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The Debate continues

First a big “well done” to all those of you who were able to attend the lobby on the 14th July. Around 30 MP’s attended which is a good number based on experience. It is still vitally important that we all keep the pressure on by contacting our MP’s to put our side of the argument on Assisted Suicide.

Here is a personal and very interesting view on the issue written by Robert Twycross a retired palliative care specialist. We are grateful to him for allowing us to reproduce it here

 

Personal view: Medically-assisted suicide

On September 11, the Second Reading of the Assisted Dying (AD) Bill takes place in the House of Commons. This would allow a terminally ill adult in England or Wales to have a lethal prescription for self-administration, supervised by ‘an attending health professional’ (doctor or nurse). The key prerequisite is a life expectancy of less than six months; the patient does not have to be in physical or mental distress. The Bill is not about long-term progressive conditions such as multiple sclerosis or dementia. Opinion polls indicate that 80% of the public favour medically-assisted suicide. In contrast, 90% of palliative care doctors are against. Why?

The main justification for such a fundamental change in the law is the right to self-determination: people should have the right to choose the time and mode of their death. Supporting arguments centre on the limits of palliative care and compassion (‘it’s compassionate to assist someone to die who is suffering unbearably; it’s cruel to force them to continue to suffer’).

However, despite upsetting ‘horror stories’ (possibly some in your own family), palliative care does not (at least, should not) leave patients to suffer unbearably. In extreme situations, increasing the dose of symptom relief and sedative drugs is already permissible as a ‘last resort option’. The most appropriate response to horror stories is to increase the availability of specialist palliative care. Interestingly, Lord Falconer has said that the primary reason for wanting to change the law is not uncontrolled pain but the intolerable thought of lost independence.

Restrictions on self-determination are legitimate if other people are likely to be endangered. Thus, the debate about AD centres on the question: can a law be devised which would allow terminally ill people to end their lives (should they wish to) without endangering others (who do not want to)? Already some people fear (and refuse) palliative care because they fear they will be ‘done away with’ – and suffer as a result. This number would surely increase if AD became lawful, enhancing the perception of doctors and nurses as potential killers.

Although both sides claim compassion as a major motivation, palliative care and AD are essentially mutually exclusive philosophies. Palliative care is based on the belief that life has meaning and purpose up to the moment of death, whereas AD is essentially nihilistic. Expecting health professionals to deliver both palliative care and AD – to face in two directions simultaneously – is simply too big an ask. Chris Woodhead, an AD activist who suffered from motor neurone disease, said:

‘The only way you can deal with [terminal illness] is to live from day to day… The more limited your world, the richer it can become… There are benefits. You can be brought closer to people who love you. This has brought me closer to [my wife]. That is something to be grateful for.’

These sentiments reflect well the ethos of palliative care.

The common denominator in patients who desire to hasten death is despair – a sense of hopelessness, helplessness and lack of control – related to actual or anticipated severe pain or other distressing symptom, loss of independence, and becoming a burden. The wish to hasten death is generally not constant unless the patient has a depressive illness, which normally responds to treatment. In practice, almost all patients change their minds when in receipt of high-quality palliative care. In fact, an expressed wish by a terminally ill person to hasten death does not mean they want AD; they want to be heard, to express their frustrations and fears, to be understood.

Prognosis, when more than a few weeks, can be wildly inaccurate. Some patients live much longer than estimated, sometimes 10–20 years. There is also risk of coercion: both doctor-on-patient and family-on-doctor. A Dutch doctor commented:

‘In the past, if I suggested euthanasia (a lethal injection administered by a doctor), nine times out of ten the patient would choose euthanasia; now when I suggest palliative care, they choose palliative care’.

In Belgium after 13 years of euthanasia, families much more consider dying as undignified, useless, and meaningless, even when it is peaceful; and demands for fast active interventions, particularly in relation to elderly parents, are increasingly direct.

Indeed, once the barrier of legislation is passed, AD seems to take on a dynamic of its own. Last year in the Netherlands, a member of a Regional Euthanasia Review Committee wrote:

‘Whereas the law sees assisted suicide and euthanasia as an exception, public opinion is shifting towards considering them rights, with corresponding duties on doctors to act… Don’t go there.’

In contrast in the UK, the law at present provides a clear ‘bright line’. It may occasionally be crossed by doctors (and others) but it is unambiguous. Indeed, it is perfectly consistent to argue that medically-assisted dying is ethically legitimate in some extreme cases but that it would be wrong to change the law. As now, it could be better to allow hard cases to be taken care of by various expedients than to introduce new legislation which would become too permissive.

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