Recently, a retired art teacher known only as Anne committed suicide at the Dignitas clinic in Switzerland. The 89-year-old from Sussex had suffered from ill health in recent years, but was neither terminally ill nor seriously handicapped. One of the guests joining VoR's Juliet Spare for this discussion about assisted dying helped Anne with her application to Dignitas.

Juliet Spare is joined by:

Dr Miran Epstein, reader in Medical Ethics and Law

Dr Andrew Fergusson, Care Not Killing

Michael Irwin, founder of the Society for Old Age Rational Suicide, who helped Anne with her application to Dignitas

Baroness Ilora Finlay, professor of palliative medicine at Cardiff University, and chair of the All-Party Parliamentary Group on Dying Well

Soundbites

MI: “Anne contacted me about six months ago and I met her at her home. She was 89 years old. She had problems with her heart and lungs, which were slowing her down in her physical activities. She was a feisty old lady. She had been born in Kenya – she had experienced the days of the days of the Mau Mau in that country. She had trained as an art teacher in England. She had worked in Australia and France, and she was a very independent lady. She knew at the age of 89 that she could not expect many more normal years to live. Her physical problems were slowing her down, her energy level was getting less and less, and she wanted to go out with a bang rather than go out with a whimper. So, she had contacted Dignitas and there’s a whole bureaucratic procedure to be followed. It takes an average of five or six months from the day you first contact Dignitas to the day that you can end your life with their assistance in Switzerland. The Swiss are very bureaucratic. All kinds of documents and medical records to prove who you actually are had to be produced, and so, I helped her in that process.”

“Anne was a good example, to me anyway, as a retired doctor, of somebody who was mentally competent, who wanted to end her life when she got to the stage of what she felt was a completed life. She had done that in a sense of a kind of balance sheet – the pros and cons of wanting to stay alive.”

“I want to quickly quote one sentence from the European Court of Human Rights, which in April 2002 said – ‘In an era of global medical sophistication combined with longer life expectancies, many people are concerned that they should not be forced to linger on in old age or in states of advanced physical or mental decrepitude, which conflict with strongly held ideas of self and personal identity’.”

IF: “I think you have to differentiate suicide from assisting suicide. People commit suicide, people have always committed suicide. What you’re talking about here is involving somebody else in the process of assistance, and in a way, that is where the most dangerous aspects come in, because at what point does assistance become encouragement?”

“You use the term ‘Dignitas clinic’… It’s not a clinic, this is a suicide facility! A clinic implies that there’s some kind of therapeutic arm to this. So, my concern here is that we have somebody who had an enormous amount of experience, who probably had a great deal still to offer to society around, but instead of harnessing what people can do and how they can contribute, and helping them re-find meaning in their lives, we’re getting so focused on suicide, as if that is the only way that you can look at spending the end of your life. I find that very dangerous.”

“The guidelines for prosecution for assisting a suicide in this country, which were produced by Keir Starmer under request from the House of Lords, make it quite clear that if you are assisting somebody purely out of compassion, with no other motive, then it will be reviewed carefully and you are very unlikely to be prosecuted, but it also recognises the importance and the magnitude of assisting somebody in their suicide – the dangers of coercion and the dangers that people in authority, such as those in healthcare, who have such an influence over somebody, them being involved is potentially much more serious than somebody who is a friend, a neighbour or a concerned family member.”

AF: “I think the quote that Michael Irwin read out mixes up issues. As Ilora has just made clear, patients are quite at liberty to decline further interventionist treatment, and I understand that Anne had a ten day admission at some point earlier, which she described as ‘unadulterated hell’, and she didn’t want to go back that way.

"Medicine is almost a victim of its own success in these last few decades and sometimes, for reasons of their own, doctors don’t know when to stop. Meddlesome medicine is never good medicine. Yes, patients should be involved in a dialogue, a dialogue of two experts: the doctor – the health professional who is an expert in their own speciality, and the patient, who is an expert two things – how he feels and what he wants. If that dialogue happens, and I think many elderly people who know they’re reaching the end of life, the next acute illness might be the last one, would choose not to go back to hospital, not to have aggressive treatment. We mustn’t muddle these issues up, and we do need to remember that we’re having this discussion in the UK, at a time when we’re more strapped for cash in the National Health Service and in social service budgets than we’ve been for a long time. More people living longer, society fragmenting, this is not a good time to be encouraging assisted death as the way out.”

IF: “I was on a Select Committee that was looking at public services in the face of demographic change and the increasing number of old people. We were very clear that the potential of old people in the UK, who are getting older, is phenomenal, but it is under recognised and underutilised, and comments that have emerged, and I never met this lady before she died, about feeling that communication in society wasn’t good because of emails and so on, reflects the view that people have become increasingly lonely and isolated behind walls of technology. But, there are some very good examples of good housing, good community, of pulling people together, where actually people will say they never believed they could get so much out of life again! That’s really important!”

MI: “…Anne was not in any way lonely. She had two wonderful nieces, one of whom went with her to Switzerland. She had many friends, she just was a feisty old lady who felt that the time to go had been reached, and when she made comments about present day society, believe me, many people in their eighties, and I’m almost 83, agree with her. I think there are all kinds of changes going on in this world which are terrible, not just for old people but for young people as well!”

ME: “In principle, there are two issues here that I think that we need to distinguish between. One of them is the moral legitimacy of euthanasia and assisted dying. The other one is a completely different question, which is about who is going to be involved, who is going to perform the act. I think the second question should be answered on the basis of the first question. Concerning the first question, philosophically speaking, strictly philosophically speaking, we have two conflicting arguments here.

"One is in favour of autonomy, promotion and support for the autonomy, the wishes of the patient. The other one is about sanctity of life. Sanctity of life is a typically, not exclusively, religious argument. The argument appealing to the autonomy of the patient is typically a liberal argument, but none of these arguments, in my opinion, are able to convince us to really deliver a conclusion that could lead us to the answer on whether euthanasia and assisted dying should be legitimate, legalised in our society. The most important issue here is the context. We need to ask ourselves or to imagine two completely different societies, two completely different worlds. One in which people have an increasing meaningful right to live with dignity, and also a right to die with dignity and another world, where they have a diminished, constantly decreasing right to live with dignity, but at the same time, an increasing right to die, whether with dignity or without dignity. This is a very big question.

"I think that the second scenario is really the one that reflects what is happening in our society. It means, just to cut a long story short, that doctors are being turned, not just doctors but whoever is involved in shortening life of patients, is actually doing shortage management. That is a very serious point I think. It works really well in the context of our society – saving money, getting rid of the burden on the NHS, getting rid of the burden on banks, getting rid of the economic burden on family and so on… And this leads us, ultimately, to the final second question – who should be involved in this? The answer, in my opinion, is definitely not doctors! Should doctors be shortage managers on behalf of banks or shouldn’t they?”

AF: “I think Dr Epstein is quite right to say there’s a reconcilable ideological divide – the yes and no camp. What we have to do is look at what this means in reality. The law is there to tell us what we find valuable. The Royal College of General Practitioners in Britain just announced the result of a yearlong consultation of its members. These are doctors who are very close to dying people and the evidence elsewhere shows that the closer doctors are to the dying, the more resistant they are to changing the law. After a yearlong consultation conducted at a very sensible intelligible and high level, the RCGP came out very clearly, not just maintaining its previous opposition to a change in the law, but strengthening that opposition. It’s all very well having views on one side or the other. Public policy is about public safety. First duty of government is to safeguard the lives of vulnerable citizens and we’re delighted that both the Prime Minister and Deputy Prime Minister recently came out strong against this, even though if it comes to the Commons in the next year or two, there will be a free vote…”

IF: “I do think we have to differentiate the sad situation of an individual from the fundamental question – is it safe to change the law, which is what Miran was addressing just now. When we talk about autonomy we must also remember we live in a society which means we are inter-related. We don’t live on isolated islands. We might feel that we’re on an island, but actually what we do has an effect on others. Quite simply, if we drive too fast, we may endanger the lives of others. Things that we do in our society affect other people. If you change the law to say that one person can assist the suicide of another, however you put it around, as Lord Faulkner himself said – no safeguards will be 100 percent safe. The danger is that this so-called autonomy argument and the risk of people feeling pressurised in exactly what was described as this shortage management of actually saving money, people being made to feel that they’re a burden, people feeling that their situation is hopeless rather than us saying – we actually value you as an individual. I personally don’t like this term ‘sanctity of life’ because it has all kinds of religious connotations and this really isn’t a religious argument. This is how we behave towards each other in a civilised society. Do we go to the assistance of somebody else or do we just ignore them because there’s nothing in it for us?”

“I think it’s really important to ask the question – is it safe to change the law or is it safer to leave the law as it is… Even though, there will be some people who don’t get what they want, which is to be able to, using the phrase, ‘go out with a bang’. But that’s a balance that we have with everything we do in society. We have rules about how we behave to protect people who are vulnerable…”

MI: “Although some people in this country don’t like to think about it, this country is part of Europe and in four other European countries – the Netherlands, Belgium, Luxembourg and Switzerland we have, I feel, wonderful systems which make it possible for people who are competent, who are suffering unbearably for various medical reasons to have the right to ask a doctor to help them to die. I think it’s essential that doctors are involved in this process… Doctors are involved first of all, because they can successfully judge the competence of someone asking to be helped to die, they can evaluate the medical conditions that someone is suffering from, and it works very well in these four countries. Are we so different to the Dutch or the Swiss? Of course, not!”

IF: “Belgium has just extended their laws of euthanasia of children! I’ve been talking to paediatricians in Belgium and what I heard from them is that it’s not the children that are asking, it’s because the severely handicapped children are a burden!”

MI: “That is nonsense Ilora! The other day, in this country, there was a report in the Daily Telegraph of an 11 year old child, who’d been suffering for years from cancer, who decided enough was enough, and with the agreement of his family he said please stop this ridiculous treatment. And the decision in Belgium was passed by a democratic vote, an overwhelming vote...”

AF: “And it shocked around the world! This is the one change in the euthanasia debate globally that’s woken the world up to the dangers of where we’re going with this. There may be four countries in Europe that have legalised this Michael, but there are well over thirty that have said a firm no, and the UK is going to continue saying a firm no!”

ME: “The question of suicide and assisted suicide is an existential question. It’s not a medical question in any way. There is no knowledge that is particularly medical that is required to shorten the life of a patient or another person. If the government wants these people dead, let it train special people with black gowns to do the job, not with white gowns, not to conceal this action behind a white gown of a doctor, a gown that should remain white.”

MI: “Well I think it is [a medical question], because for example in the Netherlands you have doctors there, general practitioners who know their patients very well and for me it is a final compassionate act of a good doctor to do what is best for his or her patient.”

IF: "One in 34–35 of all deaths in the Netherlands are from euthanasia and that would translate to about 13,000 in this country. Now that is a sea change from the situation you were trying to describe and advocate for earlier on!”

MI: “We already have euthanasia in this country! Professor Clive Seale said in two surveys – 2004 and 2007, surveys that were quite reliable because they were reported in the General Palliative Medicine, showing that even now in this country we have at least a thousand cases of voluntary euthanasia and two thousand cases of non-voluntary euthanasia, and one death in six is brought about by continuous deep sedation – a popular procedure in hospices, which is just slow euthanasia!”

AF: “It’s completely different doses of drugs that are used in the Netherlands compared to here!”

ME: “But the intention is the same…”

AF: “No it isn’t actually. No, the intention is to treat patients’ symptoms, we can foresee that might shorten their life but we don’t intend it... ”

ME: “Once you put a patient into deep sedation, you effectively kill the patient…”

AF: “They’re dying anyway.”

IF: “There are two things, deep sedation is used anyway in intensive care to put people on a ventilator or whatever… It may be used when somebody who is very distressed. But you do not continue it until death. What you do is that you go back and review, and you lighten the dose when the patient is back out of that state of sedation, to make sure the cause of their distress is under control. You may use very small doses of anti-anxiety drugs if somebody is agitated in the last day or two of life, just to calm them down, but those are doses which would not sedate them – it’s quite different. The Dutch protocol is to use heavy doses six - ten times what we would use in this country, deliberately to render people unconscious and maintain them unconscious until they die…”

MI: “Well, I’m very much pro-life. It may surprise people to hear that. I’m enjoying life to the full right here right now, but I have problems with walking following a major car accident seven years ago. I’m getting less and less energy in the things I do… I’d like to have the option, when I’m older, I’m going to be 83 very soon, perhaps, to say I’ve had a wonderful life in this world, it’s like leaving a party, it’s time to say goodbye with a certain amount of dignity, and I’d like to have that option of a doctor to help me to end my life when I feel that the time has come. It’s a matter of basic human rights.”

ME: “I would agree completely with Michael, just adding one sentence. I would also like us to have a proper NHS – something that we can count on and that could make us want to live rather than want to die.”

AF: “Care Not Killing holds that assisted suicide and euthanasia are wrong, they are unnecessary, and if we’re foolish enough to change the law, it will be uncontrollable and will change the whole climate of healthcare. We should care for people, not kill them.”

IF: “I would agree our current law is like a bright line. It is a line that we do not cross, but society, in that framework, then has a duty to provide care, to do all it can to enhance the quality of life of all its citizens and if it’s not doing that, to redouble efforts to do so, and not to play into this view that there comes a point that you can throw a life away and just get rid of it. But we must also accept that everybody will die, everybody will live up until the time they die, and during that time, however long, it is our duty in society to make that life as good as possible.”

(VoR)