Medical Ethics Assisted Dying

Does Britain need legislation to permit assisted dying?

In Britain suicide and attempted suicide is not illegal although helping someone kill themselves is a criminal act. The Suicide Act 1961 makes it an offence, punishable by a prison sentence of up to 14 years, to "aid, abet, counsel or procure the suicide of another." Euthanasia (whereby someone kills an individual who wants to die but is not able to take their own life) is also illegal. Various attempts have recently been made by Parliament to amend the law on assisted dying: four private members' bills were unsuccessfully introduced into the House of Lords between 2002-2006 and in 2009 a further attempt (also unsuccessful) was made to amend the law so as to allow people to help someone with a terminal illness travel to a country where assisted suicide is legal. In February 2010 the Director of Public Prosecutions provided new guidelines designed to help people know whether they would face prosecution for helping someone kill themselves. The guidelines contain a range of factors that will be taken into consideration when a decision to prosecute is made. These include whether the 'victim' (i.e. the deceased) reached a "voluntary, clear, settled and informed decision". There is also particular emphasis on the motivation of the 'suspect' (i.e. the person who assisted the deceased to die). They would be expected to have acted "wholly compassionately" and not for financial motives. The idea behind the guidelines is to give people who are asking friends/ relatives to help them die an indication of whether they will be prosecuted. The law concerning assisted suicide was not changed by the guidelines and it remains the case that all individuals who help someone to die will still face a police investigation. All this parliamentary activity together with the reporting of many tragic cases of terminally ill patients wanting the 'right to die' has meant that the issues of assisted dying have been kept in the public eye for some time. My own interest in this matter arises from a summer 2011 placement in the Oncology Department of the Chelsea and Westminster Hospital. I was able to observe firsthand the support given to terminally ill patients in terms of end of life care by the hospital. The patients were supported by the palliative care teams at the hospital and every effort was made to maximise the patient's quality of life while taking account of their medical conditions. Assisted dying is obviously an incredibly sensitive area which provokes deeply held views on both sides of the debate. I examine these in detail below.

Proponents of assisted dying argue that a 'right to die' should be a fundamental freedom for each person. They argue that it is up to individuals to judge for themselves whether or not their life is worth living and, if they do not think that it is, they have a right to act on that judgment with the help of others if they need it. This 'right' is not a legal right. The European Court of Human Rights in the case of Pretty v United Kingdom (2002) was asked to consider this point in the case of Diane Pretty. Mrs Pretty suffered from motor neurone disease, a progressive and incurable illness, which eventually leads to complete paralysis leaving the patient in the last stages of the disease dependent on others. Mrs Pretty did not want to reach this stage. She was incapable of committing suicide herself and asked the DPP to confirm that if her husband helped her to die that he would not be prosecuted. The DPP refused to give her this assurance and she took her case to the Court of Human Rights. The Court was not however prepared to find that Mrs Pretty's rights had been infringed and ruled that although she had a right to life under Articles 2 and 3 of the European Convention of Human Rights she had no right to death. It should also be pointed out that if Mrs Pretty had been able bodied she could have committed suicide and that if she had been subjected to medical treatment such as chemotherapy she could have legally refused it. (It is the legal right for any patient to refuse medical treatment even if this will cause their death.) General sympathy and compassion for the terminally ill is another argument used to support assisted dying. Many of these people suffer considerably before they die. It is argued that people should not have to endure such acute suffering. Other arguments include the fact that in countries supporting some form of assisted death that such legislation brings benefits to patients as they have the option of assisted death to fall back on when conventional medical methods are exhausted. They point out that the numbers of

also cite the fact that the present law encourages journeys abroad to various voluntary organisations (for example, Dignitas in Switzerland) where a patient is helped to commit suicide at the time of his choice. This service is expensive so is not available to everyone and can mean that people die sooner than they want to, for fear that if they leave it too long they will not be able to travel abroad because they are too ill. Supporters also point to the need to bring consistency into clinical practice. The medical profession already have to make life and death decisions when further treatment would be 'futile'.

Opponents of assisted dying base their arguments on the 'value and sanctity of human life'. This value is based on the absolute belief that human life is of the utmost value. They believe that legislation supporting assisted dying would undermine this principle as it would give the message that some people are better off dead. They also believe that this principle supports the idea that whatever happens in a person's life has to be balanced against the rights and responsibilities of others. They point in particular to the evil consequences to society that would follow: that this is the beginning of `a slippery slope` leading to involuntary euthanasia of vulnerable groups such as the elderly, the disabled and the sick. They argue that such groups could feel under pressure (real or imagined) to ask for early death because they see themselves as a burden on their families/ society in general. There is also the concern that if a doctor was involved in the assisted dying process that this could erode the trust between doctor's and patient's as patients might fear going to see their doctor because they would always be wondering if he was going to cure/kill them.

As can be seen from the above the issue of assisted dying generates a lot of debate on a variety of levels. It is also clear that this is an issue which society as a whole must decide on. We need to establish whether we have a policy of 'life at any cost'. There are indications that opinion in Britain supports some form of assisted dying. A British social attitude survey published in January 2007 showed that 80% of a large sample of the public was in favour of some form of assisted death. In many cases it appears 'morally right' that a patient be helped to die because of their unbearable suffering. Few, on compassionate grounds alone, would not have supported Mrs Pretty's right to die. The central difficulty here is to draft a law that would permit assisted dying in cases where there was a strong moral case (to relieve intolerable suffering) and to rule out other cases where it would be abhorrent (to inherit money). Difficult though such legislation would be to draft other countries have managed to do this. In Switzerland, for example, it is lawful to help someone to commit suicide if the motive is 'entirely honourable'. In the American State of Oregon assisted suicide is lawful for the terminally ill (doctors can prescribe lethal drugs to help patients commit suicide although they cannot administer them). In Belgium voluntary euthanasia is legal (to qualify patients must 'be in a futile medical condition of constant physical or mental suffering that cannot be alleviated'). In the Netherlands when a patient is deemed to be mentally competent and his suffering is severe he can lawfully be helped to die by his doctor, either by being helped to commit suicide or by lethal injection. The new guidelines published by the DPP do not go far enough and are therefore unsatisfactory. The police still have to investigate cases of assisted suicide as possible murder and decide whether or not to prosecute on a case by case basis. It is no real comfort that to date no relatives/friends have been prosecuted in Britain for helping people travel abroad to end their lives. I think that it would be possible to draft legislation that tightly defined the class of persons who could be supported to die while at the same time containing stringent safeguards to prevent abuse. There is public support for a special tribunal to look at cases of people wanting assisted death. The tribunal would be required to establish the facts of each case, ensure that the patient's decision is consistent and truly voluntary, that they are suffering from a life threatening and incurable illness, that all palliative options have been explored, and that no duress is evident. There would also have to be a role for specially trained medical teams. Self administered drugs can be difficult to administer so assistance by a doctor is desirable to prevent unsuccessful attempts as well as to assist patients with neurological disorders who cannot swallow/use their hands. In the Netherlands, for

example, doctors have made it their usual practice to administer euthanasia in the event that the assisted suicide is unsuccessful. The issue of assisted death is certainly one in which society as a whole will have to confront on an ever increasing scale as people are living much longer than they used to. We must all also face the fact that many of these people will end their lives in great pain and distress, often suffering from dementia, and that some will want to end their lives at a time of their own choosing rather than suffer a horrible long drawn out death from incurable diseases. In February 2006 the British Government Actuary Department estimated that by 2076 1.2 million Britons will live to be 100 and that many thousands will reach the age of 110. The majority of these people will spend their last few years in hospitals or care homes and for many of these people the quality of their life will be poor. The public, shocked by the stories in the press of neglect, are increasingly questioning the way end of life care is managed in Britain. This is a good thing as at present far too few patients have access to good care. I see a far greater role for palliative care in assisting people to have a more dignified end to their lives. I think that if a patient, whatever he suffers, wants to stay alive, then he must be allowed to do so and he should be made as comfortable as possible. However, I also think that there will always be some people for whom palliative care is not the solution and who quite genuinely would prefer death to remaining alive and in great pain. It seems wrong to deny these people (provided they are competent to make their own decisions) of the right that able bodied people have of ending their own lives at a time of their choice just because they are physically incapable of carrying out such an act. In July 2011 BBC 2 broadcast a programme called 'Choosing to Die'. The programme recorded the assisted death of Peter Smedley's at the Dignitas clinic. Mr Smedley was suffering from a terminal illness (motor neurone disease) and was accompanied to Switzerland by his wife, Christine, and the author Sir Terry Pratchett. The film was unbearably moving and Sir Terry neatly summarises the dilemma facing all of us when considering assisted death when he says (immediately after Mr Smedley's death) "I was spinning not because anything bad had happened but something was saying 'A man is dead...that's a bad thing' but somehow the second part of the clause chimes in 'but he had an incurable disease that was dragging him down, so he's decided of his own freewill to leave before he is dragged' so it's not a bad thing". Perhaps it is time for society to recognise that it is everybody's right to be able to die with dignity at a time of their own choosing. Sir Terry, who is himself suffering from Alzheimer's disease and has expressed a wish for someone to help him to die when his illness means that he can no longer enjoy life, would like "to die in his garden under an English sky" or "if it's wet in a library". Does society really have the right to interfere in this decision? I think that they do not and that legislation should be passed to allow assisted death. Of course the class of persons that the law should apply to must be tightly defined and adequate safeguards put in place to stop abuses.