Any GP can tell “good death” stories. The patient is free from distressing symptoms, often because of effective palliative treatment. Then there’s “leave-taking”: the opportunity to have said important things to important people; and, as death approaches, the presence of those most loved.
Again and again, “good death” stories feature humbling details: the person lived long enough to see his daughter married, or her son return from Australia. Beyond mere timing, there is acceptance – on the part of patient, family, friends, health-care professionals – that this is the natural end of life. With these deaths, perhaps paradoxically, the dying person experiences a measure of control. A good death is one with dignity.
There are also plenty of “bad death” stories. Too often, doctors conspire with denial, pressing on with active treatment long past the point where the focus of care should change. Acceptance may come too late or not at all, and so opportunities for leave-taking be lost. Then there is the unpalatable fact that, even with the best palliative care, it can sometimes be impossible fully to relieve suffering. I’ve had relatives plead with me to hasten their loved one’s end, pointing out (accurately) that we wouldn’t allow an animal to go on that way. With these deaths, control and dignity have been lost, and all those involved are traumatised.
The defeat of the Assisted Dying Bill in the Commons on 11 September represented a lost chance to transform up to 1,500 bad deaths into good ones each year. That is the estimate of how many terminally ill patients would take up the option to determine the timing and manner of their passing, based on experience in Oregon, where assisted dying has been legal for twenty years.
The unwillingness of British politicians to legislate similarly – at odds with public opinion – stemmed from three broad concerns. For some, legalising suicide, even in the final days of life, was a Rubicon that should not be crossed. The present situation, in which the Crown Prosecution Service exercises discretion to ignore compassionate relatives who help a terminally ill patient to end his or her own life, is surely far worse. It leaves distressed patients and their families at the whim of the law, with no clear criteria for what constitutes “allowable” circumstances in which to assist a loved one’s suicide.
Another concern was the change in the role of the doctor and the risk that this might undermine trust. The bill provided for conscientious objection, so no professional would have been compelled to participate. Many doctors would have welcomed the ability to support eligible people to achieve a good death in this way, and the strong, trust-based relationship we share with many of our patients is precisely the environment in which to discuss such options. Importantly, our role would have been limited to prescribing; only the patient would be allowed to administer life-ending medication.
The biggest objections centred on the prospect of vulnerable people coming to feel pressured to choose assisted dying because of a sense of being a burden. The bill was girded with safeguards to counter this. There is, however, a salutary example of “legislative drift” in recent times. Whatever one thinks of abortion on demand – routine now up to 12 weeks’ gestation – this was never the intention of the authors of the Abortion Act 1967, under which it is provided. The safeguards in the original legislation have become less stringently observed as the norms of society have changed.
Although the bill was defeated, the debate it stimulated should enhance a growing appreciation among doctors and patients alike of the benefit of anticipating and planning care for the process of dying. Open discussion is the only way to break the conspiracy of denial that still adversely affects too many who are terminally ill. This may transform even greater numbers of “unassisted” deaths, facilitating acceptance, leave-taking and optimisation of palliative care.
This article appears in the 16 Sep 2015 issue of the New Statesman, Corbyn's Civil War