On 29^th November 2024, MPs in the House of Commons will (for the seventh time in the last 20 years) be debating a bill to legalise assisted dying in the UK.  Every time it has been debated in the past the bill has failed to pass – MPs, usually overwhelmingly, have voted against such a significant change in social policy.  This time it feels different – there has been a generational shift in social attitudes towards, what have traditionally been believed to be biological certainties and an individual’s right to transcend them. There have also been some very compelling, articulate and intelligent advocates for assisted dying who have been given considerable airtime.  As a result I think there is quite a high likelihood that Kim Leadbetter’s “Assisted Dying for the Terminally Ill (End of Life) Bill 2024-25” will pass its first hurdle a week on Friday.

In this article I will explain why I think this move is a profound mistake and why advocates for this bill are misguided in their faith in doctors to safely carry out the duties envisaged of them as a result of this.

Call a Spade a Spade

There are many terms used for the concept of ‘helping’ someone to die.  These include Physician Assisted Suicide, Voluntary Euthanasia, Medically Assisted Dying, Mercy Killing, Self-Deliverance and Right to Die.  Assisted Dying is the most recent term coined in this history of lexicographical euphemism.  All these terms try to disguise the uncomfortable truth that if you help someone to end their own life you are partaking in an active intervention to kill another human being – albeit with their consent (but more on that in moment).

There is not a single context in the broad compass of modern medicine where an intervention takes place that is designed to actively bring about the death of a patient.  Assisting someone to die is not and cannot ever be a medical intervention and I will explain why.

Managing Death

I am a doctor of Intensive Care Medicine.  When I graduated from medical school in 1993 I made a solemn oath – not in fact the Hippocratic Oath, but instead a modern variant – the deeply humanitarian ‘Geneva Declaration – 1948’.  Building on the 2400 year old original it never-the-less starts similarly with a promise to ‘First do no Harm’.

Death is common on the intensive care unit – nearly 15% of our patients die whilst under our care.  The vagaries of natural tragedy play out on our ward, and we must be not only expert at intervening to prevent death when it is preventable but also expert at recognising when to do so has become futile.  When the saving of a life is no longer possible it becomes our absolute duty to cease interventions that artificially sustain life and instead minimise the suffering associated with the inevitable process of dying.  Doing so involves not only minimising pain and anxiety but also maximising autonomy, dignity and self-determination which are stripped from our patients by the disease from which they are dying.  There are medical interventions which can help with these critically important therapeutic goals, and these like many medical interventions can have second effects which bring about an earlier death than might have occurred had the suffering been allowed to continue without treatment (although interestingly there is good research that shows that good palliation more often extends life once the harmful effects of life sustaining treatments are stopped.)

To be clear – there is a fundamental difference (both ethical and actual) between interventions with the goal of treating suffering associated with the process of dying and interventions that have the goal of bringing about the death.  The former are medical interventions that are wholly compatible with the Hippocratic intent; the latter are not medical interventions and would be a betrayal of that oath.

Let us hold hands and together jump off this cliff

I have often heard arguments used against the idea of assisted dying that fall into the category of ‘The slippery slope argument’.  These arguments fret that once assisted dying is approved for some categories of patient that there will inevitably be a process of ‘scope creep’ that results in categories of patient that we currently don’t find acceptable to have access to assisted dying eventually ending up being allowed to.  Whilst I think this is probably true – the flaw in this argument is that it accepts that it is valid for any category of person being suitable for assisted dying.

Once we have made the decision as a society that it is acceptable to kill anybody we won’t have stepped on to a slippery slope – we will have stepped off the edge of a cliff.  A very clear Rubicon will have been crossed – we will be a society in which The State sanctions murder.  There are plenty of precedents for this, and it wasn’t so long ago that we were such a society – capital punishment only left the UK statute in 1969 and there are plenty of parts of the world where it remains possible for the ‘collective’ to decide that an individual’s life is no longer worth living.  The approval of assisted dying is an acute reversal of a social trend that had found it increasingly unacceptable for the state to be involved in ending anyone’s life – not least because the state can and very often does get it wrong.

Autonomy and Self Determination

Surely, though, this is different, is it not about the fulfilment of an individual’s right to choose how they die?  Is choosing to die not the ultimate in self-determination?

If you speak to my trainee doctors they will tell you (no doubt whilst rolling their eyes) that I am a very active advocate for the restoration of the autonomy and self-determination of patients.  I often go so far as to say that our primary purpose as doctors is not to treat disease but to restore the autonomy that has been stripped from a patient by their disease (which in most cases does involve treating the disease – but not always).  This approach has the added benefit of highlighting the many ways in which the healthcare system colludes with the disease process in robbing a patient of their autonomy and self-determination.  We have a horrible habit of thinking we know what is best for our patients – and we are not very good at stopping ourselves and actually asking them.

Notwithstanding this I do believe that there are limits to self-determination.  I think most of us have an understanding that along with individual rights we also have responsibilities, and I think it is reasonable to say that vast majority of humans exercise those responsibilities.  Our individual rights do not extend to the point that they compromise the rights of others – most of us have a strong sense of natural justice in this area. That’s not to say there aren’t tensions – these are played out daily in the public debates on social and tradition media.

So, what is the impact on others if I were to choose to exercise a right to die?  What impact would it have on the person I ask to assist me in my suicide?  What impact would it have on my family, those whom I love and love me?  I do not know the answer to these questions, but I am sure that whatever they are, the impacts will be significant and lifelong.  I am also sure that I do not want to test those questions in real life.

I alluded to the general sense of personal responsibility that most people have.  This is a powerful psychological driver of behaviours – that are largely positive for society and our collective wellbeing.  But at what point does a ‘right’ to die become a ‘responsibility’ to die?  What safeguards are proposed to detect and deter people from choosing to die for the wrong reasons?  Again, more questions I do not have the answer to – nor can I find in the text of the proposed legislation.

The right person for the job?

The proposed legislation for assisted dying seems to be clear in its expectation that the act of assisting someone to commit suicide would be one carried out by doctors.  It argues that as a profession we are best placed to diagnose a terminal condition, determine valid motive for wanting to commit suicide and prescribe an effective and appropriate method of suicide.

None of these assumptions about doctors are true.

How good are we at predicting when someone is going to die?  I have practiced my specialty for approaching 30 years, I have witnessed many patients at the end of their lives.  Supporting patients and their families through the end-of-life journey is one of the most professionally fulfilling aspects of the job that I do.  What I have learned, time and again, is that the process of dying is incredibly unpredictable.  Patients you believe to be on the point of death at one moment can rally and improve, even on palliative therapy, and go on to live for days or even weeks.  Similarly, patients can be dying slowly, but then suddenly.  Even those patients we have for years considered to have ‘terminal’ diagnoses are now surprising us.  Modern cancer treatment has transformed most cancer diagnoses from terminal conditions to chronic conditions – ones that patients ‘live with’ for years.  The categorisation of patients ‘with terminal conditions’ is really not an exact science – we do not have a reliable means of determining who they are.  And when their conditions do declare their terminal status, it would be more often than not too late for an individual to pass through the hurdles required to fulfil their right to die.

How good are we at determining patient’s wishes and capacity to make decisions?  As I alluded to earlier – not very good at all.  The whole process around consent for treatment is fraught.  We are not very good at conveying risk to patients, not least because we don’t understand it that well ourselves.  We are not very good at suggesting alternative treatments to our patients instead persuading them that what we have to offer is the best option (the powerful cognitive bias – commonly described as the ‘hammer – nail’ problem).  And finally, how good are we at determining if patients have the capacity to make decisions for themselves – at determining their ability to understand and weigh the information we give them and communicate their wishes back to us?  The answer, again, is not good at all – capacity assessment is a highly specialised skill, one best performed by a clinical psychologist, and requiring skills that barely any doctor I know has received training for.

How good are we at administering drugs that would cleanly, efficiently and painlessly end someone’s life? I don’t know the answer to this question – because I’ve never had to do it (and as you might have guessed never intend to).  I did a quick survey of my colleagues – none of them had ever considered it and none of them knew how it was done elsewhere (and my colleagues are mostly anaesthetists whom many would assume are the one specialty best equipped with the requisite skills for such a task).

The bottom line is that doctors are not equipped with the means to identify the right patients for assisted dying, determine if those individuals have valid motives for wanting to die, determine if those individuals have the capacity to make those decisions and finally are not equipped with the skills to carry out those wishes.

So, in order to bring about the desired outcome of the proposed legislation we would have to create a new specialty (I hesitate to call it a ‘medical’ specialty because they would not in my view be administering medicine).  Specially trained ‘assisted suicide physicians’ – at which point we create a huge danger because how would we (could we) assure ourselves that someone trained to assist suicide would not actually be persuading patients that to end their life is in their ‘best interests’?

In the End

That we have come to a point in our society that we are considering allowing people to be assisted in committing suicide is an indictment of our failure to invest and build services to support patients at the end of their lives.  The heroic specialty of Palliative Care Medicine remains a Cinderella service that is largely funded by charity, and almost not at all by the NHS.  This is a travesty – and one we should address long before we start even considering investing in the infrastructure, means and training of a whole new specialty of suicide medicine.

I fear that this time round the legislation will succeed, that when it does the medical profession will be asked to do something it is ill equipped to do.  In doing so it will be colluding in state sanctioned murder and will fail to prevent people committing suicide for the wrong reasons.  I fear that whatever safeguards are proposed to prevent the scope of assisted suicide broadening will be demolished by the courts (as they have been in Canada) and that before long we will be a society in which people will be expected (or at least feel a weight of expectation) to choose to die – as they do in Holland.  

We must pull back from the edge.