Assisted dying – no laughing matter

by Julian C. Hughes in THE TABLET 11 January 2024

A bill to legalise assisted dying in the UK was defeated in parliament 2015. In recent weeks the campaign for a new vote has been gaining momentum.

About 30 years ago, when our children were still very young, the topic of euthanasia cropped up over the breakfast table. I tried to explain what it was about. There was a lovely man living a few doors away called Mr Jenkins. He was very old and obviously frail. So I said it would be as if, instead of going to the clinic to see patients, as I normally did, I was to say one morning that I was just going up the road to finish off Mr Jenkins.

I was slightly taken aback when the children laughed hysterically. I had thought they might think it was a terrible or alarming thing for me to say. But then I realised they were correct in their visceral response: the thought that a doctor would be wandering around the streets killing elderly people seemed so absurd to them as to be hilarious.

A bill to legalise assisted dying (the euphemistic expression for assisted suicide and euthanasia) in the UK was defeated in parliament in 2015. In recent weeks a campaign for a new vote has been gathering support. When the subject came up in a discussion I had with my GP last week, he told me he had not gone into medicine in order to kill his patients. Unlike my children, he didn’t laugh.

Most people I speak to say they are in “two minds” about the issue. Or that there is a “thin line” between killing people and treating them appropriately at the end of life. And if I speak of “killing”, they look a little upset, as if I’ve said something too crude. Is it not, as its proponents would have us believe, a matter of compassionate care? Dignity in Dying (formerly the Voluntary Euthanasia Society) is running a well-funded and effective campaign; its chair is Rabbi Jonathan Romain and its supporters include the former Archbishop of Canterbury, Lord Carey. Care Not Killing, which campaigns against a change in the law, lists just two members of staff on its website. What seems to be persuading people to support a change in the law to allow my GP and other doctors to prescribe life-ending drugs for their patients is the thought that we should all enjoy autonomy and the right to choose to end our lives.

This conviction fits with the current Western zeitgeist. It’s seen as progressive and in accord with our liberal values. But is assisted dying really such a “progressive” idea? Moral progress is usually seen as being in the direction of seeing reasons to kill fewer people, not more. We think of states in the US that still have capital punishment as barbaric. Progressive thinkers are starting to doubt there can ever be a “just war”. Should progress not be measured in terms of decreases in loneliness, in social inequalities and the concomitant social determinants of ill health?

Why is progress not seen as improving the NHS so that everyone can have access to good quality palliative care that would relieve their suffering? And what about spending more money on research into end-of-life care? Aren’t these sorts of thing more like progress than the thought that we should allow legislation that will inevitably put vulnerable people at risk of pressure – whether overt or covert, whether conscious or subconscious – to accept assisted suicide or euthanasia?

But what about autonomy and freedom of choice for responsible adults in a liberal democracy? No one really believes in complete autonomy. Liberal democracies have never been like that. You’re free to decide the colour of your car (although not every colour is always available), but not the colour of the traffic lights at which you stop. We accept that our freedom and autonomy must take account of others. Legislation that governs our choices is not simply for the few, but for everyone.

Once we start to try to stipulate the few whom we wish to allow to choose assisted suicide, things become more complicated, especially when we consider that laws must be fair, that people must be treated equally. We may allow that those with terminal conditions should have this choice (once we have decided what a “terminal condition” is), but in that case, would it be fair to exclude those with chronic conditions? We might add the stipulation that the person who is eligible to choose to have their life ended by a doctor must be “suffering”, but how is that to be defined? Similar questions of definition arise in connection with all the other things we might feel should circumscribe autonomous choice: the person must have decision-making capacity, must not have a treatable mental disorder, must be over a certain age, must have received adequate palliative assessment to ensure their needs cannot be met in some other way, and so on. Are these questions simply theoretical? Not when we look at countries such as Canada, where the option of Medical Assistance In Dying (MAID) is now being offered to increasing categories of people, sometimes in place of perfectly plausible social interventions.

But there is a radical reason why we should not allow assisted suicide and euthanasia. It’s radical in that it’s deeply rooted in our culture. It was enunciated by Lord Walton (a neurologist) back in 1994. To paraphrase, the prohibition on the intentional killing of innocent human life has always been the cornerstone of law and of civil society. Once we have removed the cornerstone, society becomes coarser, less stable, and more problematic – especially for the poor, those with physical and intellectual disabilities, people living with dementia, elderly people, and more so for those who are lonely and ill supported. The line is not thin and, if we cross it, it will be no laughing matter. It is a matter of killing people, even if it is done with compassion.

There is much more to say. Increasing evidence is emerging from other countries that these laws are unsafe. The actual effects of the lethal drugs that are used, the way polling questions can skew results, the widespread resistance to legislative change among people in the medical profession, especially those who have the most experience of caring for those at the end of their lives: all are matters of concern. However, the immediate threat, which comes on the heels of the Assisted Dying Bill having passed on the Isle of Man and Jersey’s acceptance of assisted dying in principle, as well as planned legislation in Scotland, is that there is likely to be a Ten Minute Rule Bill early this year, brought forward by the MP Kit Malthouse. If this is successful – and with media coverage likely to be sympathetic, it may well be– then what to my children was so absurd as to be laughable might become the reality.

Julian C. Hughes was a NHS consultant in and professor of old age psychiatry. He remains honorary professor at the University of Bristol. His book, Dementia and Ethics Reconsidered, was published by Open University Press in May 2023.