to stick around. It’s the better me who doesn’t want to dwindle abed, no longer recognising my own brother.

Democrats contesting offices in areas where the party is not dominant (as it is in Ocasio-Cortez’ district) are running substantially more Left-wing campaigns than previous Democratic aspirants. And Abrahams and Gillum both put emphasis on mobilising the most Left-wing constituencies in their states—minorities and the young—with platforms to match on social and economic issues.

But how far Left is this surge? And what does it stand for? Can it really be compared with the hard Left radicalism seen elsewhere across the globe?

Rhetorically, this new Leftism rejects ‘business as usual’ and involves a sweeping indictment of the economic and political system for generating inequality and doing little to help ordinary people in the wake of the great financial crisis. Substantively, Democrats today – in particular aspirants for the 2020 Democratic Presidential nomination – are far more willing to entertain and endorse ‘big ideas’, such as going beyond the ACA, aka Obamacare (which is now vigorously defended) to ‘Medicare for all’, free college education, universal pre-kindergarten provision, vastly expanded infrastructure spending and even a guaranteed jobs programme. Taxing the rich is ‘in’ and worrying about the deficit is ‘out’.

Further reading

Could the Democrats' blue wave unseat Trump?

By Amanda Whiting

Democrats are also highly unified on core social issues such as opposing racism, defending immigrants, promoting LGBT and gender equality and criminal justice reform. In short, the centre of gravity of the Democratic party has decisively shifted from trying to assure voters of fiscal and social moderation, to forthrightly promising active government in a wide range of areas.

But this hardly means the Democrats are in any danger of becoming a radical party. Far from it. As Leftism goes, the current Democratic iteration is of a fairly modest variety, approaching, at most, mild European social democracy. Those who call themselves ‘socialist’ (as Ocasio-Cortez does) are few and far between.

Nor is it the case that incumbents and moderates are being thrown out wholesale and replaced with candidates much farther to their Left. Across the country, only two Democratic incumbents in the House lost primaries, and none in the Senate did. A Brookings study found that self-described “progressive Democrats” did well in primaries this election season but establishment Democrats actually did somewhat better. Thus, the change in the party is less a Leftward surge featuring new politicians (though this is happening to some extent) and more a steady party-wide movement to the Left.

Further reading

Here's what to read and watch if you want to understand the 'new left'

By James Bloodworth

So what caused the shift? This is, after all, a party that was dominated by aggressively moderate ‘New Democrats’ in the 1990s and, even under Barack Obama (after a spurt of major legislation early in his first term), shied away from big programmes and repeatedly tried to broker deals with Republicans to bring down the deficit and reform ‘entitlement programmes’ – Medicare and Social Security, America’s names for government-subsidised health care for the aged and pensions. Many, many Democrats were still scared of the ‘tax-and-spend’ label Republicans were only too happy to pin on them.

One thing that did happen is time. As Larry Summers, the former Treasury secretary for Obama and Harvard economics professor, noted, the last 15 years of economic, social and political developments, with the fissures and unsolved problems they have revealed in American society, should have moved open-minded people to the Left. These challenges are simply too big to be solved by mild, ameliorative steps. This is a widely shared view within the Democratic party, including most fervently among some of its strongest supporters – minority and younger generation voters. But increased movement to the Left is not confined to these groups; Democrats as a whole, including leading intellectual lights like Summers, are simply becoming more, and more consistently, centre-Left.

Further reading

From Jeremy Corbyn to Bernie Sanders to Elizabeth Warren; what the Left is getting right

By Liam Halligan

Indeed, we even see former President Obama in a recent speech urging Democrats to go beyond “good old ideas like a higher minimum wage” and embrace “good new ideas like Medicare-for-all, giving workers seats on corporate boards, reversing the most egregious corporate tax cuts to make sure college students graduate”.

And, from the heart of “Hillaryland”, as the cluster of operatives around Hillary Clinton is termed, comes this robust call from Jake Sullivan, her campaign’s senior policy advisor, for going big:

“Democrats should not blush too much, or pay too much heed, when political commentators arch their eyebrows about the party moving Left. The center of gravity itself is moving, and this is a good thing… We Democrats do need to embrace a big, bold policy agenda. We do need to heed the calls of Franklin Roosevelt, who asked us to save capitalism from its excesses, and Lyndon Johnson, who asked us to think ambitiously about how government – and yes, government programmes – can help do that.”

Strong words coming from a fully-paid-up member of the Democratic establishment! But of course the real progenitor of ‘big ideas’, Left-wing politics in the Democratic party was Bernie Sanders. His insurgent campaign, which featured multiple large-scale policy proposals and fierce denunciations of the “billionaire class”, took the 2016 Democratic primaries by storm, injecting this rhetorical and policy approach into the Democratic mainstream. He particularly captured the imaginations of young voters, who gave him gave outsized majorities in most states.

Given Sanders’ success, particularly with young voters, and his continuing influence within the party (even though he is not formally a member), it is fair to ask whether the Democrats’ future lies in continuing to move Left to the point where the Democrats really become his party – or, at any rate, a party dominated by his ‘democratic socialist’ politics. In other words, could there be a “Corbynisation” of the Democratic party?

Further reading

Is global momentum with the Left?

By Angus Robertson

I am sceptical. Leaving aside structural-political differences between the UK and US – the Democratic party is not a parliamentary party and does not elect a ‘leader’ in the manner of the British Labour party – the Democrats are likely to remain a big tent party, in which the preponderance of voters and elected officials subscribe to a more moderate brand of Leftism than that espoused by Sanders. Think Elizabeth Warren, who combines big proposals with savvy-bridge building within the party and forthright support for capitalism (albeit of a reformed variety).

If there is a wild card here, it is less likely Sanders than an increasing Leftism on ‘identity politics’ issues around race, gender, LGBT issues and so on. It is possible that the Democrats could embrace these issues so thoroughly that it would come to define the party to the exclusion of economic and policy issues, however big. My sense is that Democratic politicians are aware of this possibility and will strenuously seek to avoid it out of sheer electoral self-interest. But we shall see.