Assisted dying should be legalised

Death is inevitable for us all. For some it is sudden and unexpected but for others the dying process – the irreversible loss of one or more vital functions – can extend over days, weeks or months and can involve suffering.

Mercifully, modern methods of palliative care often suffice to alleviate distress and in so doing also help to prolong life by promoting better sleep, better nutrition and tranquillity of mind. But as strength and life ebb away, side-effects created by the very methods used to relieve distress become more prominent and are themselves a threat to life, most commonly because breathing is impaired as a consequence of pain-relieving medication. But this occurs only when the dying process is far advanced and death is brought forward by a matter of hours or days at most. Hastening death is a consequence rather than an objective of treatment and, in such circumstances, is seen by many as a small price to pay to secure a peaceful, pain-free death. It is a view endorsed by the English courts.

But for some the dying process is not so gentle and its relief defies the expertise of palliative care. Slowly progressive paralysing illnesses with preservation of sensation and mentation can fall into this category, especially if the disease involves the muscles responsible for speech, swallowing and breathing, but there are other examples too. Despite the amazing fortitude and ingenuity which many of those affected display in dealing with their predicament, there comes a time when, for some, the prospect of death is welcome – indeed, more welcome than the prospect of life.

By what means can their suffering be relieved? Recent English case law has confirmed the right of competent adults to refuse life-saving treatment, but this is of little help if no life-saving treatment is under consideration. And such a decision can bring with it suffering of a different kind. For example, a fully sentient person unable to swallow who refuses invasive means of nutrition and hydration because they wish to die, is likely to experience hunger and thirst and death will not be swift.

The option of suicide is considered – and attempted – by some. But what means of ending one’s life are available to those who are unable to move and perhaps unable to swallow? Lack of knowledge, access or the ability to implement a chosen course of action are likely to prevent successful suicide, and seeking the assistance of another lays that other person open to a criminal charge. A few particularly determined individuals have achieved their objective using a Swiss service that provides the means and environment for ending life in a controlled and dignified manner. To date the numbers availing themselves of this option are small and it too could be rendered inaccessible if a residency qualification is imposed for those applying to the service.

So should we just leave this minority of the terminally ill to suffer in silence because the prospect of assisting others to die voluntarily is counterintuitive, distasteful, contrary to moral principle or appears to transgress the universal biological urge for self-preservation? Can we argue that to legalise assisted dying is certain to create a risk that the vulnerable, the elderly or the disabled will thereby be disadvantaged? Is there any evidence to suggest that this might be so?

Assisted dying is permitted in a number of other jurisdictions and experience from the State of Oregon is the most useful comparator because the Death with Dignity Act introduced there in 1997 is the nearest in concept and application to Lord Joffe’s Assisted Dying for the Terminally Ill Bill which is currently under consideration by a Select Committee of the House of Lords. Experience in Oregon is reassuring. A report published in 2004 indicated that assisted dying accounted for 0.14 per cent of all deaths in Oregon in 2003. There was no upward trend in the figures over time and those availing themselves of the option were often determined personalities for whom autonomy and independence were of paramount importance. All had received, or were receiving hospice care.

The Assisted Dying for the Terminally Ill Bill proposed by Lord Joffe contains even more precautions and safeguards than the corresponding legislation in Oregon. The Parliamentary Joint Committee on Human Rights has considered the proposals and concluded the bill incorporates sufficient safeguards to protect the interests and rights of the vulnerable. National opinion polls show a rising proportion of the public – currently 82 per cent – is in favour of legalising assisted dying. Representatives of the medical profession submitting evidence to the House of Lords Select Committee have adopted an entirely neutral stance and, although identifying practical problems that would require careful regulation, do not regard them as insuperable.

Society relies upon the lawmakers to determine acceptable boundaries in matters evoking ethical conflict, and to change the law from time to time to reflect changes in the perceptions and aspirations of society. Currently an increasingly knowledgeable, articulate and secular society seeks greater involvement in medical decision-making and respect for personal autonomy. The majority now believe that assisted dying should be available at the request of competent adults who are terminally ill and suffering unbearably. It is time for the lawmakers to act.

Dr Margaret Branthwaite is now retired but practised formerly as consultant physician and anaesthetist at the Royal Brompton Hospital and subsequently as a barrister. She spoke at the spiked conference ‘Whose choice is it anyway? Questioning the new conformism’, in central London on Friday 11 March 2005 (see http://www.spiked-online.com/choice).