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.

Getty
Show Hide image

The polls are bad, but Jeremy Corbyn’s office has a secret weapon

How a shake-up of the leadership team has steadied nerves at the top of Labour. 

If polling had existed back in 1906, Jeremy Corbyn quipped at one recent strategy meeting, the Labour Party would never have got started.

As far as Labour’s direction is concerned, it is that meeting at four o’clock every Monday afternoon that matters. The people who attend it regularly are the Labour leader, his aides, the shadow home secretary, Diane Abbott, and the shadow chancellor, John McDonnell, as well as the party’s election co-ordinator, and their respective aides.

In recent weeks, the meetings have been stormy affairs, and not only because the numbers from the party’s own pollsters, BMG Research, mirror the uniformly bleak picture from the public polls. There is also concern over Karie Murphy, Corbyn’s office manager. Murphy is highly rated by Corbyn for having brought increased intensity and efficiency to the leader’s office. Corbyn often struggles to deliver bad news in person and appreciates that Murphy will intervene on his behalf.

Her intensity is not uniformly welcomed. “She could start a fight with her own reflection,” in the wry words of one friend. An argument with Jon Trickett – the Hemsworth MP whose unusual career trajectory took him from being a parliamentary aide to Peter Mandelson to the inner sanctum of Ed Miliband’s leadership and finally to the role of election co-ordinator for Corbyn – led to Trickett going on a two-week strike, recusing himself from vital meetings and avoiding any contact with Murphy.

That row eventually led to Trickett being stripped of his role and banished from the Monday meeting. Murphy had a similar turf war with the campaigns director, Simon Fletcher, which culminated in Fletcher resigning on 17 February. In a letter to staffers, he called on the party to “keep the promise” of Corbyn’s first leadership bid, a period when Fletcher was central and Murphy had yet to start working for the Labour leader.

All of which, in better political weather, would simply be part of the back-and-forth of office politics. However, set against the backdrop of unease about by-elections in Stoke-on-Trent Central and Copeland, and a series of unhelpful leaks, it adds to a sense of vulnerability around the leadership. One loyalist shadow cabinet minister calls it “the most dangerous time” for Corbyn since he was first elected leader.

Why the danger? Contrary to popular myth, the backbone of Jeremy Corbyn’s successive landslide victories was not a hard-pressed twentysomething, struggling to find a fixed job or to get a foot on the housing ladder. The shock troops of Corbynism, at least as far as the internal battle in the Labour Party went, were baby boomers. Many of them were either working in, or on early retirement from, a charity or the public sector, deeply concerned about the rightward drift of British politics and worried about the next generation.

Corbyn’s decision to whip Labour MPs in support of triggering Article 50 – the process whereby Britain will begin its exit from the European Union – was, in their eyes, a double heresy. The vote signalled acceptance that the forces of the Eurosceptic right had won on 23 June, and it conceded that visa-free travel, membership of the single market and freedom of movement are over.

None of this is automatically great news for Corbyn’s internal critics – not least because the vote on Article 50 is rare in being an issue that unites Corbyn with most Labour MPs. Yet it adds to the sense that his leadership has passed its best-before date.

Adding to the general malaise is a series of unhelpful leaks. There was a story in the Sunday Times on 12 February claiming that the leadership was road-testing possible replacements for Corbyn, and on 20 February the Mirror claimed that the Labour leadership had commissioned a poll to find out whether or not the leader should quit his post. These stories are hotly denied by the leader’s office. Some in Corbyn’s inner circle believe they are the work of Trickett, embittered at his demotion.

It is true that Corbyn is not enjoying the job as much as he once did. However, if the conversation shifts from the minutiae of Brexit to his natural terrain of the NHS and the continuing consequences of government cuts on education and the prisons service, he could quickly find himself relishing the role once more.

Corbyn retains two powerful cards. His newly energised office, under Karie Murphy, is one. Although her brisk approach has generated some public rows, the feeling in the leader’s office is that a chief of staff was needed, and Murphy has assumed that role. The media team has also grown sharper with the addition of David Prescott (son of John), Matt Zarb-Cousin and the former Momentum spokesman James Schneider.

Corbyn’s second asset is more unexpected. His rivals inside the party now fear rather than relish an immediate end to his leadership. A former shadow cabinet member splits his supporters into two groups: “idealists and ideologues – the first we can inspire and win over, the second have to be got rid of”. In their view, the idealists have not yet moved away from Corbyn enough to guarantee victory; the ideologues, for their part, will slink off as Corbyn puts the demands of his office above their interests, as he did over Article 50.

Although self-defeating panic has never been a rare commodity in the Labour Party, the settled view of Labour MPs is that their leader must be given time and space rather than hustled out of the door. There is an awareness, too, that MPs who are united in opposition to Corbyn are divided over many other issues.

So, while the inner circle’s Monday meetings might be fraught, and Labour’s current polling would have given Keir Hardie pause, Jeremy Corbyn is safe. 

Stephen Bush is special correspondent at the New Statesman. His daily briefing, Morning Call, provides a quick and essential guide to British politics.

This article first appeared in the 24 February 2017 issue of the New Statesman, The world after Brexit