10 reasons to be wary of assisted dying

1. Assisted suicide is almost certainly not as popular as its supporters claim.

Dignity In Dying claim that 82% of British people support assisted suicide, based on an online survey by the polling organisation Populus. This oft-repeated figure is a very bold claim, and so deserves to be subjected to some severe critical scrutiny (and even if it is accurate, it would not clinch the argument: sometimes we need to protect minorities regardless of majority feeling).

So should we trust the 82% figure? One alarm bell is that the Populus poll was online only, which meant it immediately excludes non-internet users (i.e. the elderly, poorer people, people with disabilities and impairments – just the kind of individuals who often fear assisted suicide).

Furthermore, assisted suicide is a very complex issue. Many do not know very much about the issue, or have not considered the potential downsides in full. End-of-life ethics is an area of enormous complexity, a fact reflected in the cumbersome length and complexity of the questions posed in the Populus poll (which is one reason not to draw too many wide-ranging conclusions based on the answers given). Clear thinking about this area of medical ethics involves familiarity with a large number of subtle but important distinctions.

When people are presented with the hard cases, or with a seemingly watertight and easy bill for assisted dying, of course they like the sound of it! People fear dying and pain! However, there are many different angles to consider, and people’s views can change quite dramatically when new information or scenarios are presented. This is shown by polling work done by ComRes in July 2014, which sought to find out how many people who initially supported assisted suicide changed their mind when presented with new information. Care Not Killing, the umbrella group for organisations opposing assisted suicide, note that

“Overall 42% of those who originally supported the bill changed their mind on the basis of at least one of the arguments”.

2. Groups representing people with disabilities don’t want it.

SCOPE, Britain’s largest disability charity, is opposed to assisted suicide, on the grounds that the safeguards in the proposed Bill are inadequate, that it has not worked well overseas and that we should do a lot more to help people with disabilities live before we start helping them die.

In July 2014, a poll commissioned by SCOPE and carried out by Opinium found that two-thirds (64%) of people with disabilities would be concerned by a change in the law. 62% of those who said they were “concerned” worry that disabled people would face pressure to end their lives prematurely if assisted suicide were legal. Over half (55%) of all those surveyed believed that the current prohibition of assisted suicide protects vulnerable people from pressure to end their lives. The same proportion are concerned that disabled people might choose assisted suicide to avoid being a burden on their family and friends.

The survey also found widespread negative views of disability in society – for example, 76% of 18-34 year olds with a disability have experienced explicit negative comments and assumptions about their quality of life.. This matters deeply in the assisted suicide debate, because our collective treatment of disabled people helps to form those people’s attitudes and beliefs about the value of their own lives, and so may feed into subtle coercion and pressure.

3. Doctors who work with the elderly and with dying patients don’t want it.

A survey of members of the Association for Palliative Medicine, an organisation for doctors who work with the dying which is firmly opposed to assisted suicide, found that 82% opposed legalised assisted suicide and 72% thought that it would be bad for hospice care. Only 4% said that they would be willing to take a full part in the assisted suicide process if it were legalised, with 89% saying that would not be able to take a full part.

Similarly, the British Geriatrics Society, the body for doctors specialising in care for the elderly, is also opposed to assisted suicide, saying in their position statement that “a policy which allows physicians to assist patients to die is not acceptable to us”. They are right at the sharp end when it comes to patients who are approaching the end of their lives, and they recognise that the legalisation of killing as a treatment option is not the answer. Interestingly, they state that “our experience shows us these are more often a cry for help than a genuine desire for death”.

4. The current law is not “unclear”, as is often alleged.

The legal situation concerning assisted suicide in England and Wales is not some kind of arcane legal puzzle, comprehensible only to highly-trained criminal lawyers. The 1961 Suicide Act states that:

“A person who aids, abets, counsels or procures the suicide of another, or an attempt by another to commit suicide, shall be liable on conviction on indictment to imprisonment for a term not exceeding fourteen years.”

This seems quite straightforward. At present, if you encourage or enable someone to kill themselves, you are committing a criminal offence (a serious one, for which the maximum penalty is fourteen years in prison). Any difficulty with how the law is applied comes from the lacklustre and inconsistent approach of the CPS, not with the law itself.

Assisted suicide prosecutions are rare. In the five and a half years from April 2009 to October 2014, 101 cases of euthanasia or assisted suicide were referred to the CPS by police forces. The CPS took no action in 69 of these cases, while the police withdrew 16 more. Of the remaining 16 cases, 5 were prosecuted as murder or assault and 11 as assisting a suicide. As of October 2014, 10 of those cases were ongoing – in the remaining case, the CPS obtained a conviction for attempted assisted suicide in October 2013. By way of comparison, in a somewhat similar time frame (2008-2012), 126 Britons travelled to Dignitas to end their lives there. Many of those individuals will have had help from family or friends. Clearly the prosecutorial regime in the UK is not especially draconian when it comes to assisted suicide.  

5. Some slopes are slippery.

It’s fashionable to be dismissive of slippery slope arguments. And sometimes they aren’t helpful. Saying, for example, that “everything will inevitably get worse because we have legalised this particular objectionable thing” is vague and unhelpful. But logical slippery slopes do exist, especially when considering legal matters. Legal reasoning relies heavily on precedent and equal treatment, i.e. once you have conceded a particular legal or ethical principle, it can become very difficult to control the further application of that principle. The internal logic of the pro-assisted suicide position means that any law or court decision allowing any assisted suicide contains within itself the seeds of its own expansion.  

6. Oregon isn’t the assisted suicide utopia that we’re told it is.

Supporters of the Marris Bill are fond of telling us to look at Oregon, where a similar law to the one they favour has supposedly worked well. They seem less keen to look close to home, to the Netherlands and Belgium, where laws allowing forms of assisted suicide and euthanasia have swiftly broken free of whatever safeguards they may once have contained. But even in Oregon, there are problems: the numbers have been climbing steadily ever since 1997, and more seriously palliative care there remains poor compared to the UK. To quote Baroness Ilora Finlay, one of our leading palliative care specialists:

‘Hospice care in Oregon isn’t the same thing as hospice care in Britain.  In Oregon, hospice care means for the most part basic nursing care.  If you go into a hospice, it’s for comfort care only – and you sign away your rights to clinical treatment.  As a House of Lords select committee was told on a visit to Oregon, “It pretty much is a one-way ticket opting out [of life, if you opt] into hospice.”’

7. We already have assisted dying.

Britain already helps people to die well. We have some of the finest hospices and the best palliative care in the world – indeed, the hospice movement was largely founded and developed in this country by the remarkable Dame Cicely Saunders.

8. Once we concede the principle of assisted suicide, it will be hard to control its expansion.

This point bears repeating. The constant reassurances that this is a limited Bill designed to be used in a small number of extreme cases do not ring true, because simply on their own terms, the arguments for assisted suicide appear to demand expansion – if it’s about autonomy, why exclude anyone who wants to exercise their autonomy in this way? If it’s about pain or indignity, why are only people whose pain or indignity is part of a terminal illness included? This expansion is exactly what has happened in the Netherlands and Belgium. In the Netherlands in 1994, a judge ruled in the Chabot case, that the definition of unbearable suffering need not be limited to physical illness, a huge conceptual change. That case, of course, arose from assisted suicide being given to a woman who was suffering from serious clinical depression. More recently, both Belgium and the Netherlands have expanded the scope of their legislation to minors and those who are not dying or in unbearable pain but are merely “tired of life”.  Recent papers from Belgium and the Netherlands showed that euthanasia is routinely given to people with mental illness.

9. It’s very difficult to define and detect when patients are experiencing coercion and pressure.

People talk very glibly about safeguards as if they were the simplest thing in the world. The Marris Bill legislates for a judicial process through which anyone seeking assisted suicide must go, and lays out a careful procedure. But it remains true that it is very difficult to tell when people are under coercion and pressure, and human nature being what it is, all safeguards tend to become box-ticking exercises, especially under the unique pressures of a hospital environment. We need to think too about how the very existence of the option of assisted suicide changes people’s thinking about the value of their own life and their day-to-day lived experience.

The late Professor Nicholas Tonti-Filippini, an Australian ethicist who spent many years fighting a terminal illness, often in severe pain, put it this way:

“As a chronically ill person I know well what it is to feel that one is a burden to others, to both family and community, how isolating illness and disability can be, and how difficult it is to maintain hope in the circumstances of illness, disability and severe pain, especially chronic pain…The fear of being a burden is a major risk to the survival of those who are chronically ill.  If euthanasia were lawful, that sense of burden would be greatly increased for there would be even greater moral pressure to relinquish one’s hold on a burdensome life.”

10. No-one is “forced” to go to Dignitas.

A common rhetorical trick played by those in favour of assisted suicide is to suggest that people who travel to jurisdictions where assisted suicide is legal are in some sense being compelled to do so. This is not the case. Travelling to Switzerland remains a choice. In any case, as a specific argument for the Marris Bill this collapses on closer inspection. Large numbers of those going to Dignitas would not be eligible for assisted suicide under the Marris Bill, which applies only to those who are terminally ill with a prognosis of six months or fewer. Some of the British “patients” who have gone to Zurich are not seriously ill or impaired, and would not have been allowed assistance to kill themselves even under quite liberal assisted suicide legislation. Does this mean that Mr Marris and other legislators who have brought forward assisted suicide bills are guilty of forcing people to travel overseas to get “treatment”?