Why I’ve changed my views on assisted dyingBMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3566 (Published 03 August 2017) Cite this as: BMJ 2017;358:j3566
On Thursday 23 March I conducted my usual clinic, but this was like no other day. I knew that at 1.30 pm precisely, one of my closest friends was going to die.
Fabi’s death, at the age of 51, by euthanasia—something that I had been utterly opposed to throughout my career—is legal in Belgium, where she lived. I used to believe that if we got the balance of palliative care right to minimise distress then “assisted dying” was an irrelevance. Fabi’s death reversed my views.
I first met Fabienne “Fabi” Vanheuverbeke in Florida in 1983 on our gap years. With two other foreign exchange students (Tim and Françoise) we formed a lifelong bond. On her return to Belgium, Fabi, then 24, fell ill with a pituitary tumour and then a more widespread disorder—multiple endocrine neoplasia. She developed tumours in her pancreas, stomach, and liver over the next 27 years. In September 2016, I got the call I’d dreaded. She was now terminal, and we must all meet. In November, the four former exchange students met for one final time, along with her partner Jan. It was a truly precious weekend—we dined, laughed, and remembered a lifetime of fun.
I last saw her in February 2017 and was so impressed by Fabi’s palliative care—it wasn’t all about drugs. Fabi’s closest friend and Jan took paid compassionate leave to share her care. In the UK, they would almost certainly have had to give up work to do so. Gazing at Fabi’s frail frame, I could just imagine what would have happened in the UK—ending up at some point on an emergency department trolley. Belgium invests 10.2% of its GDP on health and social care compared with the UK’s 8.5%, and this makes a difference. Saying goodbye to my friend as she rested in her own living room seemed infinitely more civilised than a hospital corridor.
In March 2017, I got another call—Fabi had had enough. The discomfort was too much, she was going to ask for euthanasia. Belgium has had euthanasia in place since 2002. In 2003 it accounted for 0.2% of all deaths, rising to 1.7% in 2013. I was in a state of shock. She was clearly completely rational with access to a superb palliative care team. Yet Fabi was asking to die, and die she would later that week. It could not be any sooner as a number of checks had to be made to ensure that this was her fully informed decision. All patients have to give their written consent and be assessed by at least two doctors to ensure that they are mentally competent (a third doctor is required if they have a psychiatric condition).
It is vital that the vulnerable are protected, yet assisted dying is fundamentally about consent and autonomy. I began to question my views. I respected Fabi’s wishes—who was I to challenge them? Fabi was pleased that I had changed my mind, joking with a friend, just hours before she died, that when the UK law changed, they should call it Fabi’s Law.
I couldn’t be present for her death, but stayed with Jan on the eve of her funeral, and he explained what happened. Once the independent assessment had determined that her request was appropriate, her euthanasia was set for 1.30 pm on the Thursday. That morning, Jan told me, Fabi was counting the minutes to her time. Her family and friends were able to say their farewells by her bedside in her home. Then, with Jan by her side, her GP, who had known her for decades, administered the injections, a sedative and barbiturate. She smiled, gave a gentle wave to Jan and her family, drifted to sleep, and died within minutes.
For most of us, death will be completely unexpected. For a small but important minority, having a sense of control over how they depart this life is crucial to a good death. What right do those who oppose this as a “slippery slope” have to impose their view on others?
Legalised euthanasia is available in Colombia, Luxembourg, and the Netherlands, as well as Belgium. In Canada, Germany, Japan, and Switzerland doctor assisted dying, where patients take the final action themselves, is legal. In the US, doctor assisted dying is legal in five states. No one is forced to opt for assisted dying, no more than anyone is forced to get married. But in some other countries, there is now a choice. Elsewhere, for those who can afford it, there is the desperate trip to Dignitas. The campaign group Dignity in Dying estimates that one person a fortnight from the UK travels to the Zurich clinic. This is the outsourcing of assisted dying because of our failure to deal with the legal and ethical issues.
Doctors and politicians are out of step with the public. In 2014, a YouGov poll found that 56% of the public would consider assisted dying if it were legal and they were suffering a painful and incurable disease.
In contrast, in a 2014 survey I helped organise for the Royal College of Physicians, 58% of doctors opposed a change in the law. One year later, MPs opposed a change in legislation. In the debate, Keir Starmer—who, ironically, as head of the Crown Prosecution Service drafted the current guidance—stated: “We have arrived at a position where compassionate amateur assistance from nearest and dearest is accepted but professional medical assistance is not, unless you have the means to get to Dignitas.”
I didn’t agree then—I do now. A change in the law would enable those in the UK faced with a terminal illness the same choice that my friend Fabi had—a death with dignity on their own terms.
The views expressed are personal and do not reflect the views of any organisation David Nicholl works for.
Patient consent: obtained from next of kin.
Competing interests: None declared.