At the time of writing, the UK’s Terminally Ill Adults (End of Life) Bill is in the House of Lords’ committee stage, having won the approval of the Commons but still struggling to get past the scrutiny of the Lords. 

Centre Write reached out to one of the Bill’s most formidable supporters, Andrew Copson OBE, to discuss the principle behind the Bill with one of its most gifted opponents, Dan Hitchens.

Would legalised assisted dying devalue the lives of the sick, the old and the suffering?

Andrew Copson: NO

Medical science has extended our lives decades beyond the dreams of our ancestors. But our lives still end. If we are lucky, they may end suddenly with a minimum of suffering. But in our society, it is more likely that the process of dying will be more drawn out. In some cases, it will be accompanied by such intractable suffering — suffering that cannot be palliated — that it is easy to see how it might become unbearable.

Under these circumstances, the choice to end your life is rational and should be respected as a fundamental aspect of wider personal choice.

In a good and free society, we should place a high premium on the right of each person to live according to their lights. Dying is part of life and our legal and policy approaches to it should be shaped by the same respect for individual choice as any other aspect of life. Because every human life is of unique value, when deciding whether medical assistance to die should be provided, of course we should make sure that the choice has been made freely and authentically and that it is a reasonably settled decision. But, under such circumstances, to give the dignity of choice to those suffering at the end of life is not to devalue them, but the opposite. By respecting their choices, we give them the same agency that we should all have in our life choices.

This equates not to a devaluation but profound care and respect. It affirms that the sick and the elderly remain the authors of their own stories, retaining the same agency and value as any other person.

Dan Hitchens: YES

One striking thing about the current legislation is just how much alarm it has caused — precisely among the people who devote their lives to the sick, the old and the suffering.

The British Geriatrics Society oppose the Bill, saying it presents an “unacceptable” risk and could result in systemic pressure to use assisted suicide to drive down the health and social care bill; concerns echoed by Age UK.

The Royal College of Physicians says “vulnerable patients … are not adequately protected.”

The Royal College of Psychiatrists “cannot support” a piece of legislation which seems to undermine the psychiatrist’s duty of care.

Palliative care doctors, as a rule, both dispute the way death is presented by advocates of law change, and believe that the proposals contradict their vocation.

These objections are complex and various, but one point lies behind them. Under current circumstances, if someone says they want to be handed lethal drugs to end their own life, society responds by encouraging them to stay alive. Yet, under this Bill, as long as you meet some — pretty broad — medical criteria, you will be facilitated, by the whole weight of the healthcare system, to take your own life.

It creates a kind of two-tier society — those whose lives we protect, and those we consider not worth protecting. International experience suggests which people will end up on a pathway towards death: those who cannot pay for adequate care, who are depressed, who have been failed by public services; the poor, the disabled, the lonely.

Andrew refers to people being the authors of their own lives, but for many people that authorship is already compromised. The question is whether we help them to regain it or hurry them towards an ultimate ‘solution.’

Andrew: I do not agree that the current situation is that “if someone says they want to be handed lethal drugs to end their own life, society responds by encouraging them to stay alive.” People in England and Wales can travel to Switzerland to end their lives, and Crown Prosecution Service guidelines make it clear that relatives should not normally be prosecuted for helping them. NHS guidelines mean that health practitioners must facilitate dying patients who wish to end their treatment and hasten their deaths. They must also facilitate patients who decide to starve or dehydrate themselves to death.

If “society” is currently saying anything, then it is saying something like: “You can kill yourself at the extreme end of life. We will let you do so and facilitate you, but only begrudgingly. We won’t make it easy and you have to suffer along the way.” Under the Bill being considered in Westminster, people with a terminal diagnosis of six months or less will be able to receive assistance to die comfortably at a time of their choosing.

The choice before us is between the status quo and that potential increase in compassion and autonomy.

When it comes to citing professional opinions, we can all find different authorities to argue from.

All the professions Dan cites are divided rather than unified in opposition. Since the last vote in 2015, the biggest change has been that all of the Royal Colleges and the BMA have dropped their opposition to assisted dying. Age UK and the Royal College of Physicians are neutral, the British Geriatric Society’s survey shows a huge split in views and the Royal College of Psychiatrists has been heavily criticised for its response to the Bill. Surveys of nurses and surgeons show they are supportive.

Still, I do not think invoking these authorities is particularly helpful in a debate which is about a whole new paradigm for us, so let me address Dan’s specific point about those who are “poor, disabled, or lonely.”

We should strain every sinew to empower and improve the lives of those who are “poor, disabled, or lonely.” I would love it if national policies were directed towards those ends and happily pay the taxes required to enable that. But I do not think the fact that it is not currently the case means that we cannot do other things conducive to expanding human freedom and happiness.

Indeed, it is wrong to say that the 31 jurisdictions in which assisted dying is already legal have led to worse outcomes for people in these positions, as Dan would imply. International evidence shows that palliative care improves, that there is no heightened risk to these vulnerable groups and that, in practice, the non-disabled, wealthier and more educated are far more likely to have an assisted death.

One of the difficulties of discussing this question is to know whether we are talking in principle or about the specific Bill currently proposed in Westminster. But, if it is the latter, then it is quite wrong of Dan to say that the criteria are “pretty broad.” In fact, they are the narrowest in the world. Eligibility is limited to mentally capable adults with a terminal illness and a prognosis of six months or less and includes multiple layers of safeguarding — more than anywhere else in the world, with the possible exception of Spain.

Dan: I’m grateful for this vigorous response, but I don’t think it grasps my central point.

When I say society discourages suicide, I mean things like the Samaritans, local authority suicide prevention plans, NICE guidelines, foot patrols on Clifton Suspension Bridge and Beachy Head, the protection of even the worst criminals in prison, the instinct to rally round loved ones who want to end it all. This is a strong consensus, and the possible-semi-exceptions Andrew describes hardly annul it. Last year, only 37 Brits, from a population of 69.3 million, went to Dignitas.

As Rose Lyddon has observed in an astonishing memoir of mental illness, “The only defence I’ve found against chronic suicidality is to make it unthinkable, never an option, no matter how bad things get. This is my main objection to assisted suicide becoming law.”

Suddenly, we accept that some suicides are to be welcomed, encouraged and facilitated with the gigantic institutional force of the NHS — whose founding principles would be redefined; and that one role of doctors, nurses, psychiatrists, social workers, KCs, hospices and care homes is to enable access to unlicensed drugs whose sole purpose is to kill. Andrew calls it a whole new paradigm. Correct.

However much the Bill’s proponents insist they want to limit its terms, they struggle to give a principled reason for welcoming some suicides and discouraging others. Indeed, the Bill’s Commons sponsor, Kim Leadbeater, already acknowledges that assisted suicide could be deployed for the sole motive of relieving your family’s emotional or financial burden. Lord Falconer, the Lords sponsor, says “the reason” might be “your circumstances — for example, because you are poor.”

Around the world, people receive assisted death for reasons like feeling a burden; long waiting lists for care; a lack of family support. All these motives would be comfortably within the Leadbeater remit, as long as you have a — generally unreliable — six-month prognosis.

Andrew offers three pieces of reassuring evidence. One is a rash generalisation in the Health and Social Care Committee’s report — a generalisation which has been comprehensively taken apart by Professor David Jones in a 23-page study of what assisted suicide really does to palliative care.

Then there are two studies, one from 2016 and one from 2007, which say there is no disproportionate impact on the vulnerable.

On closer inspection, the 2016 study seems to base its assertions, firstly on Oregon — where, famously, the healthcare system is so tangled that the wealthy, educated and determined tend to be most of the people who can get an assisted death.

On the 2007 study, its most relevant finding is that, a quarter of a century ago, Dutch people using a more safeguarded law were as likely to be euthanised if they were in a poor postcode as a wealthy one.

Although many organisations are neutral on the general principle, not one — leaving aside campaign groups like Dignity in Dying and the Assisted Dying Coalition — is prepared to assert that the bill is safe. By contrast — and as well as the medical bodies I mentioned before — domestic abuse experts, the government’s suicide prevention adviser, eating disorder charities and a coalition of 350 disabled people’s organisations led by Disability Rights UK all say the same thing about the legislation: it’s Pandora’s box.

Andrew: Dan thinks that the availability of assisted dying will redefine our paradigm in a harmful way. I believe it will redefine it in a beneficent way that will give dying people control of their own destiny.

Judging by his last response, his fear stems from a belief that we must force people to continue living even when they face nothing but suffering, for fear that any relief of their suffering might encourage suicide elsewhere. Even if this were true — and I don’t think it is — I don’t believe that it would be an argument to deny assistance to those who want it.

We are all currently free to take active steps to bring our lives to an end. In healthcare specifically, we are facilitated to kill ourselves by refusing food and drink, and we are free to kill ourselves by refusing life-sustaining treatment.

I return to my original point that allowing assisted dying for the terminally ill would be a token of a greater valuation of their lives by wider society, not a devaluation. It will lead to an increase in dying people’s agency and freedom and a reduction in human suffering, a desire to alleviate which is itself an expression of love and respect for the old and dying people who have chosen that path.

Dan points to the relatively small number of Britons who travel to Dignitas as evidence that demand is limited. But that overlooks what ‘availability’ actually means in practice.

For many people who are seriously ill, travel is physically punishing or impossible, and the costs are prohibitive. The logistical and emotional burden is immense and, crucially, it remains against the law, exposing family and friends to the fear of jail cells, seized passports and police investigations, even if prosecutions are rare.

If we are discussing scale, we should also be honest about the suffering that already exists.

Twenty people a day die in some form of suffering that cannot be relieved by palliative care. The UK Government’s impact report estimates that 1,000 to 5,000 people a year will eventually use the service. Opponents treat that as a warning. I see it as a measure of need. Thousands of terminally ill people want this option and are currently denied it.

Dan criticises the Health and Social Care Committee’s work as making a “rash generalisation” about palliative care improving in jurisdictions that introduce assisted dying. Despite the majority of the Committee being opposed, their report was not a casual remark; it rested on extensive evidence-gathering, including 63,000 responses from the public, over 300 submissions of written evidence, two closed-door roundtable discussions and five oral evidence sessions. Their report builds upon a report by Australia’s neutral palliative care sector, which similarly found that, “If anything, in jurisdictions where assisted dying is available, the palliative care sector has further advanced.” I deny that 23-page essay from a Catholic bioethical centre compares to this comprehensive study.

The overwhelming public support for this freedom is long-standing and unyielding. It does not evaporate when faced with a media onslaught about the topic, nor does it change when examined in extraordinary depth by a citizens’ jury made up of the public. The public, including disabled people, supports this Bill.

A back-and-forth about studies and statistics won’t bring back Dirk Vervoots, who died with blue police lights illuminating his deathbed and police officers outside his door, only because he expressed a clear and settled wish to die.

It won’t provide comfort to Charlie Wardle, whose dad couldn’t afford Dignitas, but he still wanted to choose a gentle end to his terminal cancer.

It won’t eliminate the anguish that Sue Lawford faced while spending 16 hours in a police cell for accompanying a woman to Dignitas.

Real people’s real suffering arises from the present situation, and this is really what devalues lives.

As Sir Nicholas Mostyn said, you could hardly make up a law as malign as the current one. A law that moves away from our paternalistic ‘doctor knows best’ approach to the end of life, replacing it with a safeguarded, regulated free choice, will always be the most compassionate approach possible — and the most respectful.

Dan: Well, we’ve managed something unusual: a serious, evidence-based debate on assisted suicide which has been more about statistics than soundbites. I will limit my quibbles with Andrew’s footnotes, resist the urge to correct a couple of misrepresentations and start with where we agree.

I don’t deny that there will always be at least some people who want an assisted death to relieve their suffering. Andrew presumably doesn’t dispute — and hasn’t in this exchange — that a law like this will wreak at least some collateral damage in the lives of the unfortunate. Which of these considerations, then, should be decisive?

This month Lord Falconer confirmed again that some people will choose death, under the Bill he is sponsoring, because “there isn’t enough money to go around.” This in a world where care homes charge an average of £949 a week. Another reason for assisted death, he says, will be “the absence of palliative care.” That’s good news for whichever company gets the assisted suicide outsourcing contract, since 100,000 people a year die without the end-of-life care they need, two-thirds of the population fear palliative care will indeed be absent in their last months and hospices everywhere are making emergency cuts.

Poverty, according to Falconer, will be another source of demand. One wonders if he knows that charities increasingly see elderly people who have become ill “from being forced to sleep in their car for months, having to sleep on camp beds in emergency shelters and seeking homelessness support even while suffering illnesses such as cancer;” that the Children’s Commissioner has found kids increasingly complain about “not having enough water to shower, rats biting through their walls, and mouldy bedrooms;” that doctors say A&E wards resemble “medieval” disaster zones, with untreated cancers bursting through people’s skin and patients self-harming in order to stay in hospital. The cost-of-living crisis is the biggest issue in politics. It will probably keep getting worse. The cost of dying may soon become comparatively cheap.

All this, of course, in an NHS which, from the Liverpool Care Pathway to the DNR scandal, has an unfortunate habit of inadvertently building systems which accelerate death. And in a country defined by not wanting to be a bother.

The impact assessment for the Bill predicted 5,000 deaths a year based on an inexplicable methodology. It could be three times that within a few years, and rising fast.

This is not, for the most part, because of physical pain. As Linda Ganzini, a leading academic expert on Oregon’s assisted dying law, has observed: “Everybody thought this was going to be about pain. It turns out pain is kind of irrelevant.”

Samuel Johnson, the greatest of Tories, said the true test of civilisation is a decent provision for the poor. For some people, the prospect of the state shepherding dozens or hundreds or thousands of its most vulnerable citizens towards a lethal drug overdose is simply unjustifiable, whatever the benefits. But since Andrew presses the benefits, allow me two last numerical wrangles.

First, he claims that “Twenty people a day die in some form of suffering that cannot be relieved by palliative care.” Katherine Sleeman, professor of palliative care at KCL, has shown, this is a dud statistic. It is a vast extrapolation from a wholly unrepresentative population and was not based on “suffering that cannot be relieved.”

Second, Andrew cites two studies concluding that assisted dying benefits palliative care. But that evidence is outdated, and mostly derives from countries where governments introducing assisted dying also made generous funding commitments for palliative care.

More recent evidence is that, between 2012 and 2019, European countries without legalised assisted dying were three times better at improving palliative care than those where it is legalised; and that, in the same period, hospital palliative care increased three times more in US states without legal assisted dying.

This legislation will create such a perilous legal environment for hospices, and will make so many palliative care doctors reconsider their position, that two former Presidents of the Association for Palliative Medicine say the bill could “destroy the hospice sector.” We began by wanting to prevent suffering at the end of life. But what is the best means of such prevention? The pioneering British institution of palliative care. And what is the biggest threat to palliative care? This indescribably reckless Bill.

The exchange took place over email between the eighth of December and the twenty-eighth of January.