Assisted Dying

We’re all going to die, but sadly not all quickly or with dignity. The provision of good palliative care in the UK remains patchy but even with the best that palliative care has to offer, some deaths remain very protracted and distressing. As Professor Ray Tallis puts it: ‘Unbearable suffering, prolonged by medical care, and inflicted on a dying patient who wishes to die, is unequivocally a bad thing.’ MD would willingly assist such deaths were it legal to do so, but the High Court has repeatedly made it clear that any change in the laws would have to come from Parliament, and it seems unlikely that politicians will ever enact the overwhelming will of the people to have the right to exit with dignity. And so the pointless suffering continues.

One of the strongest arguments against assisted dying is whether it could be legally and practically introduced in an understaffed NHS that struggles with assisted living. If we can’t give many patients decent humane lives, what chance decent humane deaths? To counter the concern that assisted dying would become the ‘go to’ option, we would need to offer everyone excellent palliative care first, and there is little sign the government wishes to invest in this.

In countries and states that have legislated for assisted dying, there has usually been increased investment in palliative care services. In Oregon the proportion of people dying in hospice care increased from 37% in 2002 to 52% in 2009 – one of the highest rates in the USA. And nearly 90 per cent of those seeking assisted dying do so from within those services, proving the point that even with the best palliative care, some people still suffer and wish to choose when to die.

The BMA conference regularly votes against assisted dying, worried that it would damage trust in doctors. But a survey of nine European countries put levels of trust in the Netherlands at the top. Countries with assisted dying are generally more open and transparent about death and end of life care, and offering patients the choice of a humane death may enhance rather than diminish trust.
Dr Ann McPherson died in 2011 from pancreatic cancer and fought hard but unsuccessfully for the right to have an assisted death. As her husband, Prof Klim McPherson, observed: “There is nothing humane about forcing people with terminal illness to stay alive for as long as they can — no matter how good the care they receive from a profession forced into cruelty by an inadequate law.”

In countries with a mature attitude to death, well-regulated assisted dying and good palliative care, the number of assisted deaths has remained low. In Oregon it has been legal for terminally ill, mentally competent adults to have an assisted death since 1997, without any of the predicted dire consequences and – thanks to strict safeguards – no proven cases of abuse. The 2013 Oregon report showed 71 people had an assisted death. 90% were receiving hospice care, and the majority had terminal cancer. Assisted deaths are 0.2% of total deaths in Oregon, a number that has remained stable over the last 5-6 years. 122 people requested life-ending medication in 2013. 51 did not take the medication – many of them took comfort in knowing the option was there. Around 90% of people who had an assisted death were also enrolled in hospice care. And the majority of people who had an assisted death had terminal cancer and were aged between 55-84.

An undignified, unpleasant death is the biggest failure of medicine. It is usually avoidable. Healthcare professionals can legally hasten death by withdrawing or withholding of treatment, or through the principle of ‘double effect’ where a treatment given to relive suffering ‘inadvertently’ hastens death. Patients are usually excluded from these decisions. It would be far kinder and more ethical to allow – within a proper legal framework – for the wishes of terminally ill, mentally competent adults to be respected. Assisted dying has always, and will always, occur but not always humanely. As Tallis observes: ‘Death from dehydration and starvation in patients, who have no means of securing an end to their suffering other than by refusing food and fluids, or botched suicides, reflect the unspeakable cruelty of the present law.’ And not everyone can afford, or is able, to make the grim pilgrimage to Switzerland. Time to legislate for kind deaths for all.