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The dangers of assisted dying

21 August 2015

The new Bill could harden attitudes against frail people, argues Robert Twycross


Not dead: a protest outside Parliament in January against assisted dying

Not dead: a protest outside Parliament in January against assisted dying

THE Second Reading of the Assisted Dying (AD) Bill takes place in the House of Commons on 11 September. The Bill would allow a terminally ill adult in England or Wales to receive a lethal prescription for self-administration, supervised by “an attending health professional”.

For some, AD is perceived to be a “no-brainer”: people who are terminally ill should be accorded the right to self-determination. Opinion polls suggest that 60-80 per cent of the public are in favour. However, like 80-90 per cent of palliative-care doctors in the UK, I am against a change in the law.

My reasons are: (1) legislation will do more harm than good; (2) negative attitudes towards the disabled and the frail elderly will increase; and (3) incremental implementation is inevitable.

Palliative-care doctors are against a change, not least because almost all patients change their minds when in receipt of high-quality palliative care. Generally, an expressed wish by a terminally ill person to hasten death does not mean that they want AD; rather, they want to express their frustrations and fears, and to be understood.


THE key prerequisite in the Bill is a life expectancy of less than six months; the patient does not have to be in physical or mental distress. The Bill is not about long-term progressive conditions such as multiple sclerosis or dementia.

Prognosis, however, becomes increasingly inaccurate when more than a few days. In Oregon, where assisted suicide has been available since 1997, the Public Health Division annual reports indicate that, after receiving a lethal prescription, more than ten per cent live longer than the mandated six months — some for two or three years. In medical practice generally, instances of wildly inaccurate prognosis are common.

Even more important is the fact that some people already refuse palliative care because they fear that they will be “done away with” — and they then suffer greatly as a result. All palliative-care professionals are aware of this, even though the problem has not been quantified. This number will surely increase if AD becomes lawful, enhancing the perception of doctors and nurses as potential killers.

There is also a real risk of coercion, both doctor-on-patient and family-on-doctor. When commenting on the subtle and not-so-subtle pressures that doctors can exert on patients, a Dutch doctor noted: “In the past, if I suggested euthanasia, nine times out of ten the patient would choose euthanasia; now, when I suggest palliative care, they choose palliative care.”

Further, in Belgium, after 13 years of legal euthanasia, many more families now consider dying as undignified, useless, and meaningless, even when it is peaceful. Demands for active interventions, particularly for elderly parents, are increasingly common and direct.


THE reason that many disabled people are against a change in the law is because they fear — rightly, in my opinion — that the widespread negative attitudes to chronic disability and frailty will be exacerbated, and they will be treated even more as second-rate citizens and a burden on society.

The charity Scope recently stated that 66 per cent of the disabled people whom it surveyed were concerned that a change in the law would create pressure on them to end their lives prematurely — even though most disabled people do not come within the terms of the proposed Bill.

It is also important to understand that AD activists see the present Bill as only the first step. Campaigning will continue until: (a) the law is extended to euthanasia (a lethal injection administered by a doctor); (b) there is no arbitrary restriction to a prognosis of six months; (c) people with early dementia are able to make an “advanced decision” for euthanasia at a later date, when they have lost “mental capacity”; and (d) when anyone over 70 who is “tired of life” will be able to obtain a lethal prescription.

This can be confirmed by activists’ statements, as in I’ll See Myself Out, Thank You (Skyscraper Publications, 2015). The Patients’ Rights Council also provides a chilling review of developments in Belgium (www.patientsrightscouncil.org).


EVEN more disturbing are recent data about euthanasia for psychiatric disorders. In both the Netherlands and Belgium, the essential prerequisite for voluntary euthanasia is an intolerable incurable condition, for which there is no reasonable hope of improvement; there is no limitation in terms of length of prognosis. DutchNews.nl reports that in the first half of this year, 18 people died at a Dutch psychiatric euthanasia clinic, and there are almost 100 patients on the waiting list.

An article in BMJ Open reviewing requests for euthanasia by psychiatric patients in Belgium gives the diagnoses in 100 applicants. Depression and personality disorder were the most common; others included schizophrenia, post-traumatic stress disorder, Asperger’s syndrome, complicated grief, and chronic fatigue syndrome. About half of the applicants had their request accepted. In both the Netherlands and Belgium, the situation has progressed (regressed?) from voluntary euthanasia to voluntary eugenics.

Once initial legislation is passed, AD seems to take on a dynamic of its own. Professor Theo Boer, a former member of a Regional Euthanasia Review Committee in the Netherlands, has written: “Whereas the law sees assisted suicide and euthanasia as an exception, public opinion is shifting towards considering them rights, with corresponding duties on doctors to act. . . . Don’t go there.”


THE current law in the UK provides a clear boundary. It may occasionally be crossed by doctors and others, but it is unambiguous. Indeed, it is perfectly consistent to argue that AD is ethically legitimate in some extreme cases, but that it would be wrong to change the law. Thus it would be better to continue to allow hard cases to be taken care of by various expedients than to introduce new legislation that would inevitably become too permissive.

I would urge people to visit www.notoassistedsuicide.org.uk, and to contact their MPs, asking them to vote against a change in the law: abstaining is not enough.


Dr Robert Twycross is Emeritus Clinical Reader in Palliative Medicine at the University of Oxford.


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