The terminal confusion of Dignity in Dying

The closer you look at the campaign to legalise assisted dying, the less reassuring it all becomes

5 July 2014

9:00 AM

5 July 2014

9:00 AM

If you were around in the days when the US series M*A*S*H was a regular feature on British television, its sing-song theme is probably still lodged in your memory: ‘Suicide is painless/ It brings on many changes/ And I can take or leave it if I please’.

However catchy, it is broadly untrue. The human life force is stubborn, and it takes a visceral struggle to extinguish it. Suicide, as commonly practised by amateurs, is not painless: it is frequently agonising, complicated, botched and has ample potential to leave one still alive but with a cruel legacy of permanently damaged health to add to one’s existing woes.

Many of us nonetheless carry the very notion of suicide around in a pocket of our psyche as a brutal form of hidden comfort, like second world war spies with their little cyanide pills. I think of suicide, if I contemplate it at all, as something resembling that pill, to be deployed only for imagined circumstances in which ordinary life has become intolerable: a possible means of release from an outrageous extremity of suffering. Yet its practical difficulty remains an essential part of its nature, a necessary disincentive to nudge us back towards life.

Falconer & Goldsmith Make Announcement On Magistrates Courts
Lord Falconer Photo: Getty

It is, however, human nature to crave control where none seems available. That is why numerous people will back Lord Falconer’s Assisted Dying Bill, which will receive its second reading in the House of Lords on 18 July. It proposes that terminally ill adults with less than six months to live could be legally helped to end their lives by means of prescribed medication. To that end, it is publishing advertisments featuring the gruelling ‘obituaries’ of individuals whose suffering was prolonged, the campaign argues, by the absence of ‘assisted dying’.

The stories within are undoubtedly powerful and moving. But they do not give the full picture of the Assisted Dying Bill, and why so many others are alarmed by it.

The Bill would, for the first time, invoke the state’s support for openly assisting an individual to die. That is a fundamental shift. And while the Bill speaks reassuringly of its checklist — the terminally ill patient would need to be mentally competent and receive the sanction of two doctors — the longer one looks, the less reassuring it grows. What is this clause of ‘six months or less’ to live? As most doctors know, such diagnoses can be deeply unreliable. And by what logic do we attach an ‘assisted death’ to a six-month prognosis but not, say, that of a year? As Lady Butler-Sloss sharply observed, the Bill exchanges ‘a natural frontier’ for ‘arbitrary criteria’.

If ‘assisted dying’ is to be permitted for the terminally ill, why would we then deny it for the kinds of conditions which terrify many of us far more: the prospect of prolonged advanced dementia, for example, or ‘locked-in’ syndrome of the sort which the late right-to-die campaigner Tony Nicklinson bravely endured? Many campaigners see no reason why euthanasia should not also be afforded in such instances.

The limitations outlined in Lord Falconer’s Bill are far from absolute: they are there because they are thought to be the maximum that the public would presently accept.

Such a rolling process was suggested in the 2012 report from Lord Falconer’s Commission on Assisted Dying, which chilled a number of prominent disabled commentators. It observed that the commission could not agree on whether to extend the ‘assisted dying’ option to those with disabilities, concluding that ‘we do not consider that it would be acceptable to society at this point in time to recommend that a non-terminally ill person with significant physical impairment should be made eligible.’

The clear implication was that at another point in time it might indeed become acceptable. Tanni Grey-Thompson, the disabled peer, wrote eloquently of her deep unease that: ‘while I am not seen as a potential candidate for assisted suicide right now, I am in the waiting room’.

Dignity in Dying has often invited the public to contemplate the distress of those who have wished for death and been denied it. Yet we must also consider the effect of such a law not simply on those who want to die, but those who wish to live.

The Assisted Dying Bill argues that the terminally ill are a special group who could be legally hurried towards death. Campaigners have hinted that this could one day be extended to the disabled. What then would we really be saying about equality of value, if the terminally ill and disabled were the only groups in society granted permission for assistance to die?

It is disingenuous simply to argue that ‘assisted dying’ would only be open to those who truly desired it. Desire itself is subject to external pressure, and vulnerable to shifts in social atmosphere: it can be generated, not only from independent will, but also from isolation, guilt and despair. The terminally ill patient endures the gross indignities of a failing body, is acutely demanding of resources, and clearly sees the cost that care exacts from weary family members. The last months can no doubt be horrifying for some. And yet I have also seen friends approach their final days with remarkable serenity and lucidity.

Our current treatment of the terminally ill is a morass of compromises, involving fine judgments around palliative care, the escalation of morphine as pain relief which may speed death as a side-effect, the right to have medical treatment withdrawn, and a legally compassionate approach towards loving family members who might assist a relative in lengthy torment to die.

Yet it may simply not be possible to frame a law that fulfils the understandable wishes of campaigners such as the late Mr Nicklinson, but protects wider numbers of intensely vulnerable people from insidious pressure to end their lives prematurely.

Once the euthanasia option exists, it immediately alters the nature of the conversation. The suggestion that a patient conveniently embrace the opportunity might remain unspoken, but it will not go unconsidered.

The radical on the edge of this discussion is Ludwig Minelli, the flamboyant Swiss lawyer and founder of the euthanasia clinic Dignitas, who is an equal opportunities purveyor of prescribed death. His view on assisted suicide is that it should be ‘without conditions. A human right is without any conditions except capacity.’ The Dignity in Dying group is troubled by Minelli, and has in the past disowned his position. Yet while I do not agree with Minelli, his universally applied ideology seems in its way more bluntly honest and less disturbingly illogical than those who seek to erect a halfway house in which only selected groups in our society are invited on the professional fast-track to death.

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  • tjamesjones

    I remember my father making one of these points in a sermon in the 1980s: nobody needs to say anything for Grandma to feel she is in the way, spending the inheritance, maybe she should just…..

  • Kitty MLB

    Its very difficult. Dignity in dying, suddenly other people take control of your life.
    I knew a very elderly chap. who had a long active life, he was a maths teacher, wrote rhymes and loved walking . A short stroll for him was a 7 mile walk even
    at 60 years of age.
    But when he became very old and in pain ( but still with all his wits about him)
    he just wanted to go, but others thought they knew best.. but eventually he just refused to eat and speak. and thankfully they respected his wishes and cared for him
    until he went.

    • Damaris Tighe

      But this happened informally as it should be; it wasn’t enshrined in law. A formal law of euthanasia would send all the wrong messages.

  • Damaris Tighe

    I find it significant that Lord Falconer, prominent member of the liberal-left which has done do much to destroy this country’s values (24 hr boozing, relaxed restrictions on gambling, laws against thought crime, mass immigration, deconstruction of the idea of family, ‘human rights’ & a justice system that favour the criminal) is also behind this proposal.

    We have abolished the death penalty for even the worst of criminals but it’s ok to hasten the death of the sick? Another instance of a completely inverted value system designed to fundamentally change our society. It is, as the article states, a recipe for abuse. These things are best handled informally, not enshrined in law. The horror stories that are trotted out in favour of euthanasia should not be used to overturn the fundamental principle that life is sacred. Legalised killing is a red line that we cross at our peril.

  • Judy

    The prospect terrifies me. I have two daughters in their twenties, serious mental illnesses and many suicide attempts. The rhetoric of ‘euthanasia’ eats away at society’s will to protect the lives of the vulnerable.

  • Retired Nurse

    Have a close look at the definition of ‘terminally ill’ these two shysters have used. The Bill is here:


    Take a close look at Section 2 (2):

    “2.Terminal illness
    (1)For the purposes of this Act, a person is terminally ill if that person—
    (a)has been diagnosed by a registered medical practitioner as having an
    inevitably progressive condition which cannot be reversed by treatment (“a terminal illness”); and
    (b)as a consequence of that terminal illness, is reasonably expected to die
    within six months.
    (2)Treatment which only relieves the symptoms of an inevitably progressive
    condition temporarily is not to be regarded as treatment which can reverse that
    …so that’s COPD, Diabetes, heart failure…anything you cant survive on without the tablets they’re convincing older people to do away with nowadays under the guise of ‘overmedication’….

    Joffe and Falconer are both a couple of utter shits.

    • Retired Nurse

      and Norman Lamb is a bigger one.

    • Winston Jen

      You’re an example of a soulless sociopath with less compassion than a crocodile. If you had seen someone suffering unbearably when palliative care fails, you’d change your tune quite quickly.

      Especially if palliative care failed YOU.

  • Gergiev

    Supposing for the sake of argument that the current proposals are in themselves desirable, is it not still the case that the remorseless logic of equal opportunities will mean that the law will be constantly tested at the fringes and over time move inexorably towards Minelli’s absolutist position? Then once death becomes a right for all will it not then become a duty for some: the old, the infirm, the disabled and the depressed? A nice holiday for all at aged say 70 with a one way ticket to some virtual paradise for a week before a special meal with friends and family where desert includes a cocktail of drugs that takes the lucky camper on a permanent vacation? How better to solve problems posed by the gerontification of society and so-called inter-generational “unfairness”?

  • mikewaller

    Why do all these debates have to be conducted in such an appallingly adversarial way? As the late Alistaire Cooke pointed out in respect of abortion, good cases can be made either side of the fence, so why do both sides have to proceed on the basis that the other is talking dangerous nonsense? Yes, getting poor old mum bumped off so that you can realise your inheritance is a wicked thing to do; but then leaving her for years as a very unhappy, unpaid carer for a husband who has lost any semblance of the man she married ain’t to kind either. As far as I am concerned, if in the latter case he has clearly specified the conditions beyond which he would not wish to live, assisted suicide is OK by me. Certainly it is what I would want for myself.

    • Tony

      This is a classic “false dichotomy” argument: the notion that there are only two extreme options. The one option is legalised assisted suicide. The other option is “leaving her for years as a very unhappy, unpaid carer for a husband who has lost any semblance of the man she married.” If she doesn’t want to be in this situation, she’s free to leave her husband! She’s not a helpless victim in this situation. Are you saying it’s better to kill someone than “leaving” a person in an unhappy marriage?

      You are using an argument for suicide to argue that assisted suicide should be legal. They are ethically different. If a person “has specified the conditions beyond he would not wish to live”, he can commit suicide under current legislation. This act would directly involve only one person (although others are affected). Assisted suicide involves at least two people. One of these people would be involved in killing another person. To make it legal for certain people to kill others, is a serious shift in the mentality of society and open to abuse.

      • mikewaller

        “Open to abuse” is very much the position of, for example, Alzheimer patients left in care even with the the continuing interest of family members. God help those whose kin simply walk out and leave them to their own devices. Yours is a classic small scale argument that simply does not scale up. Given our current demographic and the major advances made in medical science, if a sizable proportion of the many hundreds of thousands of elderly carers you so generously give the option of walking out to take that option, the care system would collapse. We have already loaded the young down with debt built up to sustain the quality of our lives in the post-war era, dumping the unsustainable costs of a massive care programme on them would be the last straw.

        I very much agree that what is being proposed is open to abuse in the sense you mean. I recall the case of a raid on an abortion clinic in which the two doctors concerned had pre-signed whole batches of the key documents. However I believe practical solutions can be found. For example by having the GP provide one signature and then randomly selecting the second opinion from a very large pool of possible candidates. Then any GP found to have been signing in appropriately would be in fear of his or her professional career.

        • Tony

          Here are some examples of what I mean by “open to abuse”.
          1) Vulnerable people could be emotionally abused. They could be pressured subtly or not so subtly to request death. It would be impossible to ensure a person’s request to die is 100% free and 100% their own choice.
          2) A person could be suffering from grief, trauma, a major life change or undiagnosed depression. These conditions would make them vulnerable to subtle or not so subtle suggestions that death is the solution to their pain. If these conditions are addressed, their desire to die may disappear.
          3) A doctor could be mistaken about the length of time a patient has to live. After all, how long a person has to live can only be an educated guess at best and never a fact. 4) A doctor could give an overly negative prognosis to encourage a person to request death.
          5) A doctor could be biased towards assisted suicide.
          6) A doctor could be prejudiced towards certain groups of people, affecting their diagnosis or prognosis.
          7) The second doctor could be partial to the first doctor or biased in favour of assisted suicide. It would be impossible to guarantee impartiality and objectivity.
          8) A doctor could neglect to present, or be ignorant of, all available treatment options and then intentionally or unintentionally label a condition as terminal.
          9) A doctor could make a wrong diagnosis, intentionally or unintentionally.
          10) A doctor could kill a patient without the person’s request. 32% of reported assisted dying cases in Flanders, Belgium were without consent according to a 2010 study.
          11) A doctor could kill a person without that person’s request and report it as an assisted suicide or report it as a different cause of death.

          Because there’s a confidential patient-doctor relationship, it would be up to the doctor(s) to act with an integrity, follow procedures exactly and report accurately. What if they don’t act with total integrity? No-one may ever know. If doctors break the law, it will be too late for the patient who is already dead.

          The death penalty is illegal due to the risk that vulnerable, innocent people may be killed. Law enforcers should not have this much power.

          Assisted suicide should remain illegal for the same reason: Medical professionals should not be given the power to intentionally kill people, because vulnerable people may be risk.

          • mikewaller

            Again you proceed on the basis that all the pluses are on one side, all the negatives on the other. Yes there would be abuse (there is anyway – remember Shipman) but this could be minimised with well-thought through regulations and very harsh penalties for those who act inappropriately. Note my randomly selected second doctor model.

            And you entirely fail to address the huge health crisis an aging population, many of who have eaten themselves into type 2 diabetes, is creating. I am put in mind of the situation in Egypt at the end of WW1. We had shipped out hundreds of thousands of horses to prosecute the war. When it ended, the bean-counters decided it would be uneconomic to ship them back home and said they should be sold locally. The British units seem to have gone along with this, however reluctantly. However the Australians were made of better stuff. Having seen how the Arabs treated animals, the Australians went to the horse lines and each shot his own mount. I know who I admire most.

            One very important thing the Catholic church has added to this kind of debate is the idea of sins of omission. It seems to me very pertinent here. Allowing folk who have volunteered for euthanasia to instead live out their final years in a state that, when fully compos mentis, they would have found deeply humiliating, seems to me disgraceful.

          • Tony

            Another example of a false dillemma / false dichotomy logical fallacy: Either we have a health crisis with an aging population or we legalise assisted suicide. It is a logical falacy, because there at at least one other option beyond the ones you are considering. Killing is not the only solution. Here are other options: Most of these diseases are lifestyle diseases, which means they are preventable and reversible. Another solution is care, given by professionals. Another solution is care given by members of the community.

            You say you admire people who kill animals for economic reasons and propose we should kill humans for economic reasons. These horses you are referring to were not given a choice in the matter, as are other animals that are being put down. They are being killed without consent. Is that what you propose for humans too? Are you saying the elderly, the disabled, the mentally ill, the unemployed, the intellectually inferior – anyone who may not be as economically valuable to society as others – should rather die to make resources available for the more worthy? This is eugenics. This is the thinking behind the Nazi euthanasia gas chambers.

          • mikewaller

            This typical of the kind of tosh Alistair Cooke was on about. I have repeatedly made clear that I am talking about situations where the individual has pre-specified the circumstances under which they would find death preferable to life. That seems to me a perfectly reasonable human choice and, subject to sensible controls to avoid abuse, I would consider it rank interference for folks such as you to interfere. As for you changing the nations lifestyles to avoid diseases like Type 2 diabetes, get real. That is precisely what governments have been trying to do for years and failing. A new campaign has started this week; but don’t hold your breath. As for your armies of professional carers, again get real. There are simple not enough candidates of the right calibre to go round. Only a week ago I was listening to a friend railing about the shabby treatment a parent is receiving in very expensive care home in the home counties. Trouble is they can’t find anything better. As for your care in the community the prospects would be worse than the very patchy standards achieved with the mentally ill.

            IMHO, you have a very simple principle to which you are determined to cling no matter what the wider implications are. Remember, just post WW2 each pensioner was supported by about 15 workers; we are now heading into an era when the ratio will be less that 3:1. Even you will have eventually to think the unthinkable. Certainly the enormous costs of your “noble” principles cannot forever be shoved onto the shoulders of the younger generations. They are already bowed down by the costs of education, housing and pensions whilst heading into an increasingly turbulent global economy . Dragging out the lives of the ever-lucky baby boomers against their will is an ask to far.

  • Charles Cowling

    “The Assisted Dying Bill argues that the terminally ill are a special group who could be legally hurried towards death.” Honestly, Jenny, how can you expect to be taken seriously? The case against assisted suicide deserves more rigorous advocacy.

  • Diggery Whiggery

    Has this measure ever been presented in a manifesto? Have people voted for this?

    As most European countries seem to be going through the same debates at the same time, it seems like this is either an enormous coincidence or another case of governments looking to change the law before a European court forces them to. I’ll guarantee that there’s some ECHR or ECJ potential decision at work here.

    • Damaris Tighe

      It has already existed for quite a few years in that beacon of liberality, The Netherlands. That alone should put us off.

      BTW, a recent poll of elderly people in The Netherlands found that many are indeed feeling pressurised to consent to being put down.

      • Tony Powell

        Why are gulags better than hospices, Damaris?

        You don’t have to die naturally in hospices.

        • Damaris Tighe

          Not sure what you’re referring to, but in another comment here I’ve said that helping someone along their way at the end of life should continue to be informal, but not be enshrined in law.

          • Tony Powell

            So only the rich and the well-connected should have access to end-of-life compassion?

          • Damaris Tighe

            Anyone with a doctor has always had access to it. These things have always been done quietly & informally. We interfere with this at our peril.

          • Tony Powell

            Why should a peaceful death be available only to the fortunate and the wealthy?

          • Damaris Tighe

            see my previous answer to your previous comment

  • Tony Powell

    All anti-choice politicians and voters should be denied ALL analgesia under anti-hypocrisy legislation.

    There’s no justice like poetic justice.

  • George Kato

    Each of us should recognize that, in the fight for liberty, knowledge is our most potent weapon. Arm yourself: http://www.amazon.com/dp/B0094KY878

  • Retired Nurse

    Joffe made his mint in insurance (Hambro).
    We’re privatising healthcare.
    They dont want to pay for long term conditions in the elderly.
    They dont want to pay for cancer treatment of the elderly.
    Barbiturates are very cheap, and you save several years of pension and care costs too if you can persuade someone to swallow them.

    This unelected man is a complete turd.