'Assisted Dying' / Taking One's Life with the Help of a Doctor - Should we Legalise it in the UK?

(A longer [20 minute] read)

In recent current affairs, Keir Starmer has brought the ‘Assisted Dying’ bill back to the House of Commons. On the 29th November 2024, in a debate followed by voting, he is giving MPs a free vote - based on individual conscience - as to whether this bill should be brought into law.

Such a bill has been on the radar for a while; the last time it was debated in UK parliament was in 2015, and since then, proponents such as Esther Rantzen (the TV presenter and founder of Childline) have regularly made ripples in the media through advocating that people of Britain, if in the final stages of life, should be able to end / take their own lives with the support and help of a doctor.

The campaign of Esther Rantzen - herself having been diagnosed with terminal cancer of the lungs - was very prominent in the earlier months of this year; in her campaigning prior to then - through numerous articles in the papers, and indeed through speaking on TV and radio - she had already been very clear about her desire that people of the UK should not have to endure the heartache and pain that is brought both for the person who is dying in pain and the family of that person. In a crescendo of her message in the early months of this year, she memorably and emotionally articulated that the final stages of a person’s life - when surrounded by indignity and pain - sadly colour the family’s memories, and particularly endure in the family’s minds many years beyond the death of their loved one. Indeed, having signed up to Dignitas in Switzerland, Rantzen has actively and politically campaigned in the UK - with the backing of the BBC and a number of tabloids - that (what she calls) ‘Assisted Dying’ should be legalised in this country - as it is, for instance, in Canada, Holland, Belgium, Switzerland, and a number of States in America.

The voice of Rantzen and other proponents - such as the group known as ‘Dignity in Dying’ - has been well and truly heard; through a petition set up earlier this year (which received around 200,000 signatures) the issue has been prominently returned to the thinking of the public. Heeding the tide of the public, Keir Starmer promised (before the summer election) that (if elected as Prime Minister) he would bring the issue up for debate and voting; so, having been elected, and keeping his word on the matter, the issue returns to the Commons for debate on the 29th November.

In relation to that forthcoming debate, the encouragement of Rantzen and other proponents - claiming that 73% of Britons are in favour of ‘Assisted Dying’ - is that that mood of the everyday people is aired to the MPs involved in the debate; proponents are encouraging UK citizens to speak with their MPs about the subject to let their feelings be known in advance of the debate.

Such involvement of the everyday public in this live and contemporary discussion is obviously to be commended, but whilst listening to the advocacy and encouragement that people politically air their views on the matter, it should be said that, in heeding any such call to action, that those expressing an opinion on the topic would do well to be thoroughly aware of the issues surrounding the debate, and indeed have properly considered the ethics involved in this significant matter.

The feeling at an emotional level

Of course the topic of ‘Assisted Dying’ is one that is very emotive. A number of us have had family bereavements in which the last days of a relative’s life were particularly difficult and distressing, and whilst it’s an ethical discussion - for rational consideration and discussion - it is of course experienced and felt emotionally very close to home. Moreover, different stories recounted in the media, highlighting the experiences of those who have suffered intensely - and longed that they could end it much sooner - do much to move compassionate readers and influence public opinion.

Further, with people living longer, with limitations on the medical resources available, with the recognition that latter years healthcare can vastly diminish the family inheritance, it is commonly expressed by patients themselves that ‘I don’t want to be a burden on anyone - on my family or on society’, ‘I want to die with dignity’, ‘please can I just end this - I want to die in dignity and peace’.

Clearly Defining the Issue

Of course, everyone wants a person to be cared for right up to their dying day. We want our loved ones to be ‘assisted’ by carers and medical professionals - as indeed by family and friends - desiring that our loved ones have compassion expressed to them right up to the moment they die. And it would be helpful to highlight, in law, that a patient is already legally entitled to refuse treatment that is ‘cumbersome and futile’. Both of these are givens - already accepted by all involved in the discussion. So what exactly is being proposed? What are Rantzen, ‘Dignity in Dying’, and indeed the bill being debated proposing?

In answering the question, it should be said that the language of ‘Assisted Dying’ and indeed ‘Dignity is Dying’ is not particularly clear and has blurred the issue in the minds of a percentage of the everyday public. The organisation named ‘Dignity in Dying’, for instance, changed their name, in 2006, from the ‘Voluntary Euthanasia Society’ to their preferred ‘Dignity in Dying’ - the latter being a name that carries more grace and appeal than the former (but clearer) self-description. Indeed, the phrase ‘Assisted Dying’ has resonances of honour and has warmed the hearts of the public . . . Yet in more transparent terms, ‘Assisted Dying’ in this specified instance is the wanting a person to be able to end their life with the help of a physician (doctor). Made explicitly clear, what proponents of this position desire, and what the bill is proposing is that, under certain specific conditions, patients should be able to take their own life with the help of a physician - what is termed in ethical journals (where terms have to be clearly and exactly defined) as ‘Physician-Assisted Suicide’.

If a dying person can satisfy the following criteria then the bill being debated proposes that that person should be legally entitled to a procedure in which a physician would set-up a lethal dosage of drugs in such a way that the person / patient could administer the procedure and bring their life to an end.

In the proposed legislation, the person seeking Physician-Assisted Suicide would have to meet the following criteria. S/he would have to:

1. Have mental capacity to make the decision

2. Make the decision entirely voluntarily (and having stated that desire twice on separate occasions)

3. Have a terminal prognosis of having 6 or less months to live

and in terms of the role of medical professionals, the above criteria above would

4. Have to be certified by two different doctors (again on two separate occasions)

Interestingly, whilst 73% of the UK say they are in favour of ‘Assisted Dying’, when it is made explicitly clear exactly what is being proposed, that number diminishes. Once it is specifically clarified that it is Physician-Assisted Suicide that is being proposed, and the specific criteria is laid out (as well as details given of what is involved in the procedure), public opinion drops from 73% to 43%.¹ Indeed, when MPs last voted on this matter in the House of Commons (in 2015), whilst entering the chamber carrying the public’s general mood and popular views on the subject, a large number of those MPs had their minds changed in the debate by hearing more specifically and exactly what is being proposed. Moreover, it was particularly the insights of those who worked on the front line - those working in palliative care, for instance, or in geriatric nursing, as well as those working in ethics - that brought about a major change in the views of MPs (the final outcome of that 2015 vote was 117 for, 329 against).

Examining the Criteria

So why exactly is there such a large drop-off in public support when the matter is actually clarified? Part of the reason - both in 2015, and still the case now - is the criteria as detailed in the paragraph above. Particularly criteria 3 - ‘a person should have a terminal prognosis of having 6 months or less to live’ - is recognised as being arbitrary and problematic; why is the criterion 6 months or less? Why not 3 months, or 1 month, or indeed 6 years? And indeed, why does the prognosis have to be terminal? Why, in instances of far-reaching pain, shouldn’t a patient have the right to die even if their condition isn’t terminal? Indeed, in Canada - where Physician-Assisted Suicide [PAS] was legalised 10 years ago - the criteria which were similar to the above have been loosened since it was originally put into law; now the 6-month clause has been lifted and people can make advanced directives for PAS. Indeed the terminal aspect has also been lifted and so now patients can request PAS if having a serious-enough mental health condition. In Holland, where PAS is also legal, the criteria have become loosened still further; there, once a child is aged 12, that child is legally able to request PAS. There are even some European scholars currently arguing that homelessness should be a category for allowing a person to request PAS. In Belgium there is no age limit, and recent cases of PAS have included 2 children who were legally allowed to take their lives under such legislation. This highlights that criteria 3 in the UK’s proposed thinking - that a person must have a terminal condition with a 6 month prognosis or less to live - is evidently not water-tight or adhered to once PAS is legalised.

In light of this realisation, the words of Judge Lady Butler-Sloss (former President of the Family Division of the High Court) seem pertinent:

“Laws, like nation states, are more secure when their boundaries rest on natural frontiers. The law that we [in the UK] have rests on just such a frontier. It rests on the principle that we do not involve ourselves in deliberately bringing about the death of others. Once we start making exceptions based on arbitrary criteria such as terminal illness, the frontier becomes just a line in the sand, easily crossed and hard to defend. We tinker with the law at our peril”.

Examining Human Autonomy - the underlying driver of Physician-Assisted Suicide

In looking at the issue more closely, the main principle that is driving the desire for PAS in popular thinking is that of the autonomy of the individual. Coming from the Greek words ‘auto’, meaning ‘self’, and ‘nomos’, meaning ‘law / rule’, this principle has sometimes been described as the sovereignty of the individual. As the poet William Henley expressed, ‘I am the master of my own fate, I am the captain of my soul’; and this way of thinking, in the western world, has become deeply ingrained in society: ‘It’s my life, I will do with it what I want’.

Flowing on from this western assumption, if someone loses their sense of autonomy - their sense of being strong and independent - then with that they feel that they lose their dignity. To have to rely on others - to become a burden on another - is regarded as humiliating because once one’s sense of independence - one’s sovereignty as an autonomous being - dissolves into becoming dependent, so one’s dignity, it is assumed, by consequence then disappears. Indeed, whilst in a minority of instances it was issues of pain that brought patients to call for PAS, studies from 2015 (when the issue was last debated in the Commons) found that in 91% of instances it was called for, it was this issue of the person’s autonomy - it was their fear of becoming dependent - that was the heart of the issue; they feared becoming a burden, their losing their sense of dignity.

Deeper thinking about autonomy

Now, if the issue of human autonomy is such a large factor in the debate, then of course not just the autonomy of the patient (and indeed members of their family) but also the autonomy of doctors needs to be taken into account in the discussion. And here, whilst a percentage of doctors are in favour of PAS, the number of those who would actually be willing to participate in such a procedure is lower than those who would just advocate for the view. This may be due to the findings of other countries in which PAS is legal, where studies have shown that physicians who have been involved in the procedure later suffer adverse effects - whether those being effects on their mental health, or being accused, in certain instances, of having been coercive in the discussion with the patient. Whilst current proponents of the bill are advocating that the law would have a conscience clause for doctors (namely, only those who were willing to participate would be involved in the procedure), in other areas of bio-ethics, where conscience clauses were originally inserted, those clauses have subsequently waned and now doctors not willing to participate in such procedures have found themselves under pressure to participate, or found their careers suffering from not being willing to be involved. So it is not just the autonomy of the patient, but also that of their family, and also that of the doctors that are implicated by PAS.

But this already begins to indicate that, rather than being just groupings of individuals - as western liberal ideology espouses - humans are a lot more inter-connected. John Dunne once famously wrote ‘no man is an island’; we are communities and societal beings who rely on one another and do life in relationship with one another. Indeed, contra the western ideological claim / aspiration that humans are to be strong and independent beings - masters of our own fate and captains of our souls - experience shows that, in reality, that isn’t true, and in fact that cannot be true.

When one thinks about the pattern of human life, no-one chooses to be brought into existence - that was not an individual’s autonomous choice; we were brought into existence by our parents, then were dependent on our mother through the pregnancy, then dependent on those who brought us up during childhood. Whilst western laws declare a human an adult / independent at aged 18, in reality human adults continue to be dependent beings - we are thoroughly dependent on each other throughout life and in wider community. An obvious example of such is the dependence humans have on farmers, supermarkets and vendors to provide the food that is needed; or every day we go to work, we are dependent on those who drive public transport / or on the roads for us to get there; in desiring to live in a secure home, we are dependent on these who provide services - such as gas, electric, water providers etc. All of us are thoroughly dependent - throughout the days of our lives; and when reaching older age, that dependence level just increases as a natural part of the human condition.

To be dependent in older age, or dependent in younger age - indeed, to be dependent in disability - is not an embarrassing indignity, it’s a natural part of human nature - being those who are finite and dependent beings. Indeed, as bodily persons, it couldn’t be any other way. The human body as a living organism requires food, it digests, it excretes, it respires, it reproduces - and it grows in earlier years and then decays in later years. Contra the western desire / aspiration, humans are not strong independent beings, we are bodily, finite beings - those with obvious limitations which make us dependent not independent beings.

When recognising the human condition, far from it being a loss of dignity to rely on another - at any stage in our life - it is a natural part of our human nature, to be those who exist in relation and to rely on one another - indeed, to share one another’s burdens.

A Shift in Human Perception

Once the western axiom is highlighted, the argument from autonomy is exposed in a way that is humbling for us as humans but in a way that is additionally liberating. Sociology and psychology reveal that one’s perception of your own dignity and worth - indeed, in fact, one’s perception of suffering as well - is seen and coloured by the perception one has of how the people around you view you. In the non-western world, in nations less affected by human autonomy, the older and dying members of the family don’t feel a lack of dignity; in fact, it’s often the opposite - the older members of society are held in high esteem, they are looked after until their dying day, and, perceiving such feelings from their surrounding community, the older and dying members of the community ultimately die feeling a sense of dignity. It is the western ideal of autonomy that is the underlying driver that causes people (living in the west) to think that they might be a burden and so might die without dignity.

Indeed, there is a parallel phenomenon to this that has been discovered in the perception of pain. As experts in palliative care have revealed, for a patient in a state of suffering, that person’s perception of the pain s/he’s enduring is affected not just by physical conditions but also by social, spiritual, psychological factors.² Even in instances sometimes termed as ‘total pain’ - where pain levels feel unbearable - studies have shown that palliative care is able to reduce the feelings of pain if the palliative team have disclosed to them relevant psychological, spiritual, and social factors to then help mitigate the pain. On an everyday level, our experience affirms the scientific research; if one feels loved through an experience of pain, sensing that others are expressing compassion towards them through that period of suffering, then one’s perception of the pain reduces. Our perception of indignity and suffering is affected by the relationships we are part of and how we feel we are being viewed and treated by others we are in relationship with.

Fuller Palliative Care - An Alternative to Physician-Assisted Suicide

Given these state of affairs, it seems that, rather than legalising PAS, a better response to the issues would be to invest fuller time, research and money into our nation’s palliative care. Whilst the UK is already doing well in this regard - and is recognised, globally, as providing some of the best palliative care in the world - there have been occasions in the past where fuller palliative care has been needed but not been able to be forth-coming. Whilst still more needs to be done in this regard, the solution to any such short-falls is not Physician-Assisted Suicide, rather it is to seek to improve what we already have and for patients to be able to die naturally and well, knowing the compassion and love of relatives, friends and medics around them.

The debate on the 29th November

Drawing these strands together, Rantzen et al’s desire that people of the UK speak with their MP to let their feelings be known on the matter - in advance of the vote on the 29th November - is a helpful suggestion. But rather than allowing one’s opinion to be swayed by emotive stories and media publications that affect primarily at the emotional level, one’s opinions on the ethics involved also need careful and rational consideration. Having laid out a number of those considerations, it is hoped that readers will speak with their MP - as proponents are advocating - but doing so as well-informed thinkers, knowing what the bill actually entails, the ethics entailed in the discussion, and so engaging responsibly with insight when discussing this significant matter.

1. See https://care.org.uk/news/2014/07/charity-releases-polling-showing-diminishing-support-for-assisted-suicide-in-practice (accessed 19/4/24). See also https://www.dyingwell.co.uk/wp-content/uploads/2021/09/Survation-Assisted-Dying-Survey-July-2021-Summary-3.pdf - the two polls indicating that such attitudes have generally remained the same over the last 10 years.

2. Cf. Shenouda, Blaber, George and Haslem, ‘The Debate Rages on: Physician-Assisted Suicide in an Ethical Light’ British Journal of Anaesthesia (January 2024): 1 https://doi.org/10.1016/j.bja.2024.01.002 (accessed 12 / 4 / 24)