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Introduction

I was prompted to write this by a Church Times article about the private member's bill currently (April 2022) being considered in the UK, and after a number of conversations over the years.  Assisted dying, or assisted suicide, is one of the ancient moral conflicts, where different and valid moral considerations are pitted against each other.  These considerations include:

• respect for life;
• respect for individual autonomy;
• avoidance of unnecessary suffering; and
• the commitment by Doctors to save life.

In the original Hippocratic oath, physicians swore never to administer poison, even when asked, and never to suggest such a course of action.  But, in many countries, both assisted suicide and physician-assisted suicide are legal.  Bound up in the complex moral issues are equally complex cultural issues to do with duty and honour, about autonomy and obligation, assumptions about the proper way to behave, and how to handle debts to your family, your boss, and your society.

To start with the obvious: it is impossible, at an abstract 'in principle' level, to reconcile the various ethical principles which arise in association with assisted dying.  But that is the problem with all ethical systems: whatever you choose, any non-trivial ethical system will produce contradictions in some circumstances - for almost the same reason that any non-trivial logical system will either be incomplete or contain contradictions.  So our task is not to produce some perfect abstract system which satisfies all ethical considerations in all situations, but to describe a system which is good enough, which people are willing to accept as a reasonable, if imperfect, compromise.  And a 'good enough' system will have to balance the ethical considerations in a way which is culturally acceptable.

Many of the moral arguments I have heard on this subject assume a certain cultural setting, and generally assume that the culture will not change - which in the modern world seems like a rash assumption.  They also often assume that people behave in a rational way - which is also generally a rash assumption, and especially so in the current context.  In areas like this, when we change the law, we change the culture - and we can't always predict exactly what the effect of the changed law will be.  So let's tread carefully.

(See also Assisted Dying: the November 2024 Bill for consideration of some of the practicalities involved.)

Suicide

Assisted dying is a difficult subject, so let's talk for a bit about suicide.

Suicide is the largest cause of death in males under 45 in the UK.  If we look at 20-34 year olds between 2001 and 2018, there were 21,098 suicides.  By way of comparison, there were 11,400 land transport accidents - the next highest reason.  And the figure for suicides does not include accidental poisoning (8,851) or death from mental disorders caused by drugs (5,691), some of which may reasonably be assumed to have been some form of suicide.  Suicide is also the largest cause of death among females of the same age, and are also more than double the deaths from the next highest cause.

To approach it slightly differently, in recent years somewhere between 5,500 and 6,000 people in the UK take their own lives every year; just over three-quarters of them are men.  There was a general decline in the suicide rate between 1981 and 2007, but since then the rate has been rising again, slightly complicated by Covid in recent years.  The figure hovers around 10 people per 100,000 - which is the usual measure, as it allows you to compare populations of different sizes; in 2022 the figures were 16.4 per 100,000 for men and 5.4 per 100,000 for women.  The age group with the highest suicide rate are those aged 50-54.

Suicide is a massive issue in our society, but it receives hardly any public attention.  Part of the reason, I assume is because there is no clear cause, and nothing simple or straightforward which can be done about the various identified causes.  In a report about male suicide produced by the Samaritans, men talk about relationships breaking down, separation from children, job loss, addiction, lack of close friendships, loneliness and being unable to 'open up': these seem to be reasons for suicide for people who do not have the capacity to handle such challenges in a way that mentally healthy people are capable of doing.

A range of different mental health issues are another obvious source of reasons; other causes have also been suggested.  Depression is the recognised cause of over two-thirds of the 30,000 reported suicides in the USA each year, and it is reasonable to assume that undiagnosed depression will have been the cause of some of the remaining third.  Over 10% of people with schizophrenia kill themselves; 40% of parents with disabled children consider it.

To complicate things further, suicide rates can make it look more like a communicable disease than a rational - or even irrational - choice.  Publicity about a known figure killing themselves for some reason will spark an increase in other people killing themselves for the same 'reason'.  Once it is culturally an acceptable thing to do, it becomes a choice to be considered - perhaps as a way of demonstrating that you really could not live without the object of your affections, or a way of getting revenge on those who have hurt or ignored you, or perhaps it is seen as the only honourable 'way out' of a situation.

(I can't help quoting the wonderful Kai Lung at this point: "There are few situations in life that cannot be honourably settled, and without loss of time, either by suicide, a bag of gold, or by thrusting a despised antagonist over the edge of a precipice upon a dark night." )

People tend to assume that suicide bombers are religious or political fanatics - people who are so motivated by the cause that they are willing to give their life for it.  In reality, most of the time, they are disturbed young men who want to kill themselves, and who want to find a good reason to do it - a good excuse, if you like.  The fact is that people can justify suicide in many different apparently reasonable and rational ways.  That is, they can justify suicide in ways which seem to them at the time to be reasonable and rational - but which may later seem like very bad reasons, if they could only receive receive the love and the support they need to work through their problems.

In other words, in normal circumstances, we regard the desire to die as an expression of mental illness.  I know this is horribly simplistic, but as a summary of a big and complex subject, I think it is fair.  I know many people who have wanted to kill themselves, often who have tried and failed several times, and who now live happy and fulfilled lives.  And, it is worth pointing out, many people who become disabled consider suicide for a time, because they cannot have the life they had planned: they cannot imagine having a good life if they cannot see / walk / hear / ... as they once did.  Many of them go on to build and enjoy a life which, at one time, they could not imagine, but the suicide rate for disabled men is three times the rate for non-disabled men - and the rate for disabled women is four times higher.

Terminal Illness and Suffering

Talk about assisted dying usually describes someone who would want to live if it were not for a terminal illness which is causing unbearable pain.  And I feel deeply for people in this situation: we should not ignore their plight.  But there will be many people who have a terminal illness and whose lives are not that neat and tidy - who may have been considering suicide for many difficult and complicated reasons, who may be suffering from undiagnosed mental illness, who may be feeling they are a burden on their family, or that they are taking NHS resources which would be better used on the young.

Talk about assisted dying always insists on it being a free choice.  But how can you tell?  And what counts as a free choice?  A parent who sees themselves as a burden on their children may well make a free choice to make their children's lives better.  And the children may take care to ensure that the elderly parent knows that assisted dying is a free choice open to them.  Our choices always have reasons, but we are not good at identifying those reasons in ourselves much of the time, so what hope do we have that we can be sure of someone else's reasons for choosing assisted dying?  It's just not possible.

And we may think of assisted dying as being about the prevention of unbearable suffering, but the reality is somewhat different.  The Assisted Dying Bill does not talk about unbearable suffering.  When, then, is assisted dying likely to take place?  In the USA, the state of Oregon did a survey in 2015 of people being given medical assistance to die.  They asked what their biggest end-of-life concerns were: 96.2% of those people mentioned the loss of the ability to participate in activities that once made them enjoy life, 92.4% mentioned the loss of autonomy, or their independence of their own thoughts or actions, and 75.4% stated loss of their dignity.

To state the obvious: we are all dying.  Some of us have a clearer expected timescale than others, but nobody is going to live forever.  None of us is autonomous: we all depend on other people to grow our food, deliver our water, heat our homes, make our clothes and furniture, create the songs and films and podcasts we enjoy.  If we are living for the sake of gaining pleasure , then maybe we need to re-think what life is about (remember: 96.2% of those given medical asssistance to die in Oregon said that a lack of enjoyment was a significant factor for them).  And anyone who has survived being a baby should not worry too much about personal dignity: you lost it on the changing mat and in the childhood tantrums.  Learning how to live is challenging, at any age, but that doesn't mean we shouldn't try.

We have operated with the principle of double effect for a long time: sometimes it is permissible to cause a harm as a side effect (or “double effect”) of bringing about a good result.  When a patient is suffering badly, with no hope of recovery or of the suffering coming down to an acceptable level, doctors will, with the permission of the patient or their proxy, increase the painkiller dosage to alleviate the suffering, even though that dose will lead to the patient's death in the near future.  It seems to me that this is a compassionate and ethical response to a difficult and distressing situation, and meets the concerns of many of those who want to make assisted dying legal.

Comment

In a comment below, we read: "I am adamant that I want the right to die in my own timing if I am diagnosed with an incurable, distressing and debilitating illness or injury and likely to lose my autonomy. I do not want to have concerns about anyone else being prosecuted or about my life insurance being rendered invalid. I really don’t see why anyone has the right to stop me."

Firstly, there is nothing in the current position which prevents a sick person from killing themself: if you have "an incurable, distressing and debilitating illness", then you are free to kill yourself.  If you are incapable of the necessary activity - which must be an incredibly rare situation, because there are many ways to kill yourself - then, if the situation is causing you significant distress, the doctor can provide medication according to the 'double effect' principle.

However, I really don't think that it is reasonable to take out life insurance, choose to kill yourself, and then expect the life insurance to pay out, any more than you would expect to deliberately wreck your car and then have the insurance company pay for a new one: insurance just doesn't work that way.  I recognise that this approach occasionally leads to an outcome which most people would consider unfair, but to change the rules and allow people to claim on insurance for an event which they themselves have caused - this would have far greater negative consequences.  We live in an imperfect world, and insurance - like much else - is a balance between what we would like and what we are capable of delivering.

"It is sometimes argued that relatives might persuade a vulnerable person to take their life prematurely if they stood to benefit: but this is a very theoretical possibility" - absolutely not!  People do sometimes encourage vulnerable relatives to choose to end their life; this is not a binary "they did encourage/they did not encourage" situation, but there are many varying degrees of suggestion and pressure.  We also know that people do worse, and kill relatives in order to inherit.  It doesn't happen very often (as far as we know...) but it is foolish to ignore what we know to be the case.  Elder abuse is a real problem, which we are only slowly starting to recognize, and we do not know the full extent of it: to imagine that allowing people to kill the elderly and vulnerable would not make this problem worse seems pure fantasy.  "There would be safeguards put in place," they say - but we already have safeguards to prevent vulnerable people from being abused, and we know these safeguards sometimes fail - and we know they increasingly fail as the health service and the police and the social services struggle for funding.  Our government and the statutory services are already unable to deliver many things which we have a legal right to receive, so how confident can we be that these new safeguards (which are never spelled out in detail) will be effective in all cases?

It is also the case that changing the law to allow assisted suicide would itself put pressure on some vulnerable people to choose it: once the law says this is acceptable, then it becomes a valid option to be considered, and anyone who does not want to become a burden - to the state, or to their family - will inevitably feel some pressure to remove that burden.  How large a pressure will vary from one person to another, but - again - it is foolish to ignore what we know will be the case.

"Some doctors oppose Assisted Dying, but the “Doctor as God” concept has had it’s day, and in the 2020s they should be working with clients not controlling them."  I think the reference to the “Doctor as God” concept is not appropriate here.  When we talk about a doctor 'playing God', then it is either a reference to the doctor choosing who will live and who will die, or to a doctor choosing to kill patients to 'put them out of their misery'.  When doctors work to reduce suffering and save lives, they are not 'playing God': they are doing their job.

And, as I point out above, since the days of the Hippocratic oath, the job of the doctor has been clearly and consistently understood: they are to save lives, not kill people.  To change the job description, so that they are sometimes required to save life, and sometimes required to take it - that is a massive change.  And - this is difficult to say - when you change the job, you change the people who apply for the job.  As soon as the job of a doctor becomes - officially - to end life, even if it is only sometimes, then people who rather like the idea of being able to kill another human being will be more likely to work to become a doctor.  Thee is absolutely no way to avoid this - and you would not want to, any more than you want to prevent such people from going into the army.  If the job involves killing, then you want to recruit people who are able to do it, who will not be reluctant when the need arises.  If you change the job, you change the people, and you change the relationship of the patient with the doctor.

The people I talk with who support assisted dying have all believed that a change to the law would make no difference to anybody, other than enabling a few suffering people to end their lives a little sooner.  They cannot see, or refuse to recognize, all the inevitable changes which would happen as a consequence of such a change.   Other countries have gone down this route, and the consequences to the society, to family relationships, and to the role of the doctor have all been studied: you may like these changes and approve of them, or you may regret them, but please don't shut your eyes and pretend that these changes will not also happen in the UK if the law changes here as well.

Postscript

Re-reading the above, it seems that I start by recognizing that assisted dying is a difficult and complex issue, but end by suggesting that it can be easily solved by staying with the principle of double effect.  To be clear: I don't think that this is easy or simple, and I don't think that it satisfies all that people have asked for in this area.  But I do think it is the best option, out of those which have been proposed to date.

Using the principle of double effect is a compromise.  A valid ethical principle says that medical professionals should never kill their patients, although they may at times withhold life-giving  treatment - the 'Do Not Resuscitate' status is an obvious example.  Another valid ethical principle says that medical professionals should follow the wishes and instructions of their patients.  The 'double effect' approach is a way of attempting to reconcile these two principles - which, of course, means that it fails to satisfy all those who want one principle (whichever it is) to over-ride the other at all times.

Also, the principle of double effect is a simple compromise.  Those who argue for the legalization of assisted dying (in my experience) generally fail to understand the importance of simplicity here.  In matters of life and death, you need clear and simple rules.  When people are stressed, sick and confused, they often fail to understand what is being said, or what they are being asked; they are vulnerable and will often believe what they are told, because their memory is unclear and they do not understand the situation.  Vulnerable people should not be placed in a situation where their continued survival depends upon a number of other people, who they do not know, operating a complicated legal system which they do not understand.

And the principle of double effect is a compromise which requires no change to UK law. Assisted dying is a deeply emotive subject, and whatever the law says, it will not satisfy everyone.  We have seen this in other countries: the law is changed to allow this to happen in these circumstances, but then another group of people, facing a slightly different set of circumstances now feel doubly cheated, because the law does not allow them to do what they want, and it has been changed to meet other people's needs, but not theirs.  Any change to the law in this area will not be the end of the problem, it will only be the starting point for other people to campaign for yet more changes.

Finally, we need to create much better end-of-life care - not just for people who are disabled or in pain, but for everyone.  I know of no better work on this subject than Atul Gawande's Being Mortal.  When medical professionals talk with dying patients about their desires and preferences - incredibly, far too often, this does not happen - then there are three significant changes.  Not for everyone, of course, but for many people.  The patients choose to receive less medical treatment (and the treatment they do receive costs less time and money); the patients and their carers report a better quality of life; and the patients live longer.  It is a clear win-win-win.  But it all depends on a really difficult cultural change: it requires us to treat dying patients as people, and really listen to them.

We need to take seriously both the suffering which exists in our current system, and the fear which this generates.  People in the UK (rich people) travel to Switzerland in order to die on their own terms, and clearly more people would do so if they could afford it.  This is clear evidence that the current system is not working - but we knew that: the NHS has been under-funded for years.  But the answer is not to implement a new, more complicated and more expensive system: the answer is to make the current system work well, work for everybody, and work in a way which gives everyone the confidence that, at the end of their lives, they will be cared for with dignity and without unnecessary suffering.

References

• Assisted Dying Bill (House of Lords Library)
• Assisted Dying: the November 2024 Bill
• Assisted Suicide (Wikipedia)
• Being Mortal: Medicine and What Matters in the End (Atul Gawande)
• Disabled people and suicide (Disability Rights UK)
• Kai Lung's Golden Hours (Ernest Bramah)
• Leading Causes of Death, UK (ONS)
• Parents with disabled children study (University of Birmingham)
• Seppuku (Wikipedia)
• Suicide (Wikipedia)
• Suicide Rates in England and Wales 2000-2022 (Statista)
• Suicide Statistics in the USA (DBSA)
• Tackling the root causes of suicide (NHS)
• What happens when people with acute psychosis meet the voices in their heads? (Guardian)
• What to expect from end of life care (NHS)
• Williams and Carey take opposite sides in debate on assisted-dying Bill (Church Times)