Tony Nicklinson and a doctor's take on assisted dying

A GP lays out his reservations about the potential legalisation of euthanasia

It would take the proverbial heart of stone not to feel for Tony Nicklinson. Paralysed from the neck down after a stroke, the father of two is fighting a case in the High Court to argue that a doctor should be allowed lawfully to end his life. He has described his life since the stroke as "dull, miserable, demeaning, undignified and intolerable" (he communicates using a computer that converts his eye movements into speech).

The subject of assisted dying has been played out many times in the media. But it has, over the years, become a subject only commented on by those who want the right to die, or the Great and Good in the House of Lords and other august institutions. I feel there’s a voice that’s conspicuous by its absence: that of those at the coal face upon whom it would be incumbent to carry out our wishes should we decide we deserve the right to die. So I emailed Dr Nick Ramscar, a GP working in the South of England, and asked him his opinion.

Dear Alan,

The debate around and assisted dying is one that’s relevant to everybody. None of us come to this debate tabula rasa. We all bring the baggage of our personal beliefs regarding the likelihood of an afterlife. Our views are coloured, sometimes overwhelmingly so, by any deaths we may have witnessed, and the comfort or otherwise that accompanied them. We perceive, with varying degrees of clarity, what our own attitude will be when we follow Iris Murdoch and sail into the dark. We lie along a spectrum – some, like John Donne, are so buoyed up by faith that they don’t fear dying, agreeing that “poppy or charms can make us sleep, as well and better than [death’s] stroke”. Others might join Philip Larkin in staring in red-eyed terror at the dawn, a sleepless night having brought them one day closer to oblivion. I suspect most of us are somewhere in between, and that our exact position is changeable.

Assisted dying is also called physician-assisted suicide, and its legalisation is the declared aim of groups such as Dignity in Dying that see a natural extension from the choice we enjoy in other areas of our lives to the timing of our ends. Their website provides a clear definition of assisted dying. It is: “where a doctor prescribes a life-ending dose of medication to a mentally competent, terminally ill adult at their request, and the patient then chooses to administer the medication themselves”. I’d like to discuss the five things I find alarming within that short statement.

Firstly, consider the suggestion that a doctor should write an order for the lethal drugs. I am in the final stages of the training for general practice, an area that would be hugely affected by any change to legalise assisted dying. The idea of writing a lethal prescription is something I struggle to reconcile with the motives that brought me to a medical career. Surveys of doctors’ attitudes have repeatedly shown that this is the majority view. Even if the prescription were to be made out by somebody else, a government agency perhaps, it is unrealistic to think this could be done in isolation from the mainstream medical care of the patient – and their relatives. The patient’s GP, and their specialists at the hospital, would be called on to at the very least confirm the diagnosis and likely prognosis. There would without doubt be cases where patients’ relatives asked the doctors whether they thought assisted dying was the right choice for the patient. We would become complicit, if only in failing to discourage it, even if a different signature was on the prescription.

An implicit assumption in the concept of assisted dying is that a prescription should be written by a doctor who knows the patient well. The death of a patient is something that affects doctors more deeply than I suspect many people know. To ask a physician to deliberately end the life of someone they may have known for decades is not a trivial thing, any more than it would be for any other person. The BMJ recently published a tragic letter from a Dutch doctor, profoundly affected by the times she had been involved in deliberately hastening death. An assumption that a detached attitude could be taken does not marry up with my own experience, nor can I imagine it would be any easier for any of the doctors I have worked alongside.

The second issue raised in this definition is that of mental competence. This is an incredibly complex concept glossed over with disquieting speed. Competence is not binary; an individual cannot be said to be either competent or not.  It’s possible to be competent to make decisions regarding some matters, but not others; a person might be able to decide matters for themselves in their own finances, but not to weigh up new and complex medical information. Nor is level of competence fixed – a person may gain or lose, as the stresses of their illness wax and wane. The introduction of the Mental Capacity Act went some way towards addressing this with its increased emphasis on making patients’ views known well in advance. Unfortunately, it’s not possible for a person to predict what situations they will find themselves in, nor how they will feel when they get there. In addition, it remains the case that it’s possible to put in place an advance refusal of certain procedures, commonly cardiopulmonary resuscitation, but it’s not possible to make a demand in advance for certain treatments – including lethal prescriptions.

Immediately following on from this thorny question of competence is an equally difficult phrase, “terminally ill”. The gradations of meaning concealed here are enormous. Firstly, it strikes me as presumptuous to suggest there is a possibility of legally defining when a patient’s suffering is enough to qualify. And why should those with non-fatal afflictions be excluded? For one person, sudden blindness might be an affliction that would make life unbearable, whilst another might find plenty to take pleasure in despite disseminated liver cancer. The second could be labelled terminally ill much more easily than the first, but can we really say whose pain is greater? I do not believe we can reliably enshrine in law a threshold or set of circumstances that would constitute unacceptable suffering. Additionally, this definition seems to exclude children. Where they are unable to decide on their own care, we ask the parents. Could any civilised society put a parent in the position of deciding whether their child should be killed?

The implication that doctors can say with certainty when a person is terminally ill is flattering to the profession, but unfortunately wrong. Any honest clinician will admit to occasions when they have been astonished by patients living long after it seemed that death was imminent. This has happened in my own practice and, most worryingly, on occasions when patients had been placed on the Liverpool Care Pathway (LCP). The LCP is an invaluable tool in terminal care, an acceptance that the focus of care has shifted from curative to palliative. The patient’s comfort is the top priority, and potentially distressing investigations or treatments are discarded. The LCP is as close as it is currently possible to get to a signed statement that the patient’s medical team believe life expectancy is measurable in days. These are exactly the patients who might be the most attractive candidates for assisted dying. Yet many doctors (myself included) have seen patients in this position rally, and subsequently be taken off this pathway of care. The LCP allows us reversibility. Prescribed death does not.

The fourth point is the idea that a prescription should only be made at the patient’s request. This is a separate issue from competence; let’s assume for the moment that our theoretical patient is competent in all areas of decision-making. This doesn’t mean we can safely assume that the request is the product of a long process of unhurried reflection. Almost every patient consultation contains varying degrees of hidden agenda, and doctors vary in their skill in uncovering this. Usually the consequences of this are not disastrous, but in this case they could be fatal. To anyone who doubts that such a momentous decision as requesting assisted dying could be made on a whim, I ask them to consider the emergency departments across the country full of overdose patients who “didn’t really mean it”.

Perhaps the most practically troublesome part of that short definition comes at the end. The patient retaining control and choosing the moment of death is of course central to the whole thesis of assisted dying. But on a practical level, is this aim manageable? Either the doctor must be on hand to physically provide the drugs at the exact moment of the patient’s choosing, or a prescription must be given that will allow the patient to collect their lethal medication, to keep at home and use when the moment seems right. The first option is unlikely; medicine is moving to shift patterns and the patient’s own trusted doctor may not be “on-call” at the critical moment. This means either that the patient would have to wait until their doctor became available, making a mockery of the whole aim of maximising choice, or a doctor who the patient may never have met before might have to visit out-of-hours. The second option, of leaving deadly poison in the patient’s house, is even less attractive, for obvious reasons.

I hope this message doesn’t sound unsympathetic to the strains that patients and their families face. My stance is one of cautious opposition – I am aware that no branch of medicine, including palliative care, can hope to be perfect. Even John Donne, who saw death as disarmed by the resurrection of Christ, also knew that this did not make it free of consequence. I find much more to admire in his recognition that we are all irreversibly interconnected, and that “each man’s death diminishes” those around him. None of us lives in isolation, and none of us can die this way either. A natural death, with the patient properly supported, seems infinitely preferable to the uncertainties and danger of medically sanctioned self-destruction.

Yours,
Nick

***

Dear Nick,

Thank you for taking the time to respond to me. Allow me to peel the shroud away a little. A while ago I told an elderly relative, now in hospital, that I was getting married. She was absolutely delighted. A few minutes later she asked who I was. She is, at the moment, quite happy with life, if occasionally confused. But I worry that one day this won’t be the case. I agree with much of what you say. But I’m biased. As you point out, so are you, and so is everyone else. Nevertheless, your email gives rise to a number of questions.

1. There seems to be a sizeable minority of people using the Dignitas service at present. Doesn’t that mean that we essentially have assisted dying in Britain anyway – and it isn’t particularly well regulated?

2. Much of your argument centres on how hard a change in the law would make your job. Pouring myself a large glass of Devil’s Advocaat - how would you respond to campaigners saying: “We're not naive - we know doctors have an emotional bond with their patients, and isn't it just as hard for them to watch powerless while they suffer? Is it not, in fact, disingenuous not to mention that state of affairs?”

3. I wonder why choice should be denied on this when it’s given with other treatments. I understand you can have a Caesarean Section even if you’re advised otherwise. If patients are deemed competent to make calls on something this major, why not death?

4. Would you agree that there’s a difference between a suicide attempt and a protracted process? Having demonstrated the subjective nature of some of your work (e.g. diagnosing terminal illness), you've now cast yourself in the role of plain facilitator with no mention of the consultation you'd provide.

Yours, 
Alan

***

Dear Alan,

Sorry to hear about your relative, and of course personal involvement brings a new perspective. I have a very similar case unfolding in my own family at the moment.

To answer your questions:

1. In general terms, I’m not convinced by the argument that because people manoeuvre around the law, it should be revised to accommodate their actions. To give a specific parallel example in medicine, I am sometimes asked to prescribe medicines that are not available in this country because they are of dubious benefit or known to be harmful. If I am unwilling to provide a prescription for drug X because of this, I know that despite my advice some of my patients will buy it over the internet. That doesn’t incentivise me to provide what I believe to be an inappropriate treatment, and I don’t think it should influence any subsequent decision on licensing that treatment in this country.

2. I certainly don’t think we should avoid things because they are difficult, and I hope that’s not how my message comes across. Involvement in care of the dying can as you say be hard, but also profoundly rewarding. Through a willingness to develop in this area, the UK has become a world leader in palliative medicine - and for that reason doctors in this country are rarely, if ever, “powerless to help”. The phrase “there’s nothing more we can do” has no place in modern palliative medicine – or medicine generally.

3. This is an important misconception to clear up. A competent patient can refuse treatment, but cannot specifically demand any prescription or procedure. Ideally of course, doctors should present appropriate choices to their patients, so that a mutually acceptable plan can be agreed.

4. There’s some truth in this. Certainly I am sure that, should the law change, any process would have safeguards built in to try to identify factors such as coercion, dementia, and undiagnosed depression. But I am not convinced that these safety features could be made infallible. For that reason, even if the element of impulsivity were removed, there would still be life-ending decisions made on unsafe grounds. The duration of the decision process – a solitary desperate impulse or a legally imposed timetable – doesn’t alter that.

Yours,
Nick

***

Nick and I left our correspondence there – we’ll continue it in person at some point. To provide a summary of my opinions since this discussion would be to sell the issue short. There is no right and wrong, only varying weights of importance one can attribute to each argument. I hope readers found the discussion interesting.

The Dignitas clinic in Zurich, Switzerland. Photograph: Getty Images

Alan White's work has appeared in the Observer, Times, Private Eye, The National and the TLS. As John Heale, he is the author of One Blood: Inside Britain's Gang Culture.

Photo: Getty
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Lowering the voting age is the best way to protect the franchise we've fought so hard for

Empowering young people is the best way to renew civic and political engagement.

Too many believe that politics isn’t working for them. That those who make decisions are not acting in their interests. And too often, narrow interests win over the wider public interest. Our economy isn’t working either. It never will until we repair our fragile politics.

When I was leader of Oldham Council I recognised that to reform, it must open up. It needed to bring forward ideas and challenges from all those who are affected by decisions taken in their name.

We gave constitutional rights for the youth council to move motions and reports at our full council meeting. We opened up our meetings with live web-streaming and questions from all residents. And we embraced social media, combined with instant comments, which were shown in the chamber during debates.

It opened up democracy and gave councillors an insight into issues which affect young people. But two things stood out. The first was that many of these issues are the same ones which affect the wider public. But they are affected in different ways by decisions or the lack of action by government. Second, and most importantly, while we were engaging young people they had no say over who was making decisions on their behalf.

So of crucial importance to me is how we bolster democracy to weather the challenges it faces today and in the future. Recent events at home and abroad have convinced me of the importance of this. There are two separate approaches that parliament must take. Firstly, we must devolve more power from central government to local communities. And secondly, we must at all costs renew civic and political engagement here in the UK. I’ve come to believe that getting more and more young people engaged in politics is fundamental to realising this second point. And I see lowering the voting age as key to cementing this.

I hear the arguments against this loud and clear. Eighteen is the official age of independence. Eighteen is when someone forms their world view. And 18 is when reasoned, judgemental thought suddenly kicks in. On that basis, the years preceding that are presumably some kind of wilderness of rational thinking and opinion forming. Someone even tweeted at me this week to inform me that under-18s don’t know what they want for dinner, let alone how to vote.

Needless to say, I find all these points unconvincing and in some cases dismissive and patronising.

I speak with people even younger than 16 who have coherent views on politics, often a match for any adult. They even know what they want for dinner! And I am of the strong belief that empowering young people through a wider enfranchisement will speed up this development. Even better if votes at 16 is accompanied by compulsory political education in the preceding years.

So if your argument is that young people are too immature, that they lack political knowledge to be given the vote, or that they aren’t responsible enough – then I say to you, bring on lowering the voting age! As my argument is that empowering young people to vote will help overcome these challenges where they exist.

But where do other countries sit on lowering the voting age? Admittedly, among western democracies, the UK would be taking a bold step-forward. In Europe, it’s only Austria where all 16-year-olds can vote. There are some patchwork exceptions to this closer to home. For example, the voting age on the Isle of Man is 16. And this week we heard that the Welsh Assembly is considering lowering the voting age to 16 for local elections.

Outside of these scant examples, there is little precedent for change. However, we shouldn’t find ourselves cowed by this. Our past is littered with bold actions, proud speeches and even lives lost to win and defend the right to vote.

200 years ago on Tandle Hill in Royton hundreds of protestors, who had travelled from nearby mill towns like Oldham and Rochdale, gathered together. They were preparing to march on Peters Field in Manchester on a summer’s day in August 1819. What was at stake was a greater say in parliamentary decisions, at a time of famine and widespread poverty. Non-land-owning workers were entirely excluded from the franchise. By the end of the day, government cavalry had cut down 14 protesters, and injured hundreds more. In 1832 only men renting or owning valuable land were given the vote. And it wasn’t until 1918 that all men were included in the franchise.

This month we remember the 100-year anniversary of the Battle of Passchendaele. The sacrifices made during the First World War by our working-class men and boys, 250,000 of whom were under 18, was a catalyst for extending the vote to all men.

Next year we celebrate 100 years since the start of women’s suffrage. In Oldham, Annie Kenney and Emmeline Pankhurst fought tirelessly. They would both be arrested before seeing that privilege granted to only some women in 1918. Today it is sobering to think that women didn’t have the vote before 1918.

And it was only in 1970 that the voting age was lowered from 21 to 18, allowing teenagers to vote for the first time in the UK. Prevalent then were exactly the same arguments that stop 16- and 17-year-olds voting today.

While we recognise the fight of others, we fail in our duty if we believe the fight for democracy is settled.

So I draw inspiration from how the franchise has steadily grown throughout our history. And I reflect on the acts of courage, grit and determination that have won us that change. With the extension of the franchise have come the liberties, freedoms and values that make our society what it is today. It hasn’t happened of its own accord. Lives have been lost and bold steps have been taken for us to enjoy placing that cross alongside the candidate of our choosing.

This cannot be seen as a way to shift the political debate to young voters either. Many older voters, including many of my friends and family, feel that politics isn’t working for them either. Reducing the voting age isn’t the silver bullet to address that disconnect, but it is vital to strengthening connect between decision makers and those who pay taxes.

I welcome the debate on lowering the voting age. A debate about once again spreading the freedoms and responsibilities of our society to many more people. And I’ll match arguments against this every step of the way. Because I am clear in my mind that defending the franchise and extending the franchise are two sides of the same coin.

Jim McMahon is the Labour MP for Oldham West and Royton.

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