Assisted Dying

I attended the annual ABN meeting in Edinburgh this week. Overall an excellent meeting with a good balance between research and clinical neurology. However, the session, or debate, we had on assisted dying was disappointing. The question put to us was whether or not we simply accept the recent Royal College of Physicians new position on the issue, which is now neutral, or does the ABN need to update their own position on the issue. I am in favour of the former as the RCP’s position is neutral; almost like taking an agnostic position about god and religion to avoid the inevitable pointless debate that ensues if you state that you either a believer or an atheist.

It is worth pointing out that many of us neurologists took part in the RCP poll and a post-hoc analysis showed that we voted in line with the other physicians in the country. For some members of the ABN, the RCP’s position is flawed and not good enough. I got the sense that many people wanted to take a harder line on assisted suicide and want a vote to at least keep the current policy:

• It is the duty of the doctor to manage the end of life with sensitivity and dignity
• The individual who places their trust in Medicine as a caring profession should not be let down
• Mistakes with respect to the nature and outcome of illness may occur, especially early in the course of neurological conditions
• Personal attitudes to illness and dying may change as disability increases
• Withholding or withdrawing drug treatments and therapeutic interventions for an underlying disorder or its medical complications that are considered medically futile or excessively burdensome is consistent with good medical practice
• A doctor must use all reasonable means to maintain physiological functions that support life, must encourage the patient to do so, and must not compromise these either by act or omission.
• In the rare situations where the patient requests withdrawal of treatment or support of essential physiological functions, the courts should be consulted
• Administering a substance, medication or procedure with the intention of providing symptomatic relief even if this also has the effect of shortening life is consistent with good medical practice
• Interventions should not be given with the primary purpose of causing death even in the context of severe disability and an invariably fatal neurological condition and however merciful such an act may appear to be
• Many experts do not consider that legislation could safely be drafted in the United Kingdom that would protect the individual from the vagaries of convenience, coercion and mistaken intent
• The working party is opposed to any change that makes assisted dying an option within the legislation of the United Kingdom and that view is supported by most members of the Association of British Neurologists expressing an opinion
• Improved services for palliative care should be developed to improve end-of-life management

I have stated my position on assisted dying in a previous blog post about a BBC Radio 4 dramatisation on the assisted suicide of a person with advanced SPMS. In this specific blog post, I made the point that a personal level, I am for assisted suicide. As a libertarian, it is about choice. However, as a doctor and neurologist looking after people with manageable diseases, I am against assisted suicide. How can I, on the one hand, be trying to do my best to treat my patients, to make their lives easier and better, and on the other hand be the one offering assisted suicide? What I am saying is that the HCPs who help with assisted suicide cannot be the same HCPs looking after the patient’s other needs. They have to come from two separate teams.

I have a pact with my wife, who I love and adore, that I will help her access assisted dying if the need ever arose. She has made it clear to me what her wishes are. My wife was so affected by the novel and subsequent movie ‘Still Alice’, about a woman who develops Alzheimer’s disease, that she does not want to die with terminal dementia. She is not asking me to do the deed, but to help her travel to Dignitas, or a similar clinic, if and when this particular situation arose. My wife wants to die with her cognitive faculties reasonably intact. The point I am making is that this decision is hers, and not mine; assisted suicide is about personal choice. Who am I, or any other neurologist or person, to say that my wife is wrong and should be denied her wish?

What this ABN meeting has made me realise is that the UK is not as liberal as I thought it was. On the contrary, it is quite conservative, which on reflection may not necessarily be a bad thing. However, we may be an island but people living in this country who have the means will still be travelling to Switzerland and other countries to get what they want. In other words, maintaining the status quo on assisted suicide is unfair; as always the rich get what they want and the poor simply have to put up with their lot and suffer the consequences of being denied the option of an assisted suicide.

An argument put forward against legalising assisted suicide is that it represents a slippery slope towards euthanasia or the deliberate killing of vulnerable people. My argument against this is enshrined in what liberalism stands for; firstly ‘the protection’ and, secondly, ‘the enhancement of the freedom of the individual’. Liberals believe that government is necessary to protect individuals from being harmed by others, but they also recognize that government itself can pose a threat to liberty. In the many countries that have legalised assisted suicide, there is no evidence of euthanasia creep. Any legislation we promulgate would need the prerequisite legal safeguards to make sure this doesn’t happen and to protect the vulnerable.

This debate will continue as the ABN is likely to poll its members in a separate survey. I sincerely hope we come up with a similar position to the RCP. Neurology is widely considered to be the most conservative of the medical specialities; taking a different position to our physician colleagues will reinforce the stereotype at a time that we are trying to change our behaviour.