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.

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“It feels like a betrayal”: EU citizens react to Jeremy Corbyn’s migration stance

How do Labour-supporting European migrants in the UK feel about their leader wanting to control EU migration?

“This feels a bit different from the man I had campaigned for,” says Eva Blum-Dumontet. “It felt like he was on the side of the group that matters, regardless of whether they were actually going to make him gain voters or not. He was on the side of what seemed right.”

Blum-Dumontet is a 26-year-old EU citizen who has been in the UK for five years. She works as a researcher for a charity and lives in north-east London’s Walthamstow, where she is the local Labour party’s women’s officer.

She joined Labour just before the 2015 general election, and campaigned for Jeremy Corbyn during his leadership bid that year. She spent one and a half months that summer involved in his campaign, either phone banking at its headquarters at the Unite union building, or at campaign events, every other evening.

“When he suddenly rose out of nowhere, that was a really inspiring moment,” she recalls. “They were really keen on involving people who had recently arrived, which was good.”

“Aside from the EU, I share all of his views”

Blum-Dumontet voted for Corbyn in both of Labour’s leadership elections, and she joined Momentum as soon as it was set up following Corbyn winning the first one in 2015. But she left the group two months ago.

She is one of the roughly three million EU citizens living in the UK today whose fate is precarious following the EU referendum result. And she doesn’t feel Corbyn is sticking up for her interests.

Over the weekend, the Labour leader gave an interview that has upset some Labour-supporting EU migrants like her.

Corbyn reiterated his opposition to staying in the single market – a longstanding left-wing stance against free market dominance. He added that his immigration policy “would be a managed thing on the basis of the work required” rather than free movement, and, in condemning agencies exploiting migrant workers, he said:

“What there wouldn’t be is wholesale importation of underpaid workers from central Europe in order to destroy conditions, particularly in the construction industry. You prevent agencies recruiting wholescale workforces like that; you advertise for jobs in the locality first.”

Corbyn also emphasised that Labour would guarantee the rights of EU nationals to stay in Britain – including the right of family reunion – and that there would still be Europeans working here and vice versa. But, for some in his party who hail from Europe, the damage was done.

“I feel like he’s now trying to signal more and more that he’s not on all sides, he’s on the side of people who are just scared of migrants,” says Blum-Dumantet, who will nevertheless stay in the party to try and change the policy. “The idea that he is willing to engage in this whole dog-whistling immigration fear feeling is a bit disturbing.”

She stresses that, “aside from the EU, I share all of his views”, but adds:

“I feel like he’s chosen his socialist utopia – and I don’t mean that as a bad thing; I’m a socialist as well – over the reality of the concrete lives of three million people. For us, this is not about some abstract ideal, it’s about our lives, whether we can get jobs here, whether we can stay here. And for the sake of his ideal, he’s sacrificing that. That does feel like a betrayal.”

***

Other EU migrants who initially supported Corbyn also feel let down. Sabrina Huck, the London representative of Labour’s youth wing Young Labour, moved here from Germany in February 2014.

Having joined the party that year, she voted for Corbyn in the first leadership election, “particularly because of things like being an internationalist, talking about migrant solidarity”.

Huck, 26, who lives in south London and works in public affairs, began to change her mind about him she discovered his Eurosceptic views. “It’s kind of my fault because I didn’t really do the research properly on him, I guess!” she laughs.

“I understand the argument that we have put downward wage pressure on some jobs”

Now, she feels “disappointed” in Corbyn’s comments about “wholesale importation” of workers. “The way he articulates himself – it doesn’t sound like what I wanted to hear from a Labour leader, particularly somebody who’s been a proud internationalist, proud migrant rights campaigner,” she tells me.

“I think the way he was making his point about wages was laying the blame way too much with workers and not with the bosses, basically.”

Huck notes that Corbyn is against the single market because of his socialist view of the EU as a “capitalist club”, rather than concern about borders. But she feels he’s using “the immigration argument” to sound mainstream:

“I feel like he’s using it as an opportunity to further his own ideological goal of leaving the single market by tying that to an argument that goes down well with the Leave-voting public.”

***

However, other Labour-leaning EU migrants I speak to do not feel Corbyn’s genuine motive is to bring immigration down – and are more understanding of his comments.

“I appreciate and understand the argument that we have put downward wage pressure on some – particularly blue collar or poorer paid – jobs, that is the nature of mass migration,” says a 29-year-old Czech who works for the government (so wishes not to be named), and has lived here since 2014. She believes his comments were made to “appeal to the hard left and Ukip types”, and has left the Labour party. But she adds:

“I can understand how communities suffering through a decade of stagnant wage growth and austerity are looking for a scapegoat, easily found in the form of migrants – particularly in a country where minimum wage and labour protections are so weak legislatively, and so poorly enforced.”

She also is sceptical that a “mass deportation” of EU migrants from Britain is likely to happen. “The optics are too bad, at a minimum,” she says. “It would look too much like the 1930s. What would the government do? Put us all on boats back to Europe?”

“I kind of shrugged off those comments and they didn’t bother me massively”

“I think they [Labour] are feeling their way around the issue [of Brexit] and are listening for public sentiment,” says Agnes Pinteaux, a Hungarian-born 48-year-old who moved to Britain in 1998. “But reconciling their hardcore Brexit support, those who just hate immigrants, those who want ‘sovereignty’, and those who want Brexit ditched altogether is going to be impossible.”

“I think the debate about the ethics of free movement of labour is a legitimate one, but it has to be rooted in human rights and dignity,” says Anna Chowrow, a 29-year-old third sector financial manager who moved from Poland to Scotland in 2007, adding:

“I was thrilled when Jeremy Corbyn was first elected Labour leader, and I have admiration for his principled approach. [But] I am in disbelief that these comments – akin to ‘British jobs for British workers’ – were made by him. The dehumanising language of ‘importation’ and ‘destruction’ is beyond disappointing.”

***

Finding EU citizens in Britain who are entirely sympathetic to Corbyn’s comments is difficult. Forthcoming defenders of his stance are hard to come by, suggesting that it’s a minority view among Europeans living in Britain. But there are some who continue to back him.

“I like Jeremy Corbyn’s authenticity. He comes across as genuine and honest, and I agree with most of his ideas. Contrary to the majority of politicians, he’s actually not afraid of coming across as a human being,” says Teresa Ellhotka, 24, who moved to the UK from Austria in 2016 and works in PR.

“His ideas and visions are, in my opinion, still very progressive”

“I kind of shrugged off those comments and they didn’t bother me massively,” she says of Corbyn’s stance on EU migrants. “My mind about Jeremy Corbyn hasn’t changed drastically as his ideas and visions are, in my opinion, still very progressive and I admire that he is dedicated to change but in a human way, and doesn’t suggest fighting fire with fire – as many other politicians, and people, seem to do.”

Ellhotka admits to being “a little surprised, as I did not expect this stance from him at all”, but feels there has been “so much back-and-forth” on the issue that she’s stopped worrying about what politicians say.

“Nobody seems to know what exactly is going to happen anyway.” The only thing, perhaps, that all politicians – and their voters – can agree on.

Anoosh Chakelian is senior writer at the New Statesman.