The terminal confusion of Dignity in Dying

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[/audioplayer]If you were around in the days when the US series M*A*S*H was a regular feature on British television, its sing-song theme is probably still lodged in your memory: ‘Suicide is painless/ It brings on many changes/ And I can take or leave it if I please’.

However catchy, it is broadly untrue. The human life force is stubborn, and it takes a visceral struggle to extinguish it. Suicide, as commonly practised by amateurs, is not painless: it is frequently agonising, complicated, botched and has ample potential to leave one still alive but with a cruel legacy of permanently damaged health to add to one’s existing woes.

Many of us nonetheless carry the very notion of suicide around in a pocket of our psyche as a brutal form of hidden comfort, like second world war spies with their little cyanide pills. I think of suicide, if I contemplate it at all, as something resembling that pill, to be deployed only for imagined circumstances in which ordinary life has become intolerable: a possible means of release from an outrageous extremity of suffering. Yet its practical difficulty remains an essential part of its nature, a necessary disincentive to nudge us back towards life.

It is, however, human nature to crave control where none seems available. That is why numerous people will back Lord Falconer’s Assisted Dying Bill, which will receive its second reading in the House of Lords on 18 July. It proposes that terminally ill adults with less than six months to live could be legally helped to end their lives by means of prescribed medication. To that end, it is publishing advertisments featuring the gruelling 'obituaries' of individuals whose suffering was prolonged, the campaign argues, by the absence of 'assisted dying'.

The stories within are undoubtedly powerful and moving. But they do not give the full picture of the Assisted Dying Bill, and why so many others are alarmed by it.

The Bill would, for the first time, invoke the state’s support for openly assisting an individual to die. That is a fundamental shift. And while the Bill speaks reassuringly of its checklist — the terminally ill patient would need to be mentally competent and receive the sanction of two doctors — the longer one looks, the less reassuring it grows. What is this clause of ‘six months or less’ to live? As most doctors know, such diagnoses can be deeply unreliable. And by what logic do we attach an ‘assisted death’ to a six-month prognosis but not, say, that of a year? As Lady Butler-Sloss sharply observed, the Bill exchanges ‘a natural frontier’ for ‘arbitrary criteria’.

If ‘assisted dying’ is to be permitted for the terminally ill, why would we then deny it for the kinds of conditions which terrify many of us far more: the prospect of prolonged advanced dementia, for example, or ‘locked-in’ syndrome of the sort which the late right-to-die campaigner Tony Nicklinson bravely endured? Many campaigners see no reason why euthanasia should not also be afforded in such instances.

The limitations outlined in Lord Falconer’s Bill are far from absolute: they are there because they are thought to be the maximum that the public would presently accept.

Such a rolling process was suggested in the 2012 report from Lord Falconer’s Commission on Assisted Dying, which chilled a number of prominent disabled commentators. It observed that the commission could not agree on whether to extend the ‘assisted dying’ option to those with disabilities, concluding that ‘we do not consider that it would be acceptable to society at this point in time to recommend that a non-terminally ill person with significant physical impairment should be made eligible.’

The clear implication was that at another point in time it might indeed become acceptable. Tanni Grey-Thompson, the disabled peer, wrote eloquently of her deep unease that: ‘while I am not seen as a potential candidate for assisted suicide right now, I am in the waiting room’.

Dignity in Dying has often invited the public to contemplate the distress of those who have wished for death and been denied it. Yet we must also consider the effect of such a law not simply on those who want to die, but those who wish to live.

The Assisted Dying Bill argues that the terminally ill are a special group who could be legally hurried towards death. Campaigners have hinted that this could one day be extended to the disabled. What then would we really be saying about equality of value, if the terminally ill and disabled were the only groups in society granted permission for assistance to die?

It is disingenuous simply to argue that ‘assisted dying’ would only be open to those who truly desired it. Desire itself is subject to external pressure, and vulnerable to shifts in social atmosphere: it can be generated, not only from independent will, but also from isolation, guilt and despair. The terminally ill patient endures the gross indignities of a failing body, is acutely demanding of resources, and clearly sees the cost that care exacts from weary family members. The last months can no doubt be horrifying for some. And yet I have also seen friends approach their final days with remarkable serenity and lucidity.

Our current treatment of the terminally ill is a morass of compromises, involving fine judgments around palliative care, the escalation of morphine as pain relief which may speed death as a side-effect, the right to have medical treatment withdrawn, and a legally compassionate approach towards loving family members who might assist a relative in lengthy torment to die.

Yet it may simply not be possible to frame a law that fulfils the understandable wishes of campaigners such as the late Mr Nicklinson, but protects wider numbers of intensely vulnerable people from insidious pressure to end their lives prematurely.

Once the euthanasia option exists, it immediately alters the nature of the conversation. The suggestion that a patient conveniently embrace the opportunity might remain unspoken, but it will not go unconsidered.

The radical on the edge of this discussion is Ludwig Minelli, the flamboyant Swiss lawyer and founder of the euthanasia clinic Dignitas, who is an equal opportunities purveyor of prescribed death. His view on assisted suicide is that it should be ‘without conditions. A human right is without any conditions except capacity.’ The Dignity in Dying group is troubled by Minelli, and has in the past disowned his position. Yet while I do not agree with Minelli, his universally applied ideology seems in its way more bluntly honest and less disturbingly illogical than those who seek to erect a halfway house in which only selected groups in our society are invited on the professional fast-track to death.