Thoughts of ending your life are a common response to human suffering. Yet with care and support, they can usually be overcome. That’s why our usual reaction to someone wanting to end their life is to try to prevent suicide – including showing them we value their life at a time when they’re struggling to do so themselves. Lord Falconer’s assisted dying bill, which will soon be debated in the House of Lords, represents a radical departure from this approach: it proposes circumstances in which we should assist someone to end their life, rather than try to prevent them from doing so. But what circumstances could warrant this?
For Lord Falconer, the answer is simple: terminal illness. In his bill, as long as someone has mental capacity and is likely to have less than an arbitrarily chosen six months to live, they can receive assistance to end their life. There is no requirement that the causes of their suffering be explored, let alone addressed, nor that they receive care or support of any kind.
The only condition is that two doctors certify that the person is acting without undue influence or coercion, and has been informed of the care available to them. One of these doctors, who in all other circumstances would try to support their patient through their suffering to prevent them ending their life, would instead assist them to do so.
Falconer’s bill exemplifies a highly medicalised approach to assisted dying that is almost entirely unquestioned by supporters and opponents alike. He doesn’t justify why doctors should treat someone who says they want to end their life in such a drastically different way, just because they have a terminal illness. Instead, he implies that such patients are primarily motivated by uncontrollable pain or other intractable symptoms, and are fundamentally different to anyone else with suicidal thoughts. This is not my experience. The terminally ill patients I’ve cared for who’ve considered ending their lives have had the same complex range of concerns as other suicidal patients and, most importantly, have been equally responsive to care and support.
Similarly, official reports from the US state of Oregon, whose assisted dying law Falconer’s bill is based on, show that among the most frequent concerns of terminally ill patients who receive a medically assisted death are psychosocial issues common in those with suicidal ideation, such as loss of autonomy and dignity. Many also worried about being a burden on others – rather than flagging the unbearable pain and other uncontrollable symptoms that campaigners encourage people to expect and fear at end of life.
The implications of using terminal illness to determine eligibility for assisted dying extend far beyond those who actively want to end their lives. Once assisted dying is normalised as a healthcare option for terminally ill people, everyone with a terminal illness would have to consider whether they, too, should opt for it. The former Tory MP Matthew Parris is one of the few supporters with what he calls the “intellectual honesty” to openly acknowledge the consequences: that those who are eligible would, in time, feel pressure to take this option so as “not to be a burden” on others. For Parris, far from being a cause for concern, this is the key appeal of this approach. Indeed, he actively welcomes the prospect of assisted dying eventually becoming “considered socially responsible – and even, finally, urged upon people” .
This is not a hypothetical vision, but one that is already starting to be realised. When Canada introduced medically assisted dying for those whose “natural death was reasonably foreseeable”, economists calculated the savings to the healthcare budget. Less than five years later, access was extended to a much wider group of patients with chronic illness and disability. There are increasing examples of it being actively offered to people with no desire to end their lives either on receiving a terminal diagnosis, or when trying to access basic care and support for their disability. Even in the US, where medically assisted dying is only legal in less than a quarter of states and much less normalised, a significant proportion of patients receiving an assisted death cited concerns about being a burden on others.
Why, then, is this medicalised approach supported by many who consider themselves compassionate and progressive? Few seem to realise that there is nothing inevitable about basing access to assisted dying on medical conditions, nor requiring doctors to provide it – ending life is not a medical procedure, and supplying a standard lethal dose of toxic chemicals requires no medical knowledge or skills. Yet this approach has remained unchallenged since it was first proposed in the 1930s, in the heyday of the medical eugenics movement, by Dr C Killick Millard – member of the Eugenics Society and founder of the organisation now known as Dignity in Dying.
An approach to assisted dying free of this historical legacy would be very different to Falconer’s bill. If our motivation is compassion, and our aim is to relieve intractable suffering, then surely eligibility should be based on an assessment that someone’s suffering is intractable – not whether or not they have a particular illness, disability or life expectancy, nor any other external judgment about what makes a life worth living. Assisting someone to die would then be an option of last resort, to be used only if all other options to support them and address their suffering had been tried.
It is not doctors but rather the courts that would be best placed to judge if such a situation had been reached, with medical professionals involved only to provide relevant evidence. Specialist courts are familiar with balancing urgency with thorough consideration in the case of life-and-death decision-making, and so could make a timely decision if required for someone near end of life.
When it comes to administration, a new non-clinical professional role could be established to provide the small number of people who are likely to require assistance to end their life with access to the lethal chemicals to do so. This would ensure a complete separation between assisted dying and healthcare – protecting patients, healthcare services and wider society from the damaging consequences of them becoming intertwined.
Our politicians will be voting with their conscience on Falconer’s bill. Those determined to legalise assisted dying at any cost will vote in favour. Those who support the principle of assisted dying, and are serious about learning the lessons from other countries, should vote against – and call for a radically different approach.
