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Artillery Row

The devil is in the detail

The assisted suicide bill has practical challenges to answer before it should convince us to start down a dangerous path

The problem with legalising “assisted suicide” is not the principle of a right-to-die, but the practice. As in so many cases, the devil is in the detail, and well-meaning legislation can do more harm than good.

There is an honourable case for legalisation, but there is also an honourable case against, and nobody should make up their mind without deeply considering both. Assisted suicide can be an issue where people talk with a great deal of certainty by just ignoring the other side of the argument. It certainly makes for easier campaigning, but it is dishonest.

Campaigners focus on individual stories of unbearable pain

Speak to the people around you and it is almost certain one of them will have experienced a relative or friend dying a protracted or painful death. The case for assisted suicide largely rests on these experiences. Everybody should recognise this does happen, and that when it does, the distress and suffering can be huge. I believe even most opponents of legalising assisted suicide would agree there are people who would profoundly benefit from a change in the law. I can think of people I know who might. From listening to healthy supporters of assisted suicide, it is clear that fear of ending up heavily disabled, or in untreatable pain, is a major reason for supporting legalisation.

On a more abstract level, we have a consensus across society that attempting suicide should be legal, and that people have the right to refuse treatment, in which case it is not clear on principle why it should be illegal to assist suicide. I suspect support for euthanasia in opinion polls rests, at least in part, on support for this principle that I should possess the right to decide my own life and death, and nobody else has a stronger right to decide those questions for me.

Developments in medicine mean that the population who would benefit from assisted suicide is possibly growing. In the past, people were more likely to die rapidly, while still relatively young and in recently good health, whereas medical science is now increasingly able to keep people alive, even when so frail they have little active quality of life. At the same time this must be contrasted with developments in palliative care, pain control and in adjustments that allow those profoundly disabled to continue leading meaningful lives.

The best arguments for legalising assisted suicide are personal and individual, and campaigners wisely focus on these individual stories of people facing unbearable pain. However, the moment one steps back from those undoubtable stories of suffering, wider questions rush in.

The “slippery slope” is a sociological fact

The bill currently before parliament is modelled on the law in Oregon, USA. It restricts assistance to adults of sound mind with a prognosis of less than 6 months to live, which must be confirmed by two doctors. This is considerably more restrictive than the current law in places like Belgium, the Netherlands or Canada. The Netherlands, particularly, has moved from a similar position of only allowing assisted suicide in adult, terminal, physical cases to its current situation, where it is available for people who are not dying, the mentally ill and children. It is now even possible to inflict euthanasia on patients, who do due to conditions like dementia, are no longer able to consent.

The idea that a restricted right to “assisted dying” will lead to a much wider legal right to euthanasia is the famous “slippery slope”. It is a logical fallacy, but it is also a sociological fact. Looking across western societies in the last fifty years it is hard to think of a single issue where, for better or worse, progressive campaigners accepted an initial piece of liberalisation and went no further. Indeed, the logic of progressivism demands further continual “progress”, and on a more prosaic level, there is a whole class of professional activists whose salary depends on always having another “reform” to fight for.

This Assisted Suicide Bill looks particularly vulnerable to “mission creep” because its restrictions are in some degree arbitrary: Why six months and not one year? Why two doctors and not one? Why terminal and not chronic suffering? Why physical and not mental illness? I could go on. Given recent history, it is not scaremongering to fear that once the principle is breached, activists will seek to push the door open as wide as possible.

Sympathetic doctors may turn safeguards into a formality

Even if we reject the “slippery slope” as a fallacy, there are reasons to doubt the safeguards being proposed.  Firstly, forecasting life expectancy is not an exact science, even for the medical profession, and even with terminal illness. There is risk that people may be pushed towards assisted suicide by inaccurate prognosis, when they would have lived longer. Secondly, there is a risk of doctors sympathetic to a wider access to euthanasia turning the safeguard into a formality, like the nominal restrictions on abortion before twenty-four weeks pregnancy. Thirdly, rigorous assessment for capacity, or requirements for counselling, will almost certainly face opposition, as already occurs around medical care regarding gender transition, abortion or younger women requesting sterilisation.

It would be useful to hear campaigners explain why alternatives to assisted suicide are not preferable. Should there be a guaranteed right to increasingly strong painkillers, morphine or other drugs, even where this risks killing the person? To some degree, that would be equivalent to legalising assisted suicide, but without needing to take the step of chartering the medical profession to actively kill people. 

There is also a wider social question. There certainly are people with terminal illnesses who might benefit from assisted suicide being legal, but there certainly are also people who face anxiety, depression or loneliness, who believe their life has no meaning or hope, when this does not have to be true. I fear that I know people like this, too. Medical options are often confusing, poorly explained and restricted by healthcare rationing; doctors are often too overworked and rushed to help people properly understand their options. There are people who fear a painful or degrading death, when this is avoidable, through modern pain control and palliative care. For how many people is intense suffering or degrading conditions unavoidable, and for how many people is it a reflection of patchy palliative services, inadequately funded care, unavailable mental health treatment and insufficient pain control?

I don’t know the answer to that question, but it seems at least that we should know the answer. It would be a tragedy and a betrayal if assisted suicide became an alternative to making improvements in the care we offer. When our hospices are the best in the world, when people are guaranteed the pain control they need, and nobody faces squalid, low-quality conditions in care, then we can decide if we are justified in taking the first steps down what could be a dangerous slope. 

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