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Symposium on assisted dying
Jeff Stephenson
I would like to thank Professor John Bryant for setting out so clearly the
ethical background to the current debate on assisted dying.
It is a debate that is continually simmering in the background, and from time
to time boils over in heated exchanges in the media and within professional forums. It
is a debate that polarises opinion, and when dealing with such an emotive subject as
ending a person’s life it is perhaps understandable and reassuring that this is the case.
As a preface to what I want to say this evening let me just confirm a number of things
on which both sides of this debate are probably agreed:

Many people in this country are still dying badly with inappropriate or suboptimal care. This is both a tragedy and a scandal.

We have some of the best palliative care services in the world, but these are
under-resourced, largely financed by the charitable sector and still often delivered
in a ‘postcode lottery’. There is no doubt that we need better access to services
and better training in end of life care for professionals in all disciplines.

Palliative care is not a panacea for all end-of-life ills, and there will always remain
a small proportion of patients that, for whatever reason, would like the option of
assisted dying.

When faced with an individual who is really struggling for whatever reason and
wanting an end to their suffering, of course one cannot help but be moved with
compassion for them, and sometimes ache for their release.
The question at the heart of the assisted dying debate is whether as a society
we provide for the needs of the, at the moment, very small minority of people who
would avail themselves of that option if it were offered. As the debate heats up in
anticipation of another attempt at legislation later this year, the battle lines are again
being drawn in what many see as a struggle over the conscience of our society and the
limits to individual autonomy. On the one side there is the clarion call of compassion
to provide a means of release to those who feel that life has become unbearable. On
the other there is equal compassion but a deep concern over the morality and the
monumental ramifications of taking such a step. And at the outset, I must own to the
fact that I am opposed to any form of assisted dying. I believe that we do not need it;
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I believe it poses considerable risks to vulnerable others; I believe that ethically it is a
line that we should not cross; and as a Christian I believe that it is simply not Biblical.
I should also say that although I refer to the term assisted dying, which has
become an accepted umbrella term for euthanasia and physician assisted suicide, I do
so rather unwillingly, as a large part of my own work is to assist people to die –
namely to help them face their dying and support them through it. I think it is an
example of the evolution of euphemism in order to disguise an unpalatable reality, in
this case that what we are talking about is intentionally, prematurely ending a person’s
life or helping them to do so themselves. However, in some respects it is a useful
term as I, along with the Dutch who have considerable experience in this sort of thing,
see no moral or ethical distinction between physician assisted suicide and euthanasia.
Physician assisted suicide is simply euthanasia one step removed – the intention is
still to unnaturally end the person’s life, and the physician is still a moral agent,
without whom the act would not be able to take place.
It is important to understand the nature of the battle that is being engaged.
And I use the word battle without apology, because for all the goodwill in the world
between opposing sides of the debate this is nevertheless a battle, and one that is
waged with great skill and determination. And the stakes are high. What we are
talking about here is a crossing of an ethical line that could significantly change the
landscape of medicine and society:

We would violate long accepted codes of medical ethics.

We would create a division in the medical profession, with two classes of doctor –
those who kill or facilitate the killing of their patients, and those who don’t

We would put Britain, the country that pioneered and is the bench mark for
excellence in, the care of the dying at odds with almost the entire international
medical community

We would abandon the prohibition on killing, which has underpinned our legal
and moral framework for centuries. Indeed there are those who, with the best of
intentions, seek to drive a horse and carriage through the murder laws of our land,
and I intend to do all that I can to stop them.
There are 4 key battlegrounds:

Parliament – attempts to change statute law
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
The institutions – especially the medical institutions

The courts – changing the law through establishment of case precedent

The public square – public opinion
Parliament has seen a number of attempts to change UK law:

Lord Joffe presented 3 bills from 2003-2006, the 3rd attempt reaching a vote in
the House of Lords and being defeated by 148 to 100.

Lord Falconer submitted an Amendment to the Coroners and Justice Bill in
2009 and lost 194 to 141

Margo MacDonald’s End of Life Assistance Bill in Scotland lost 85 to 16
(2010)

Lord Falconer also chaired a Commission on Assisted Dying, conceived and
financed by the pro euthanasia group Dignity in Dying, and heavily weighted
with commissioners who are openly pro euthanasia. Many major bodies
refused to give evidence to and therefore validate what was clearly a biased
forum. When it reported in January 2012, as it expected it recommended
assisted suicide for mentally competent adults with less than 12 months to
live. It was largely ignored. However, Lord Falconer is expected to bring
another Bill to the House of Lords this May based on its recommendations.

Margo MacDonald is also expected to bring another attempt to the Scottish
parliament this year.

Any initial legislation in this country would almost certainly be to allow
physician assisted suicide, along the lines of the law in Oregon, on the basis
that assisted suicide is felt to be more acceptable to professionals and more
likely therefore to be passed than a law including euthanasia. However, this
would only be a first step, but more of that later.
The medical institutions historically have been opposed to assisted dying and proeuthanasia campaign aims to get them to at least go neutral on the subject, on the basis
that if the major medical institutions are at least not opposed to a change in the law
this will facilitate the winning of the argument in the public arena and in Parliament.
This aspect of the campaign has had limited success, as although it has made
temporary advances, currently only the RCN has moved to a position of neutrality.
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However, the Chairman of the RCGP is pushing strongly for a move to neutrality.
There are almost annual attempts to get the BMA to move to neutrality, but at present
the BMA, the RCP, RCGP and the APM are all still opposed to a change in the law,
largely due to grass roots resistance.
In the courts we have seen over recent years several highly publicised emotive
cases that have been used to try and change the law by the back door. Some success
was achieved with Debbie Purdy who secured a ruling in the House of Lords in 2009
forcing the DPP to publish guidance on the factors that would make prosecution more
or less likely in cases where people have assisted suicides (note it is still illegal).
The campaign in the public opinion arena is proving very successful. The
campaign uses a media that is heavily biased in favour of assisted dying to publicise
cases of people who have gone to Dignitas clinics, and emotive cases going through
the courts. There is prominent celebrity endorsement of the campaign. The national
media is as I’ve said heavily biased, with the major national TV channels and the vast
majority of the main newspapers all tending to be pro-assisted dying in their
reporting. In a the period 2008 to 2011 the BBC which, under its own editorial
guidelines is required to remain impartial, produced 5 documentaries or docudramas
portraying assisted suicide in a positive light. In this same period there was not one
BBC documentary or docudrama presenting the opposite view (Saunders P. The role
of the media in shaping the UK debate on ‘assisted dying’. Medical Law International
2011; 11: 239-256). Furthermore in the reporting of anti-euthanasia arguments there
is a tendency to associate these with religious beliefs and therefore undermine or
ridicule them. I remember watching Channel 4 News just after the Joffe Bill was
defeated in the Lords and the main thrust of the report suggested that the will of the
public had been thwarted by the religious lobby, despite the fact there were only
around 10 bishops in the House that night in an opposing vote on 148.
Ladies and gentleman this is a battle, a battle for the truth as much as anything.
So Christians in the audience I urge you to wake up to the danger at the door and
engage in the battle. It was Wilberforce who said: “Let it not be said I was silent
when they needed me.” Speaking in Biblical terms it is a David and Goliath battle,
with David holding the line so far. However, for fans of Les Miserables, it may
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eventually turn into a Gavroche versus the French Army battle if the urchin is finally
killed on the barricades. The pro-euthanasia lobby comprises several groups, the most
prominent of which is Dignity in Dying, formerly known as the Voluntary Euthanasia
Society before it changed its name in a move neatly choreographed to coincide with
the publicised one-way trip of Dr Anne Turner to the Dignitas suicide clinic in
Switzerland. Some viewed the change in name as an attempt to improve its public
image by moving away from the negative connotations of the word ‘euthanasia’ and
re-branding itself as a quasi-human rights group. Many were outraged at the
implication of the new name, that dignity in terminal illness can only be achieved
through euthanasia or PAS. Also prominent, and significant because of its healthcare
links, is Health Professionals for Assisted Dying, and the campaign also has backing
from the National Secular Society and the British Humanist Association. Dignity in
Dying is the more moderate wing of what is a very broad range of aspirations and
agendas within the pro-euthanasia lobby. It has considerable celebrity endorsement,
and I understand it has a turnover of more than £1 million and employs about 20 full
time staff. The main coalition of groups opposed to a change in the law is Care not
Killing, which brings together human rights groups, disability groups, professional
groups, healthcare providers, faith-based organisations and concerned individuals. It
has much more meagre resources and can only afford to employ one member of staff.
All other work for it is done pro-bono.
The principal arguments promoted for assisted dying are: We need it – the
argument from compassion. We want it – the argument from autonomy. We can
control it – with adequate safeguards we can prevent any kind of abuse or unintended
extension. In looking at these I want to first consider what I believe the Biblical
perspective is on them. Fundamental to a Christian approach to any ethical challenge
is the principle that human beings are made in the image of God (Gen 1:27). The
Lambeth Conference in 1998 sets out very well the Biblical teaching on human life:

Life is God given and therefore has intrinsic sanctity, significance and worth

Human beings are in relationship with the created order – a relationship
characterised by such words as respect, enjoyment and responsibility

Human beings, while flawed by sin, nevertheless have capacity to make free
and responsible moral choices
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
Human meaning and purpose are found in our relationship with God, in the
exercise of freedom, critical self-knowledge and in our relationships with one
another and with the wider community

This life is not the sum total of human existence; we find our ultimate
fulfilment in eternity with God, through Christ
Lives are to be valued in and of themselves, and they are to be protected from harm.
The law of love, to love God with all our being and to love others as ourselves, and
the Golden Rule of doing unto others as we would have them do unto us, constrains
us to act with compassion towards those who are suffering, just as Jesus was moved
with compassion repeatedly throughout the Gospel accounts of his ministry. We owe
it to people to provide the best care we can. However, nowhere in the Bible do I find
any encouragement or acquiescence in ending someone’s life in order to address or
prevent their suffering (not even the case of King Saul as is often suggested). Quite
the contrary, extra-judicial killing was heavily sanctioned in the Old Testament, and it
simply doesn’t resonate with the spirit of Jesus’ teachings (Gen 9:6; Ex 20:13).
Indeed the Biblical injunction against the killing of the innocent upholds the
law of love and the inherent value of lives made in the image of God. I see no
Biblical evidence of relaxation of this injunction simply because the person being
killed asks for it. Nor do I accept an interpretation of the law of love, or Golden Rule,
that encourages us to compassionately end someone’s life. Love should respect other
people’s choices, but people’s choice does not trump the responsibility to do what is
morally right. That’s not to say that one might not conceive some convoluted
hypothetical situation, as is often presented in these arguments, such as an injured
friend falling into the hands of a ruthless enemy, in which I might honestly find
myself acting out of compassion to end someone’s life. And if any here have
themselves acted in such a way out of compassion, you need to know that we have a
compassionate God and he understands and is moved by compassion in us; and he is a
forgiving God who is more ready to give than we are to receive. But that would not
make the act morally right. But neither would it make us any more sinful or guilty
than any other man, or more in need of the saving grace of Jesus Christ, who in the
Sermon on the Mount made it clear that it is not just our outward actions that make us
fall short of God’s standards, but what we think, what is in our hearts, so that our
anger or thoughts condemn us just as much as their physical expression. But thanks
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be to God for Jesus, who has paid the price for us and taken the penalty that was ours
in order to open the way back to God the Father. Christian compassion asks us to
come alongside those who are suffering, to do all that we practically can to alleviate
that while still honouring God’s law, and to die metaphorically to ourselves in pouring
out our lives for others. That’s what keeps me in my job, and often it’s the only thing.
We do not need assisted dying as an expression of compassion. This is not to
demean the perceived suffering of many who are crying out for this option, but to put
it into context. There are alternatives, more so now than ever before. In centuries
past, when very little could be done to alleviate the symptoms and distress of the
dying, the argument that it was a necessary option might have carried more weight,
but not so now. While it may not always be possible to eliminate physical symptoms,
appropriate care will bring a measure of relief, and more importantly can better equip
patients to cope. The appropriate (and I stress the word appropriate) use of analgesics
and sedatives, and as a last resort terminal sedation for physical or mental distress,
should mean that nobody need actually die with uncontrolled symptoms. In testimony
to the House of Lords in 2004, a consultant psychiatrist from Oregon stated, perhaps
rather bluntly, that “99.9 per cent of people in Oregon do not die with assisted
suicide…..and that is because nobody needs it. The other 0.1 per cent could die
without it too” (Assisted dying for the terminally ill
House of Lords Report - April
2005. Dr Hamilton, II, p333. Q954).
The second argument is that from autonomy. I have a right of selfdetermination and my life should be to do with as I please, including ending it when
and how I want. This in many ways has taken over from the compassion argument as
the main driver for a change in the law. In every area of society individualism and
choice dominate the agenda, and in the context of this debate the right to die is being
added to the ever-increasing list of supposed human rights. A published response by a
medical consultant to an article I wrote a few years ago contained this statement, a
statement that I have to say I found deeply disturbing: “Whilst it may well be the case
that the general public’s understanding of this area is inadequate, I firmly believe that
they have got hold of a truth which many professionals are trying to deny, namely that
the choice of the time of one’s death is a fundamental human right and it is not the
place of legislators or health professionals to deny that right” (Fisken RA.
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Correspondence. Clinical Medicine 2006; 6:509). When did choice over time of
one’s death become a fundamental human right? And who says it is? It doesn’t
appear in any of the Articles of the European Convention on Human Rights or the
UN’s. Indeed, it is worth noting that the UN Human Rights Committee has
repeatedly expressed concern over the extent of euthanasia and assisted suicide in the
Netherlands and criticised the inadequate safeguards to protect the rights of the
vulnerable. None of this sits well with Biblical Christianity. The emphasis in the
Gospels is on interdependence, community, and responsibility to others rather than
individualism and certainly not standing on our rights. In fact the Christian is to forgo
their rights for the sake of others. As regards autonomy the Bible has much to say.
We are created by God and the Creator therefore has rights over us. Christians are
told that Jesus has paid the price for our sin with his blood and bought us for himself,
and we are not our own (1 Cor 6:19-20). One extreme of opinion on the issue of
autonomy is: ‘Do and say whatever you want to do and say at any time you want to do
or say it, as long as you do not harm or threaten anybody else’s person or property’
(Jack Kevorkian). The concept of partial autonomy, as proposed by J Alan Branch,
fits more with our own society: ‘The right of each person to choose his or her own
course of action within boundaries of accepted standards and norms.’ Professor John
Wyatt expresses it very well in a Biblical context: ‘I have a degree of independence,
the dignity of genuine choice, the relative freedom of a creature. But it is not simply
‘my’ life to do with as I please. My life can have meaning only in relation to God.’
Quite apart from religious perspectives (do I actually have such rights over my
life?) and philosophical questions (even if I do have such rights of ownership, does
that confer a right to destroy my life – I may own a priceless work of art, but few
would agree with my decision to destroy it), when we live in society autonomy can
rarely be absolute. There are many examples in our society of where individual
autonomy has to be limited. Those who want to commit suicide have a legal
prerogative to take their own lives, if they so wish and are able, whether or not one
accepts the morality of such a decision, though it is interesting how much effort we
invest in other settings into suicide prevention programmes. However, when they
seek to involve others, and obtain the legal and moral sanction of society for that, then
that is a very different matter. Even a psychological ‘push from the bridge’,
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subliminal messages that we agree with their estimation that they would be better off
dead, are things that we need to be careful to avoid.
In the outworking of Christian faith, and the law of love, there is a particular
expectation to protect the vulnerable, and the cry for justice resonates through
Scripture. We have a responsibility to seek justice and to speak out against injustice.
We are also called to live by the truth and in speaking out we are to be guided by
truth. And I think it is this next area that causes me the greatest frustration and
indignation, in the reassurances we are spun about adequate safeguards being in place
in order to control any practice.
Legislation to allow assisted dying would undermine the autonomy of others
and would pose a danger to other vulnerable people. The very ill, the severely
disabled, the elderly already often feel themselves to be a burden. How many of these
would feel pressure, whether real or imagined, to request an early death? A ‘right to
die’ could very easily become a ‘duty to die’. That sense of duty would be very
difficult to detect, no matter how exhaustive the safeguards. I know some of the
pressures that are faced by terminally ill patients and their families. For many, to
allow the option of assisted dying would simply add to these. Such pressures may
become even greater if assisted dying comes to be seen as a cheaper, and nobler,
alternative to end-of-life care and long-term residential care for ageing western
populations with a greater burden of chronic illness. It is worth bearing in mind that
in another twenty years or so about half of all people dying in the UK will be over the
age of 85. In Canada and the USA the assisted dying debate is now being fought on
the platform of elder abuse. In Montana a vote on assisted dying in the state
legislature has just been defeated largely over the concerns about elder abuse, and this
is being replicated across the USA. The three attempts in UK Parliament to get a
change in the law have been defeated largely on public safety issues, this very real
concern that what is intended as an initially very restrictive measure for a tiny
minority of people will put others at risk.
Supporters of a change in the law stress the stringent safeguards that would
accompany any such legislation, and point to evidence from other jurisdictions where
such practices are allowed, principally Oregon and The Netherlands, as reassurance
that such safeguards can be effective.
A handful of countries currently have some form of legislation in place that
allows either physician assisted suicide or euthanasia or both. These comprise the
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Netherlands, Belgium, Luxembourg and Switzerland, and in the USA the states of
Oregon and Washington. Since Oregon’s law in 1997 there have been over a hundred
attempts to get other US state parliaments to change their laws, all of which have
failed except for Washington, which changed on the basis of a referendum. There is
not time this evening to look in detail at the legislation and safeguards in each of these
jurisdictions, but here are some general points:

I don’t have enough information about the situation in Switzerland,
Luxembourg or Washington, but certainly in the other jurisdictions the
supposed safeguards are failing to protect.

The procedures in place for monitoring activity and reporting cases are shot
through with holes. The monitoring systems in both the Netherlands and
Oregon have been described as “no more than a self-validating exercise in box
ticking by those who choose to report” (Keown. Considering PhysicianAssisted Suicide: An evaluation of Lord Joffe's Assisted Dying for the
Terminally Ill Bill, p27).

Furthermore, those administering the law have become its advocates, who
have a vested interest to demonstrate that their systems are working.

There is significant under-reporting of cases, even though doctors who comply
with the law are protected.

Even in cases that are reported there is no assurance that the doctor involved
has complied with the law.

In those places that allow euthanasia it is clear that some patients (and in the
Netherlands this amounts to thousands over the years) are being killed without
their explicit consent.
The Death with Dignity Act in Oregon, which allows only PAS and on which
Lord Joffe’s proposal was largely based, is so lax that evidence of non-compliance is
extremely likely to come to light. The first report of the Oregon Health Division into
the operation of the Oregon law admitted frankly that data on issues of noncompliance cannot be detected or collected with any accuracy. The Oregon system
relies on self-reporting by the very doctors who have practised assisted suicide. These
reports are filed, but not investigated by the authorities. There are no penalties for not
reporting. The few cases that have been made public have often raised serious
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concerns over adherence to the requirements of the Act. As far as I am aware, in the
years since the Act came into force there have been no comprehensive studies
involving doctors given immunity from prosecution similar to those in Holland that
brought to light the reality of abuses in that country. We certainly know that there is a
problem with reporting of complications. Experience from the Netherlands confirms
that assisted suicide has a complication rate sometimes requiring a doctor to intervene
and finish the patient off, and in one Dutch study this was reported to be as high as
18% (Keown, p18 citing: Groenewoud JH et al. Clinical problems with the
performance of euthanasia and physician-assisted suicide in The Netherlands. NEJM
2000). One witness to the Select Committee testified that: “It took nearly six years
before the Oregon Health Division’s flawed tracking system even reported one case of
vomiting” (II, p334, Q954).
So to point to the safeguards in other countries as evidence that this kind of
thing can be adequately controlled just isn’t good enough. But in many ways this is
this is missing the point anyway. What if we could do things a little better here?
Perhaps our safeguards could be a little tighter. Safeguards, no matter how
exhaustive, cannot be foolproof. Furthermore how can you safeguard against a right
to die becoming a sense of duty to die? One Dutch witness testified to the Select
Committee that in The Netherlands “not asking for euthanasia has become an
option…which you have to defend”(II, p441-2, Q1488).
Many of us would aspire to an ideal of fully informed autonomy that is free
from internal conflict and external pressure. Yet, in reality most decisions at the end
of life are messy and involve those who are physically and psychologically
vulnerable. I am convinced that however exhaustive the safeguards, some patients
would ‘slip through’ - people who appear to fit the criteria but actually don’t, or who
have been subject to duress or because they have felt a sense of duty to die. It is then
down to the arithmetic of suffering. How many patients dying under such legislation
before they would otherwise have wanted is acceptable? What is an acceptable fatal
complication rate? 0.1%? 1%? 5%? Would our opinion on this change as funding
priorities for healthcare and long term social care change? In truth how would we
ever know what the real rate was – our principal witness is after all dead. What
represents the greater wrong – not killing those who want it (and for whom
alternatives are available, albeit imperfect), or killing those who don’t really want it?
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Another major concern with any legislation is that once we ‘open the door’ to
such practices, with sufficient time to allow for increasing moral acceptance, the
establishment of legal case precedent, and changing social and political priorities,
assisted dying gains a much wider application than allowed for in the initially
restrictive legislation. So we may see extension of practice from PAS to include
euthanasia on request by the terminally ill, euthanasia without request, and assisted
dying for those who are not terminally ill but are suffering unbearably.
Why is there a risk of such incremental extensions to any practice in this
country? We are a society that is increasingly abandoning moral absolutes and
elevating choice and personal autonomy above most other concerns. The major step
is the initial crossing of the ethical line that assisted suicide represents. Once we have
taken that step subsequent steps in extension of the practice will be easier to justify
and take. A shifting of the moral compass. Not immediately perhaps, but over years
and decades. Once you accept the principle that there is such a thing as life that is not
worth living it simply becomes a matter of opinion as to which lives are not worth
living. Such opinions will inevitably be influenced by prevailing social, financial and
political priorities. We are a country where health care is still largely funded from the
public purse, and we face an increasingly ageing population with a greater burden of
health and social care needs. Good end of life care is expensive, and the rhetoric we
have had from government about it has not been backed up by appropriate funding.
And why should it be in the context of all the other competing demands for limited
resources?
We are also being subjected to a concerted campaign that paints assisted
suicide in a rosy hue. The phenomenon of the Werther Effect, or suicide contagion, is
well recognised. As assisted suicides are portrayed in a favourable light, backed by
celebrities and given high media profile as they frequently are in the UK, we will see
an increasing acceptance that this is a normal, valid option. Let me quote American
Professor Patricia Mann in a piece exploring this phenomenon of cultural change.
Writing of the US, that if PAS were legalised, she suggests:“Many doctors will adjust
their practices, and gradually their values as well…Medical students will learn about
assisted suicide as an important patient option from the beginning of their training.
We may expect that a growing proportion of doctors will find themselves sympathetic
to this practice, and will find themselves comfortable with recommending it to their
patients”. As regards families she says: “Once assisted suicide ceases to be illegal,
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its many advantages to busy relatives will become readily apparent. More than
merely an acceptable form of ending, relatives and friends may come to see it as a
preferred or praiseworthy form of death”. In this climate: “A lingering death may
come to seem an extravagance, a frivolous indulgence (‘Meanings of death’ in M
Battin et al, Physician-assisted suicide: expanding the debate (Routledge, 1998), p
21-23). Pressure, real or imagined to request early death.
What about the legal consequences? While I have great respect for our
legislators, I have rather less faith in human nature. We have a propensity to push the
boundaries of legislation. I believe that even if legislation is initially very restricted
more patients than initially envisaged will go down this route, whether by incremental
extensions of the law, elastic interpretation of the criteria, or downright abuse. Just as
we have seen numerous highly publicised attempts to establish legal precedent for
euthanasia by the back door, I’m sure that the passing of any Bill would not see the
end of legal challenges, argued from the point of view of human rights, with a view to
incremental extension of the law. We will only need a few horror stories of patents
who take a prescribed lethal cocktail and experience distressing complications or fail
to end their lives as planned before we will see calls to extend the option to physician
administered lethal medication i.e. euthanasia. And we can expect legal challenges on
behalf of incompetent patients deemed to be suffering unbearably. Why shouldn’t an
incompetent patient have the same legal right to physician assisted dying as those who
retain their capacity if it is deemed to be in their best interests?
And are breaches of legislation, should they ever be picked up by safeguards,
likely to incur any heavier sanction than they do in The Netherlands where there has
been a paucity of prosecutions in the face of widespread abuse, and where penalties
are almost trivial for those few who are actually convicted? These doctors who flout
the law are, after all, not Harold Shipmans but are acting on the basis of compassion.
Can we see evidence of such extensions in practice or moral shift in other
countries where assisted dying has been legalised? Again, we don’t have time to go
into a lot of detail. In many of the countries that have adopted some form of
legislation it is still too early to tell. These kinds of changes happen over decades.
But there is evidence from the Netherlands, which has allowed the practice for over
30 years.
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
In all jurisdictions there has been a progressive increase in the number of
people dying through such processes. You might say what’s wrong with that?
Maybe that is just an indication that in fact once the option is there more and
more people come out of the woodwork and express a desire for it, and as long
as safeguards are effective….Ah. There we are then.

We have evidence of changing public attitudes with increasing acceptance
over time.

We have evidence of incremental extension of practice.
In the Netherlands the codification of the law that took place in 2002 created two new
expansions of the already widespread practice:

Patients no longer have to be competent when euthanased, so long as they
have made a previous competent request in writing.

The practice has been extended to minors (as young as 12 years old).
Since then:

There is undisputed evidence of termination of the lives of incompetent
patients

There is now the Groningen protocol for the termination of infants

There has been an acceptance of euthanasia for those with early dementia

There have been moves to accept ‘tired of life’ as an indication for euthanasia.
In Belgium there have been similar extensions with proposals to include infants,
teenagers, and people with dementia.
Let me read the concluding paragraph of a paper by a well known Consultant
in Palliative Medicine from Canada published in the journal Current Oncology in
2011, that analysed the illusion of safeguards and controls in assisted dying:
In 30 years, the Netherlands has moved from euthanasia of people who are terminally
ill, to euthanasia for people who are chronically ill; from euthanasia for physical
illness, to euthanasia for mental illness; from euthanasia for mental illness, to
euthanasia for psychological distress or mental suffering – and now to euthanasia
simply if a person is over the age of 70 and ‘tired of living’. Dutch euthanasia
protocols have also moved from conscious patients providing explicit consent, to
unconscious patients unable to provide consent. Denying euthanasia or PAS in the
Netherlands is now considered a form of discrimination against people with chronic
illness, whether the illness be physical or psychological, because those people will be
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forced to ‘suffer’ longer than those who are terminally ill. Non-voluntary euthanasia
is now being justified by appealing to the social duty of citizens and the ethical pillar
of beneficence. In the Netherlands, euthanasia has moved from being a measure of
last resort to being one of early intervention. Belgium has followed suit, and
troubling evidence is emerging from Oregon specifically with respect to the protection
of people with depression and the objectivity of the process (Pereira J. Legalizing
euthanasia or assisted suicide: the illusion of safeguards and controls. Current
Oncology 2011; 18 (2): e38-e45).
As regards changing attitudes, evidence to House of Lords from Dutch
witnesses indicated that for Dutch society as a whole there has been an increasing
acceptance of doing euthanasia, reflecting a gradual change in opinion about the
moral aspects. A Dutch Professor of Medical Ethics comments that: “the empirical
data reveal that many physicians simply assume that patients would have wanted
euthanasia, even if patients have not been very articulate in requesting euthanasia or
have merely hinted at the possibility of euthanasia. This is also the case if the
patients are incompetent, psychiatric patients, demented elderly or handicapped
newborns”(ten Have H. EJPC 2003; 10(2) Suppl: 21-28). Such is the culture now
that it is up to patients to make it clear if they do not want euthanasia. And the Chair
of the Medical Committee of the Dutch Society for Voluntary Euthanasia told the
Select Committee that an ‘end-of-life’ pill for healthy old people, which could be
obtained without consulting a doctor, was ‘the ultimate goal’ and ‘one of the ideals of
Dutch society in general at the moment’ (II, p418, Q1323).
In the UK we have evidence of intent. Lord Joffe at least had the integrity to
make his intentions plain, and he admitted that his Bill was more restrictive than he
would have liked. He said: “We are starting off; this is a first stage; it is new
territory….Normally with new legislation one should go forward in incremental
stages. I believe that this Bill should initially be limited, although I would prefer it to
be of much wider application…” (II, p53, Q89); and “I can assure you that I would
prefer that the law did apply to patients who were younger and who were not
terminally ill but who were suffering unbearably, and if there is a move to insert that
into the Bill I would certainly support it” (II, p58, Q124). Many proponents in the
UK have similar aspirations for expansion of initially limited legislation, but accept
that they must content themselves with this in order to open the door.
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I believe there are real grounds for concern that if we allow limited legislation
in this country to allow PAS for a select few, it will not remain limited for long. Nor
indeed should it. If assisted dying becomes a therapeutic option for those who are
within six or twelve months of death and suffering unbearably in their own
estimation, why should it be withheld from those who have a little longer to live? Is
that a compassionate response? Surely they have longer to put up with their
unbearable suffering. And what of the rights of those who are not competent to ask
for it, but who may in the estimation of many be suffering unbearably? Should they
be condemned to a lingering death simply because they have become incapacitated?
Arguments from compassion demand such extensions. And what of the argument
from autonomy? For those who currently die through PAS or euthanasia, physical
symptoms are rarely the reasons prompting the request, but rather a desire to control
the manner of dying. If we espouse a paradigm of equitable access to services in a
society that enshrines choice and autonomy, the fact of a life-limiting illness shouldn’t
even come into it, and the medical profession shouldn’t act as the gatekeepers and
arbiters of people’s subjective suffering.
The real question here is not whether extensions in practice will take place, but
whether such expansions are morally acceptable. If we believe they are, then let’s not
disguise our real intentions behind the veil of initially limited legislation. I believe
passionately that there should be no change in the law to allow assisted dying. I also
believe passionately that if society wants to go down this route, then it must do so
fully informed of the risks and with its eyes open. It cannot do so on the diet of
misinformation that too often shapes public perception in this area. Misinformation,
for instance, about current end-of-life decision making, about the safety of morphine
and related drugs, and about the seemingly inevitable prospect of a horrible death for
certain patient groups. Naive, or worse disingenuous, assertions about the
effectiveness of safeguards in countries that allow it contribute to this misinformation,
as do dismissive reassurances about the risks of incremental extensions in practice.
Too often the public is served up a heady mix of sensationalism, misunderstanding
and sometimes misrepresentation by a well-organised campaign from the proeuthanasia lobby and a media that is sympathetic to them.
There are many voices arguing that assisted dying is a compassionate response
to unbearable suffering. I would assert that this is far from the truth. The
compassionate response, and the Christian response, is to engage with that suffering
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and come alongside those who suffer, relieving where we can and sharing it, in our
common humanity, when we can’t. If a society sanctions the killing of its most
vulnerable, then I believe it embarks on a path that leads inevitably to the dissolution
of its conscience and the killing of compassion.