Assisting or encouraging suicide remains a crime in Britain under the Suicide Act 1961, [1] but over the last 14 years there has been relentless pressure to change this. More than ten attempts to legalise assisted suicide (AS) have been made through British parliaments since 2003 — three by each of Lord Joffe and Lord Falconer in the House of lords, two in theScottish parliament by Margo Macdonald and Patrick Harvie, one by Robert Marris via the House ofCommons and one in each of Wales and the Isle of Man. Every single one has failed and the last attempt by Robert Marris was defeated by an astronomical margin of 330-118 on 11 September 2015. [2]
We have seen additional attempts to change the law through the courts — again all unsuccessful. Diane Pretty went all the way to the European Court of Human Rights in 2002. Debbie Purdy managed to force the director of public prosecutions (DPP), after a major consultation, to publish a list of criteria he takes into account when making a decision to prosecute in 2010 and in 2014 three men — Tony Nicklinson, 'Martin' and Paul Lamb brought cases which eventually reached the Supreme Court. At the time of writing, the case of Noel Conway, a 67-year-old with motor neurone disease, is being heard in the High court. [3]
This raises two key questions:
1. Why is there such pressure to change the law?
2. Why has it so far been unsuccessful?
But there have also been powerful, well resourced lobby groups pushing for a change in the law. The most prominent is Dignity in Dying (formerly the Voluntary Euthanasia Society), which has a number of affiliates such as Health Professionals for Assisted dying (HpAd). But in recent years pro-euthanasia groups with widely varying agendas have proliferated dramatically: Society for Old Age Rational Suicide (SOArS) (now My Death, My Decision), Humanists UK (formerly the British Humanist Association), My Life My Death My Choice, Friends at the End (FATE) and Exit International.
These groups have been supported by powerful celebrity advocates and sections of the media — especially the left-wing press and the BBC. They have two main arguments: autonomy (the so-called 'right to die') and compassion (the relief of suffering), which are backed by personal testimony.
In the face of this onslaught it is remarkable that the law has not changed but there are also powerful forces defending the status quo. Why has it been unsuccessful? the four main groups resisting the legalisation of assisted dying in this country — doctors, disabled people, faith groups and parliamentarians — do so primarily because they are anxious about the consequences of licensing doctors to dispense lethal drugs.
Their concerns are both about how such a system could be regulated and also about the pressure legalisation would place on vulnerable people to end their lives for fear of being a financial or emotional burden on others. This is heightened by the evidence of incremental extension or 'mission creep' in other jurisdictions.
Switzerland
Switzerland, where assisted suicide is legal, first released assisted suicide statistics in 2009, laying bare a 700% rise in cases (from 43 to 297) from 1998 to 2009. [4]
Amongst those travelling from abroad to end their lives at the notorious Dignitas facility have been many people who could not by any stretch be described as terminally ill — and included cases of people who could have lived for decades ending their lives [5] — with arthritis, blindness, spinal injury, diabetes, mental illness or people who were essentially well but could not bear to live without their spouses.
Dignitas has attracted much criticism in recent years over accounts of discarded cremation urns dumped in lake Zurich, [6] reports of body bags in residential lifts, suicides being carried out in car parks, the selling of the personal effects ofdeceased victims and profiteering with fees approaching £8,000 per death.
Oregon
In the US state of Oregon there has been a 550% increase in assisted in suicide deaths since legalisation in 1998. Notable are two people with cancer — Randy Stroup and Barbara Wagner — who were told that the Oregon Health Authority would not pay for their chemotherapy but would happily pay for their assisted suicide, which was of course much cheaper. [7]
Were AS to be legalised in the UK end of life care would be likely to worsen under financial pressures because it costs on average £3,000 to £4,000 a week to provide in-patient hospice care, but just pounds to pay for the drugs which would help a person commit suicide. Cancer treatments like chemotherapy, radiotherapy or surgery cost much more.
Is this really the kind of temptation that we wish to put before NHS managers in Britain? Is it any wonder that over 120 attempts to change the law through other US state parliaments have so far failed?
In 2016, 89.5% of those undergoing assisted suicide in Oregon cited 'loss of autonomy' as their reason, 89.5% said they were 'less able to engage in activities making life enjoyable', 65.4% listed 'loss of dignity' and 48.9% said they felt they were a burden on family, friends or caregivers. these are not physical but existential or spiritual symptoms. [8]
But should lethal drugs be prescribed to people who feel their lives no longer have meaning and purpose?
Netherlands and Belgium
The laws in the Netherlands and Belgium allow euthanasia as well as assisted suicide but illustrate further how any law giving doctors the power to dispense lethal drugs is subject to extension and abuse.
In the Netherlands, which legalised assisted suicide and euthanasia in 2002, there has been an increase of 10 to 20% of euthanasia cases per year from 1,923 in 2006 to 5,306 in 2014. The 2014 figures included 81 with dementia and 41 with psychiatric conditions. [9]
In addition, in 2001 about 5.6% of all deaths in the Netherlands were related to deep-continuous sedation. This rose to 8.2% in 2005 10 and 12.3% in 2010. A significant proportion of these deaths involve doctors deeply sedating patients and then withholding fluids with the explicit intention that they will die.
In the Netherlands children as young as twelve can already have euthanasia and a 2005 paper in the New England Medical Journal reported on 22 babies with spina bifida and/or hydrocephalus who were killed by lethal injection in the Netherlands over a seven year period. It estimated that there are 15 to 20 newborns being killed in this way per year — despite this still being illegal. The culture and public conscience have changed. [11]
In Belgium, which legalised euthanasia in 2002, there was a 669% increase [12] in euthanasia deaths between 2003 and 2013, and assisted suicide and euthanasia now account for 6.3% of all deaths. [13]
High-profile cases include Mark and Eddy Verbessem (deaf and blind twins), [14] Nathan/NancyVerhelst (depressed following gender reassignment) [15] and Ann G (anorexia). [16]
Organ donation euthanasia is already practised in Belgium [17] (transplanting organs from people who are then euthanised) and the country recently extended euthanasia to minors. A New England Medical Journal study on the practice of euthanasia in the Flanders region of Belgium found that in 2013 1.7% of all deaths (more than 1,000 deaths)were assisted deaths without explicit request. Half of Belgium's euthanasia nurses have admitted to killing without consent although only doctors are authorised to perform euthanasia. [18]
The essential problem is that the two major arguments for euthanasia — compassion and choice — can be applied to a very wide range of people. This means that any law which attempts to limit them, for argument's sake to mentally competent people who are terminally ill, will in time be interpreted more liberally by sympathetic or ideologically motivated 'assisters' and may also be open to legal challenge under equality legislation on grounds of discrimination.
Or as Philip Nitschke of Exit International asks: why not the elderly bereaved and the troubled teen? There will inevitably be pressure to extend the boundaries that may well not survive legal challenges under equality legislation once the so-called 'right' is available for some. Any law allowing assisted suicide or euthanasia in any circumstances at all will be subject to extension — or abuse.
But many will simply be too busy, too pressured and facing too many demands to make the kind of cool, comprehensive, objective assessments that this kind of law requires. And very few of them will really know the patients or their families.
We have seen this already with abortion. We began with a very strict law which allowed it only in limited circumstances. now there are 200,000 cases a year. Most of them fall outside the boundaries of the law. [19] There is illegal pre-signingof forms, abortion for sex selection, abortion on demand for spurious mental health reasons, and only one conviction for illegal abortion in 45 years.
Society is reluctant to touch and question doctors. the police are reluctant to investigate. The DPP hesitates to prosecute. The courts are unwilling to convict. parliament turns a blind eye. It is simply not safe to give doctors this sort of powerbecause some will abuse it, as they have in other countries, and it will be very difficult to stop them.
It's far better not to go there at all.
The best system available is that which we have currently — a law carrying a blanket prohibition on both assisted suicide and euthanasia but with discretion given to both prosecutors and judges to temper justice with mercy in hard cases — thecurrent law has both a stern face and a kind heart.
In other words the penalties that it holds in reserve act as a powerful deterrent to exploitation and abuse of vulnerable people. And it works — there are very few cases observed (just 15—20 per year make the trip to Switzerland) but also very few prosecutions.
Let's keep it that way.
Peter Saunders is CMF Chief Executive
1. Suicide Act 1961 bit.ly/2u64nje 2. Saunders p. defeat of the Marris Assisted Dying Bill. Christian MedicalComment 12 September 2015 bit.ly/1O84Q91
3. Saunders p. the Conway case — a change in the law to allow assisted suicideis dangerous and unnecessary. Christian Medical Comment 16 July 2017bit.ly/2tYtggI
4. Almost 300 assisted suicides in Switzerland per year. Telegraph 27 March2012 bit.ly/2wbtyyD
5. Campbell d. Suicide clinic challenged over patients who could have lived'for decades'. The Guardian 21 June 2009 bit.ly/2tbMAVf
6. Williams A. 300 urns with human ashes dumped in lake Zurich near Dignitasclinic. Daily Telegraph 27 April 2010 bit.ly/2tc0zdA
7. Don't make Oregon's mistake. Care Not Killing; 2015 bit.ly/1Nh8eOQ
8. Oregon death with dignity Act. data summary 2016 bit.ly/2u6FKTL
9. regional Euthanasia review committees. Annual report 2014. RERC; 2014:14bit.ly/2wKnuka
10. End-of-life practices in the Netherlands under the Euthanasia Act.N Engl J Med 2007;356:1957-1965 bit.ly/2tCkVvY
11. Verhagen E, Sauer p. the Groningen protocol—Euthanasia in Severely Illnewborns. N Engl J Med 2005;352(10):959-962 bit.ly/2veTGt8
12. Euthanasia is out of control in Belgium — new ten year review.Care Not Killing 14 december 2012 bit.ly/1teGqjv
13. 6.3% of Belgian deaths now E&AS. Care Not Killing 24 March 2015bit.ly/1WF6mCg
14. Belgian twins' euthanasia, and what it represents. Care Not Killing30 January 2013 bit.ly/1wanbIK
15. Belgian helped to die after three sex change operations. BBC 2 October 2013bbc.in/1v9nXkT
16. cook M. Another speed bump for Belgian euthanasia. Bioedge 8 February2013 bit.ly/1tBtmV2
17. Saunders p. Belgium becomes world leader in organ removal after euthanasia. Christian Medical Comment 16 March 2013 bit.ly/2u6NNA4
18. Caldwell S. Warning to Britain as almost half of Belgium's euthanasia nursesadmit to killing without consent. Daily Mail 10 June 2010 dailym.ai/1VNKuCC
19. Saunders p. Why 98% of abortions in Britain are now illegal and what itmeans for doctors. Christian Medical Comment 10 December 2011bit.ly/1t5YIV2
We have seen additional attempts to change the law through the courts — again all unsuccessful. Diane Pretty went all the way to the European Court of Human Rights in 2002. Debbie Purdy managed to force the director of public prosecutions (DPP), after a major consultation, to publish a list of criteria he takes into account when making a decision to prosecute in 2010 and in 2014 three men — Tony Nicklinson, 'Martin' and Paul Lamb brought cases which eventually reached the Supreme Court. At the time of writing, the case of Noel Conway, a 67-year-old with motor neurone disease, is being heard in the High court. [3]
This raises two key questions:
1. Why is there such pressure to change the law?
2. Why has it so far been unsuccessful?
pressure to change the law
Pressure for assisted suicide is in some sense inevitable in a post-Christian society that is increasingly hostile to Christian faith and values. When people no longer believe in the sanctity of life, life after death or judgment and see no meaning in suffering, euthanasia becomes more attractive as an escape from a bad situation.But there have also been powerful, well resourced lobby groups pushing for a change in the law. The most prominent is Dignity in Dying (formerly the Voluntary Euthanasia Society), which has a number of affiliates such as Health Professionals for Assisted dying (HpAd). But in recent years pro-euthanasia groups with widely varying agendas have proliferated dramatically: Society for Old Age Rational Suicide (SOArS) (now My Death, My Decision), Humanists UK (formerly the British Humanist Association), My Life My Death My Choice, Friends at the End (FATE) and Exit International.
These groups have been supported by powerful celebrity advocates and sections of the media — especially the left-wing press and the BBC. They have two main arguments: autonomy (the so-called 'right to die') and compassion (the relief of suffering), which are backed by personal testimony.
In the face of this onslaught it is remarkable that the law has not changed but there are also powerful forces defending the status quo. Why has it been unsuccessful? the four main groups resisting the legalisation of assisted dying in this country — doctors, disabled people, faith groups and parliamentarians — do so primarily because they are anxious about the consequences of licensing doctors to dispense lethal drugs.
Their concerns are both about how such a system could be regulated and also about the pressure legalisation would place on vulnerable people to end their lives for fear of being a financial or emotional burden on others. This is heightened by the evidence of incremental extension or 'mission creep' in other jurisdictions.
lessons from abroad
Switzerland
Switzerland, where assisted suicide is legal, first released assisted suicide statistics in 2009, laying bare a 700% rise in cases (from 43 to 297) from 1998 to 2009. [4]
Amongst those travelling from abroad to end their lives at the notorious Dignitas facility have been many people who could not by any stretch be described as terminally ill — and included cases of people who could have lived for decades ending their lives [5] — with arthritis, blindness, spinal injury, diabetes, mental illness or people who were essentially well but could not bear to live without their spouses.
Dignitas has attracted much criticism in recent years over accounts of discarded cremation urns dumped in lake Zurich, [6] reports of body bags in residential lifts, suicides being carried out in car parks, the selling of the personal effects ofdeceased victims and profiteering with fees approaching £8,000 per death.
Oregon
In the US state of Oregon there has been a 550% increase in assisted in suicide deaths since legalisation in 1998. Notable are two people with cancer — Randy Stroup and Barbara Wagner — who were told that the Oregon Health Authority would not pay for their chemotherapy but would happily pay for their assisted suicide, which was of course much cheaper. [7]
Were AS to be legalised in the UK end of life care would be likely to worsen under financial pressures because it costs on average £3,000 to £4,000 a week to provide in-patient hospice care, but just pounds to pay for the drugs which would help a person commit suicide. Cancer treatments like chemotherapy, radiotherapy or surgery cost much more.
Is this really the kind of temptation that we wish to put before NHS managers in Britain? Is it any wonder that over 120 attempts to change the law through other US state parliaments have so far failed?
In 2016, 89.5% of those undergoing assisted suicide in Oregon cited 'loss of autonomy' as their reason, 89.5% said they were 'less able to engage in activities making life enjoyable', 65.4% listed 'loss of dignity' and 48.9% said they felt they were a burden on family, friends or caregivers. these are not physical but existential or spiritual symptoms. [8]
But should lethal drugs be prescribed to people who feel their lives no longer have meaning and purpose?
Netherlands and Belgium
The laws in the Netherlands and Belgium allow euthanasia as well as assisted suicide but illustrate further how any law giving doctors the power to dispense lethal drugs is subject to extension and abuse.
In the Netherlands, which legalised assisted suicide and euthanasia in 2002, there has been an increase of 10 to 20% of euthanasia cases per year from 1,923 in 2006 to 5,306 in 2014. The 2014 figures included 81 with dementia and 41 with psychiatric conditions. [9]
In addition, in 2001 about 5.6% of all deaths in the Netherlands were related to deep-continuous sedation. This rose to 8.2% in 2005 10 and 12.3% in 2010. A significant proportion of these deaths involve doctors deeply sedating patients and then withholding fluids with the explicit intention that they will die.
In the Netherlands children as young as twelve can already have euthanasia and a 2005 paper in the New England Medical Journal reported on 22 babies with spina bifida and/or hydrocephalus who were killed by lethal injection in the Netherlands over a seven year period. It estimated that there are 15 to 20 newborns being killed in this way per year — despite this still being illegal. The culture and public conscience have changed. [11]
In Belgium, which legalised euthanasia in 2002, there was a 669% increase [12] in euthanasia deaths between 2003 and 2013, and assisted suicide and euthanasia now account for 6.3% of all deaths. [13]
High-profile cases include Mark and Eddy Verbessem (deaf and blind twins), [14] Nathan/NancyVerhelst (depressed following gender reassignment) [15] and Ann G (anorexia). [16]
Organ donation euthanasia is already practised in Belgium [17] (transplanting organs from people who are then euthanised) and the country recently extended euthanasia to minors. A New England Medical Journal study on the practice of euthanasia in the Flanders region of Belgium found that in 2013 1.7% of all deaths (more than 1,000 deaths)were assisted deaths without explicit request. Half of Belgium's euthanasia nurses have admitted to killing without consent although only doctors are authorised to perform euthanasia. [18]
why incremental extension is inevitable
Any law allowing assisted suicide will carry within it the seeds of its own extension. Whilst Dignity in Dying may claim to have limited objectives (assisted suicide for mentally competent adults with six months or less to live) on its coat tails are a host of other UK groups with more radical agendas who will see this only as a first step. They will not be satisfied with so-called modest changes — they want euthanasia as well as assisted suicide — but they are all using the same arguments to advance their case.The essential problem is that the two major arguments for euthanasia — compassion and choice — can be applied to a very wide range of people. This means that any law which attempts to limit them, for argument's sake to mentally competent people who are terminally ill, will in time be interpreted more liberally by sympathetic or ideologically motivated 'assisters' and may also be open to legal challenge under equality legislation on grounds of discrimination.
- If adults can have it, why can't children who are judged to be Gillick competent make up their own minds?
- If competent people can have it, what about those with dementia who, it is argued, would have wanted it?
- If people who are terminally ill, why not the chronically ill or disabled who are suffering unbearably?
- If it's for those with physical suffering, why not those with mental suffering?
Or as Philip Nitschke of Exit International asks: why not the elderly bereaved and the troubled teen? There will inevitably be pressure to extend the boundaries that may well not survive legal challenges under equality legislation once the so-called 'right' is available for some. Any law allowing assisted suicide or euthanasia in any circumstances at all will be subject to extension — or abuse.
why doctors cannot be trusted
Changing the law would also give doctors a degree of power over life and death that some will inevitably abuse. It will be doctors who see the patients, fill out the forms, dispense the lethal drugs. Some of them will push the boundaries. Some will falsify certification. there may be some who, like Harold Shipman, will develop a taste for killing and they will be very difficult to detect.But many will simply be too busy, too pressured and facing too many demands to make the kind of cool, comprehensive, objective assessments that this kind of law requires. And very few of them will really know the patients or their families.
We have seen this already with abortion. We began with a very strict law which allowed it only in limited circumstances. now there are 200,000 cases a year. Most of them fall outside the boundaries of the law. [19] There is illegal pre-signingof forms, abortion for sex selection, abortion on demand for spurious mental health reasons, and only one conviction for illegal abortion in 45 years.
Society is reluctant to touch and question doctors. the police are reluctant to investigate. The DPP hesitates to prosecute. The courts are unwilling to convict. parliament turns a blind eye. It is simply not safe to give doctors this sort of powerbecause some will abuse it, as they have in other countries, and it will be very difficult to stop them.
It's far better not to go there at all.
Dangerous and unnecessary
The legalisation of assisted suicide and/or euthanasia is dangerous — but it is also unnecessary because requests for euthanasia or assisted suicide are extremely rare when people's physical, social, psychological and spiritual needs are adequately met. this is a powerful argument for making the very best palliative care accessible to all who need it. The overwhelming majority of people with terminal illnesses, even those with illnesses like motor neurone disease, want 'assisted living' not 'assisted suicide'.The best system available is that which we have currently — a law carrying a blanket prohibition on both assisted suicide and euthanasia but with discretion given to both prosecutors and judges to temper justice with mercy in hard cases — thecurrent law has both a stern face and a kind heart.
In other words the penalties that it holds in reserve act as a powerful deterrent to exploitation and abuse of vulnerable people. And it works — there are very few cases observed (just 15—20 per year make the trip to Switzerland) but also very few prosecutions.
Let's keep it that way.
Peter Saunders is CMF Chief Executive
1. Suicide Act 1961 bit.ly/2u64nje 2. Saunders p. defeat of the Marris Assisted Dying Bill. Christian MedicalComment 12 September 2015 bit.ly/1O84Q91
3. Saunders p. the Conway case — a change in the law to allow assisted suicideis dangerous and unnecessary. Christian Medical Comment 16 July 2017bit.ly/2tYtggI
4. Almost 300 assisted suicides in Switzerland per year. Telegraph 27 March2012 bit.ly/2wbtyyD
5. Campbell d. Suicide clinic challenged over patients who could have lived'for decades'. The Guardian 21 June 2009 bit.ly/2tbMAVf
6. Williams A. 300 urns with human ashes dumped in lake Zurich near Dignitasclinic. Daily Telegraph 27 April 2010 bit.ly/2tc0zdA
7. Don't make Oregon's mistake. Care Not Killing; 2015 bit.ly/1Nh8eOQ
8. Oregon death with dignity Act. data summary 2016 bit.ly/2u6FKTL
9. regional Euthanasia review committees. Annual report 2014. RERC; 2014:14bit.ly/2wKnuka
10. End-of-life practices in the Netherlands under the Euthanasia Act.N Engl J Med 2007;356:1957-1965 bit.ly/2tCkVvY
11. Verhagen E, Sauer p. the Groningen protocol—Euthanasia in Severely Illnewborns. N Engl J Med 2005;352(10):959-962 bit.ly/2veTGt8
12. Euthanasia is out of control in Belgium — new ten year review.Care Not Killing 14 december 2012 bit.ly/1teGqjv
13. 6.3% of Belgian deaths now E&AS. Care Not Killing 24 March 2015bit.ly/1WF6mCg
14. Belgian twins' euthanasia, and what it represents. Care Not Killing30 January 2013 bit.ly/1wanbIK
15. Belgian helped to die after three sex change operations. BBC 2 October 2013bbc.in/1v9nXkT
16. cook M. Another speed bump for Belgian euthanasia. Bioedge 8 February2013 bit.ly/1tBtmV2
17. Saunders p. Belgium becomes world leader in organ removal after euthanasia. Christian Medical Comment 16 March 2013 bit.ly/2u6NNA4
18. Caldwell S. Warning to Britain as almost half of Belgium's euthanasia nursesadmit to killing without consent. Daily Mail 10 June 2010 dailym.ai/1VNKuCC
19. Saunders p. Why 98% of abortions in Britain are now illegal and what itmeans for doctors. Christian Medical Comment 10 December 2011bit.ly/1t5YIV2
