legalisation of ‘assisted dying ‘ opposed by the British Geriatrics Society

Ahead of the forthcoming second reading of the Leadbeater ‘Terminally Ill Adults (End of Life) Bill’, the British Geriatrics Society (BGS) has published its current position statement on this vital issue on 31 October, based on an open, anonymised, and invited survey of its cross-professional membership, analysed and delivered by an openly constituted and transparent Working Group.

Its position to remain opposed to the legalisation of ‘assisted dying’ (encompassing Physician Assisted Suicide and Voluntary Active Euthanasia in the UK and Crown Dependencies) is to be strongly welcomed.

Clear-cut member majorities in the BGS survey rejected (i) a change in UK law, (ii) a change in existing BGS opposition to it, (iii) engagement with delivering its process in the event of such change, and (iv) any confidence in the development of effective safeguards in that event.

A summary overview highlights:

(i) The unsustainable concept of ‘personal choice ‘ by older people (and arguably clinicians advising them) while there remains an under-resourced, fragmented and inadequate health, palliative, and social care context:

(ii) The, as yet widely unaddressed, BGS ‘priority ‘ requirements for prognostic accuracy, balanced advice and forward decision making, sharing and communication of information, Comprehensive Geriatric Assessment, high-quality palliative care, and appropriate public awareness and attitudes (versus ‘societal ageism ‘):

(iii) Clear evidence for the disproportionate vulnerability of the older population to legislative change (highlighted particularly by evidence data of safeguarding erosions from Canada and the Netherlands).

Specific issues further visited include endorsement of ‘personalised care ‘, best evidence-based practice as an alternative to assisted dying, the ‘demedicalisation ‘ of dying, the sensitive, difficult issue of non-clinician options (e.g. machines, non-clinical staff) in assisted dying, and the need to protect health care professionals conscientiously unwilling to participate in assisted dying. Importantly also, ‘autonomous‘ choice and decision are hard to define and standardise, and will invariably (because all human individuals are pre-eminently relational) impact the interests of others beyond ourselves.

The statement of the BGS’s End-of-Life Special Interest Group is provided, unequivocally rejecting assisted dying legalisation. It emphasises the reality and challenge of diagnostic and prognostic uncertainty as well as how inadequate health and social care provision augment the sense of burden and negative self-worth amongst older people themselves and also risk a wider subliminal expectation for this age group to opt for an ‘assisted death’.

The reliability of precise prognosis, free, informed consent and consistent care standards (including palliative care) remain at their lowest in this population, particularly in the context of multimorbidity and cognitive impairment, rendering them maximally vulnerable to the progressive adverse consequences of the proposed legislative shift.

The speciality and the BGS, its Society, have a long-established and defined specialist remit to advance and advocate the provision of optimal health and care services for the vulnerable, under-represented older adult population (often over the years against a background of negative attitudinal bias, clinical and resource neglect). Its position statement is, therefore, both timely and influential in the current context.

The statement might, perhaps, be seen to contain some elements of nuanced ambiguity, possibly reflecting (?) slightly disproportionate deference to the pro-assisted dying and undecided membership minority (given the clear four-point majority statements listed above) and also reflecting possible anxiety (in my view, unjustified) of BGS marginalisation from influencing policy if it retains its explicit declared opposition to assisted dying in the event of its legalisation.

For example:

(i) It commits to an immediate review of the BGS position if assisted dying is legalised and, if it is not, to a short-term (2027) and ongoing regular review.

(ii) ‘The BGS, therefore, expects to contribute meaningfully to inform the development of any future law on assisted dying, particularly with respect to developing and implementing meaningful and workable safeguards…in a ‘modern, well-run assisted dying service’.

Regarding this latter point, the need is clear for the BGS to be directly involved at the policy level in an agenda for ‘damage limitation‘ in the ultimate event of assisted dying legalisation. But a greater risk, conversely, of marginalisation might arguably occur if the BGS at this point were seen to compromise in its opposition to assisted dying by ostensibly contributing to ‘a well-run assisted dying service‘. In effect, this endorses the feasibility of ‘safeguarded‘ assisted dying being widely and freely deployed predominantly in the older age group, as already seen (80-85 per cent) in Canada and the Netherlands. Notwithstanding the BGS’s expressed wishes, such implicit acceptance (inconsistent with its core position) might paradoxically weaken the case a priori for the BGS’s continuing essential policy engagement around assisted dying, as well as its ongoing advocacy, oversight, focused leadership, expertise, protection, and accountability for progress in the health care of this vulnerable population.

It is, perhaps, preferable to restate robustly that the radical progress achieved by the speciality over decades of prior age prejudice and diagnostic and therapeutic neglect (recognised by its original founder, Marjory Warren), has at least in part been driven and enabled not just by vision and compassion, but also by the only safe, fixed, centuries-strong, and durable ethical context – the unassailable absolute intrinsic sanctity and value of an individual, personal human life, irrespective of age and status.

The compassionate and safe way forward now is to build on and fully resource the advances already achieved (but currently eroded) in comprehensive care and palliative care for older adults so that the wish or demand for assisted dying is ultimately superfluous. In the meantime, to put it bluntly, no required healthcare professional encounter with any patient of any age should ever have to conclude, ‘the only advice/response/ I can now offer you is for you to kill yourself and I will help you to do it ‘.

Meanwhile, the explicitly declared opposition of the BGS to the legalisation of assisted dying in this statement is welcome, timely, and much needed. Hopefully, the BGS will continue to promote and defend it robustly and clearly from here onwards in the interests of the vulnerable population for whom it holds primary accountability.

Cameron G Swift PhD FRCP FRCPI

Emeritus Professor of Clinical Gerontology

King’s College London.