New Internationalist

Should assisted suicide be legalized?

Issue 450

Right-to-die campaigner Debbie Purdy and palliative medicine professor Ilora Finlay go head-to-head.

ARGUMENT

Every month we invite two experts to debate, and then invite you to join the conversation online. The best comments will be printed in the next magazine.

Debbie

The current situation in Britain, that forbids assisted dying yet permits it if the act is motivated by love and compassion without providing safeguards and opportunity for full discussion on the issue, is surely not the best we can come up with.

I agree with your letter in The Times last summer that palliative care is not a blanket panacea, and therefore believe that we must be prepared to open up a discussion about what we expect and want at the end of life. This is especially true given that the current situation is leading to early assisted deaths abroad and people living their final months full of suffering and extreme desperation due to a lack of choice.

A properly considered law with safeguards would enable doctors, social workers, families and even the clergy better to support the patient, and ensure they have considered every alternative.

I see it as I do voting: I despise people who put their cross next to the BNP but I wholeheartedly defend their right to do so. We don’t have to agree with the choices people make, but if we don’t like their choices our duty is to ensure that the alternatives are appealing. We should not prohibit choices just because we wouldn’t make them.

Ilora

It’s not a question of agreeing or disagreeing with the choices that people express. I fully understand the argument that there could be highly exceptional circumstances where it might be acceptable to accede to a request to hasten someone’s death. But I would not legalize such acts any more than I would legalize other potentially understandable breaches of the law that might be committed in extreme circumstances – such as stealing food for your hungry child.

Legalization produces normalization. Look at the US State of Oregon. Since physician-assisted suicide (PAS) was legalized in 1997, such deaths have quadrupled. Oregon’s current PAS death rate would produce more than 1,000 assisted suicides in England and Wales every year. Yet with our law as it stands, fewer than 20 cases of assisted suicide cross the desk of the Director of Public Prosecutions (DPP) each year.

It’s easy to talk of choices, but decisions need accurate information, correctly understood. Safeguards for ‘assisted dying’ can help, but only if they provide a challenging process to screen out less-than-serious applicants. The safeguards so far proposed seem to be designed primarily to facilitate ‘assisted dying’ for a small minority of highly determined and strong-minded people rather than protect the vulnerable – from themselves and from others. Don’t forget that the law exists first and foremost to protect the weak and the vulnerable. It manages to do that while dealing sensitively with cases where genuinely compassionate circumstances have been present.

Debbie

I’m glad you see some circumstances that would render assistance to die acceptable. How can society find solutions or even alternatives if it doesn’t talk about the situation? Surely a full, frank and honest discussion is needed to explore people’s needs in the 21st century.

The ‘20 cases that cross the DPP’s desk’ are, as you know, all patients who have travelled to Switzerland, but many don’t. Each year in Britain hundreds of people attempt suicide because they cannot cope with the pain or indignity of a medical condition. Some succeed, others result in further problems. Either way, I don’t believe this is a situation that people are prepared to brush under the carpet, much as parents being forced to steal to feed their children was one of the building bricks of our union movement and later the welfare state.

Your suggestion that PAS deaths in Oregon have increased uncontrollably is misleading. The Death with Dignity Law was passed in 1997. Ten years later, in 2007, 85 people received the medication to end their lives, 49 used it.

About 10 per cent of patients accessing palliative care (that’s approximately 1,500 people), had initially contacted their doctor about assisted death. The patients using PAS have remained at about 0.2 per cent of deaths (65 in 2010) but as their concerns have become more ‘public’ through complying with Death with Dignity laws, palliative care has become more accessible and Oregon has leapt up the table of quality providers in the last decade (it’s now second). Far from being an alternative to the provision of good-quality palliative care, the legal framework for assisted death has been a huge motivation for its improvement. If ‘normalization’ means we improve quality of end of life care and better communication between carers, patients and their family, I welcome it.

Ilora

No-one is suggesting that we shouldn’t discuss how to relieve the suffering of terminally ill people. That is precisely what modern palliative care does, supporting people and working to maximize quality of life. But based on my experience of caring for thousands of dying people over 25 years, I don’t think helping them to kill themselves is the right way to deal with their suffering.

The cases that cross the DPP’s desk are not just those of people who have gone to Switzerland for assisted suicide (take the recent Gilderdale case, for example). They are cases where there is evidence that a suicide has been assisted, contrary to the law. You seem to imply that some seriously ill people commit suicide because assisted suicide is prohibited, but what evidence do you have for this linkage? We are not discussing suicide, but whether the law should be changed to allow some suicides to be assisted.

It’s unclear what point you are making about the number of physician-assisted suicides in Oregon. What I am saying is that the number of such suicides in 2010 was four times the number in 1998 and that the current death rate from PAS in Oregon would produce more than 1,000 such deaths in England and Wales every year.

Of course, palliative care has improved in Oregon: it has improved in most parts of the world, as a result of advances in care of the dying. Much of this progress has been spearheaded by Britain, which – unlike Oregon – recognizes palliative medicine as a clinical speciality. It is spurious to attribute Oregon’s improvement in palliative care to its legalization of physician-assisted suicide.

Debbie

Gaeten Bally / PA Images
A room rented by euthanasia organization Dignitas, where those who have decided to die spend their last moments. Gaeten Bally / PA Images

I understand your point of view but thousands of people in Britain are discussing assisted dying and politicians need to catch up. Twenty-two Britons went to Dignitas last year, and 10 per cent of the 5,000 annual suicides are people with terminal or chronic illnesses – the link between illness and suicide needs to be explored. Kay Gilderdale had to face a charge of attempted murder (she was acquitted), and pleaded guilty to assisted suicide. That a compassionate mother who spent 17 years helping her daughter live – and when her daughter decided to end her life, supported her – found herself facing life imprisonment, is a clear signal that the law is not working.

If I had lost my legal case, I would have gone to Dignitas in 2009. So I strongly believe that if society had more open, honest discussion prior to a patient’s death, lives would be improved and saved.

I would campaign against legalization of assisted dying if I saw any evidence that people would suffer or be pressured into early deaths. Residents of Washington voted for assisted dying in greater numbers than those of their neighbour state of Oregon because they’d seen the decade-long positive experience of Oregon, with improving palliative care, high numbers taking comfort from the law and low numbers using it. There are fewer lawful assisted deaths in Oregon than unlawful ones in unregulated states. Legalization shines a light on end of life decision-making, allows doctors and patients to be safer and, more importantly, feel safer. Patients know they have a choice if their suffering is unbearable, without having to resort to suicide or overseas travel for assistance.

Your use of the word ‘killing’ in relation to dying people controlling the timing of their death suggests you have a personal objection. Campaigners for assisted dying want conscientious objection clauses ensuring the choices of healthcare professionals are respected. And patients’ wishes should also be respected.

Ilora

Oregon’s population is small; if 1,500 patients asked for assisted suicide to access palliative care, that perhaps calls into question their referral systems.

Parliament discussed ‘assisted dying’ in considerable depth on at least five occasions in recent years and rejected the proposal as unsafe, and I agree. As a palliative care physician I see requests vanish when suffering people get the support they need; many are glad to be living well months or years longer than they believed possible. Listening to patients is core to care. There is nothing to prevent ‘open, honest discussion prior to a patient’s death’ – indeed, exploring patients’ feelings, fears and wishes at the end of life is a major feature of good palliative care. What the law prohibits is encouraging or assisting suicide.

You say you’d change your mind about legalizing assisted suicide if you saw evidence that society would suffer. But what sort of evidence would you accept? There is plenty of it: it’s just that it is interpreted in different ways by people with different views of the issue. I know of no evidence that supports your statement that legalization of assisted suicide ‘shines a light on end of life decision-making, making doctors and patients safer’.

It’s all very well to talk about choice. But let me suggest a parallel. Some youngsters say they would like to carry knives because it makes them feel safer. But the law doesn’t allow that. Why? Because letting them have their choice would not be safe for the rest of us. One person’s choice can easily become another person’s risk.

Debbie Purdy is an activist with primary progressive multiple sclerosis. In 2009 she won a ruling from the Law Lords (now the Supreme Court) requiring the Director of Public Prosecutions to publish his policy on the prosecution of cases of assisted suicide. Ilora Finlay is a professor of palliative medicine at Cardiff University and a member of the British House of Lords. She chairs the All-Party Parliamentary Group on Dying Well.

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