Assisted dying: it’s time to poll UK doctors

Physician-assisted suicide

Ole Hartling

There is much to indicate that there is increasing acceptance of legalization of assisted suicide and euthanasia, and I believe it has to do with the notions that no area should be excluded from the domain over which people must be able to exert power.

The dilemma is hardly ever presented in new ways, making constant reference instead to the arguments of unbearable suffering and the right to self-determination, as well as to recurring opinion polls.

One example is an editorial from 2014 in the British Medical Journal (BMJ) entitled: “Why the Assisted Dying Bill should become law in England and Wales” with the categorical ‘answer’ already in the subheading: “It’s the right thing to do, and most people want it.” [1] The article presents the usual arguments and makes the usual reference to opinion polls. The leader must have come as a surprise to doctors in the UK and abroad.

Reference to suffering holds an altogether obvious appeal for everyone including anyone who has taken the Hippocratic Oath. However, physician-assisted suicide or euthanasia is not about alleviating or removing a person’s suffering but about removing the one who is suffering. It is worthwhile thinking about what this means to the patient-doctor relationship.

The argument about the right to self-determination and free will, in particular, seems to be convincing in our part of the world and in our age. No one must touch our freedom or our right to self-determination. Those responding to the question of assisted dying or euthanasia when asked in an opinion poll can scarcely imagine not being able to make up their own minds. Getting into situations where they would not wish to have the option of having to choose is not the first thing that comes to the mind.

There is doubt as to whether the right to self-determination is always and under all circumstances exercised as the result of a free will. All essential decisions we take are made in some relation to others. The decisions we take affect other people, and they are affected by other people. We are vulnerable people, in common with others and dependent on others – colleagues, carers, friends and family.

Almost absent from the debate is the point that a beleaguered and desperate patient may need to be met with more than just a rational understanding that it is best to die now. Paradoxically, the respect for self-determination can contain an element of that “fellow man’s” dispensability and hence an unspoken repudiation or an exclusion from the community and from life.

Time and again the ideas of physician-assisted suicide and euthanasia are supported from a “democratic” perspective, that opinion polls show that legalization is what people want. An issue of the BMJ from February this year devotes itself to the debate, and the editor, Fiona Godlee suggests that it is time to poll UK doctors on the question. [2]

One of the authors, Jacky Davis, in this BMJ issue repeats an oft-heard phrase that patients with terminal illness “should be allowed a death with dignity on their own terms”. [3] She wonders why the views of the UK medical profession are so out of step with those of their patients, 82% of whom support legalization. But an immediate question to be asked is whether the 82% are indeed patients? Or are they in fact ordinary, healthy people who cannot imagine themselves being crippled, blind, deaf, suffering, on dialysis, demented and dependent on care, in which case they would rather die?

There are two essential reasons why a slippery slope argument cannot be rejected when it comes to euthanasia. The first is that a slippery slope is inherent in the matter: The aim of euthanasia is well-intentioned, for suffering must be combated, but it will be hard to place limits on benevolence and all that is well-meant. Any attempt to do so can be regarded almost as a reflection of malice.

The other reason for taking the slippery slope argument seriously is that we are seeing it in action. In a recent book “Euthanasia and Assisted Suicide – Lessons from Belgium” the legal rules in Belgium, the Netherlands and Luxembourg are described and commented on as well as developments in Belgium covering the gradual broadening of the fields of application of the directives. [4]

There is a difference between the Belgian act on the one hand, and the Dutch and Luxembourgian acts on the other. Initially, the Belgian act was not applicable to assisted suicide, whereas the Dutch and the Luxembourgian acts regulate assisted suicide in the same way as euthanasia. This has meant that in Belgium the status of physician-assisted suicide has been legally ambiguous. In the meantime, the Belgian “Federal Control and Evaluation Commission of Euthanasia” has now accepted assisted suicide as falling within the definition of euthanasia and consequently under the Euthanasia Act. [5,6]

Euthanasia cases must be reported to the Commission, which also issues annual reports, so that the development can be monitored. [5] There is a mounting volume of empirical data from both Belgium and the Netherlands showing a steady rise in the numbers receiving assisted suicide or euthanasia. [5,6,7] In the Netherlands in 2002 the annual number of assisted deaths and euthanasias was 1,882, and in 2015 it had increased to some 5,500. [7] In 2017 the number was about 7,000. [8] Moreover, the qualifying conditions under which euthanasia can be performed are being extended. [5-8] One example is euthanasia for ‘multiple disorders’ (various chronic diseases) where the number of euthanasia cases in Belgium rose from 9 in 2004 to 209 in 2015. [6]

In my view the recent surveys of the development in Belgium and the Netherlands deliver an altogether disquieting body of evidence. A quotation from the book from 2017 may be illustrative: “There is an indication that euthanasia, once the barrier of legalisation is passed, tends to develop a dynamic of its own and extend beyond the agreed restrictions, in spite of earlier explicit reassurances that this would not happen – in Belgium such reassurances were given when the 2002 law was being debated”. [9]

1. Delamonthe T, Snow R and Godlee F. Why the assisted dying bill should become law in England and Wales. Br. Med. J. 2014; 349: g4349.
2. Godlee F. Assisted dying: It’s time to poll UK doctors. Br. Med. J. 2018; 360: k593.
3. Davis J. Most UK doctors support assisted dying, a new poll shows: the BMA’s opposition does not represent members. Br. Med. J. 2018; 360: k301-2.
4. Euthanasia and Assisted Suicide. Lessons from Belgium. Jones DA, Gastmans C, MacKellar C, eds. Cambridge University Press, 2017, pp. 366.
5. Nys H. A discussion of the legal rules on euthanasia in Belgium briefly compared with the rules in Luxembourg and the Netherlands. In: Euthanasia and Assisted Suicide. Lessons from Belgium. Jones DA, Gastmans C, MacKellar C, eds. Cambridge University Press 2017: 7-25.
6. Montero E. The Belgian experience of euthanasia since its legal implementation in 2002. In: Euthanasia and Assisted Suicide. Lessons from Belgium. Jones DA, Gastmans C, MacKellar C, eds. Cambridge University Press. 2017: 26-48.
7. Boer T. Dutch ethicist – “Assisted suicide. Don’t go there”. http://alexschadenberg.blogspot.ca/2014/07/dutch-ethicist-assisted-suici...
8. Boffey D. Dutch prosecutors to investigate euthanasia cases after sharp rise. The Guardian, 12 March 2018.
9. MacKellar C. Some possible consequences arising from the normalisation of euthanasia in Belgium. In: Euthanasia and Assisted Suicide. Lessons from Belgium. Jones DA, Gastmans C, MacKellar C, eds. Cambridge University Press; 2017: 219-34.