A medic’s reflections on palliative care and assisted suicide

“How people die remains in the memory of those who live on.” – Dame Cecily Saunders, founder of the modern hospice movement.

During the last two months of my fifth year “Community Care” medical placement, I have had the precious opportunity to spend time with palliative care patients and physicians. It was an experience that not only gave me knowledge about this oft-forgotten kind of medical care, but also engaged my whole person, emotionally and spiritually, and left me with a new respect for the dying and those who care for them. I am thankful for the wisdom I gained from the experienced palliative care consultants, nurses, and chaplains at Sobell House hospice in Oxford, and Sue Ryder hospice in Nettlebed.

As a medical student, I have more opportunity than most to experience the hard realities of sickness and disease. But before this placement, I had spent little time with the dying, perhaps because I was more enthralled by the high tempo work of the emergency department, or the advanced interventions in cardiology.

Dr Adams, a wonderfully competent and compassionate palliative care consultant at Sobell House, taught me about the management of terminal patients: pain control, relief of nausea and constipation, and tending to emotional and spiritual needs. I learned about three of the big fears faced by the dying: fear of being in pain, of losing dignity, and of being a burden to loved ones. An elderly gentleman confided in me “I do love my family and I know they are all so busy, and I don’t want to burden them, so I hope I go soon.” I was told that it is not unusual to find patients concerned about becoming an unwanted burden on their relatives and carers.

Yet there were also those who took great delight in the time that they had left, and wished to stay alive as long as possible. “The thing that keeps me going is the only thing that makes me happy: spending time with my family”, one woman revealed. For some, a fear of the unknown in and after death, or a longing for forgiveness, was prominent. For others, a confidence in life after death brought peace. “I know where I am going”, reflected one man.

One of the most powerful lessons for me was the value of a good death. By a good death, I mean one in which a patient has had the chance to share memories with and say goodbye to loved ones, to set their affairs in order, to prepare themselves spiritually, and has been relieved from physical discomfort. Relatives, while grieving after a death, also shared their appreciation of the time spent together at the end. While many in our society may wish for a quick death, I think I would rather have this opportunity to spend my last days surrounded by family and friends, cared for by a team of experts.

Palliative care may begin to look very different to future medical students in the future. Next month MP Rob Marris will introduce a Private Members Bill into the House of Commons designed to allow doctors to assist in the suicide of patients with a terminal illness. At the moment, doctors are prohibited from killing and from assisting suicide, but under the proposed legislation they would be allowed to select a poison of their choice, advise the patient how to take the drug, and even insert an intravenous line for the drug to be given efficiently.

I’ve often heard people suggest that doctors currently use drugs to help people die, and that all is being proposed is regulation. But this is just not true: palliative care doctors use opioids and benzodiazepines to treat pain and anxiety, so that the precious last hours, days and weeks can be as valuable as possible. These drugs are used to improve one’s quality of life, not to end it altogether. The drugs used in assisted suicide, barbiturates in massive overdose, are completely different, designed to kill rapidly.

Of all the palliative care physicians that I spoke to, not a single one of them supported a change in the law on physician-assisted suicide. They recognise that the current law works, and that under the proposed law, pressure on terminally ill patients to end their lives may come from family members or medical professionals, but also may be self-imposed by those feeling they are a burden to others. I hope that the excellent work of the palliative care teams I joined can continue -without the threat of assisted suicide – for many years to come.

Josh Peppiatt is a 5^th year medical student at Green Templeton College, Oxford

Advertisement

The actual consequences of physician-assisted suicide

Slippery slope arguments may usually be fallacious, but hard facts aren’t. As we draw nearer to Parliament’s debate the Marris Bill, we at OSFL thought we’d cast an eye over just a few of the problems that have arisen following the legalisation of assisted suicide abroad. This is by no means a comprehensive list and more information can be found here http://www.bioethics.org.uk/evidenceguide.html, here http://www.livinganddyingwell.org.uk/, and here http://www.carenotkilling.org.uk/.

Let’s start with Oregon in the USA, since it has a law that is most similar to the one proposed in the Marris Bill. In Oregon, patients requesting lethal medicine as a result of depression or mental illness are meant to have a psychological test carried out. Only 3 patients of 105 last year had this examination. Medicaid covers assisted suicide in Oregon, but it doesn’t cover many important drugs that improve quality of life: life becomes expensive and death free. Over years, the financial costs of palliative care stack up  – when NHS budgets are squeezed, could we see economic pressure to end lives?

The state of Washington has largely copied Oregon’s Death with Dignity Act, with some frightening results. The briefest doctor-patient relationship before the prescription of an assisted suicide was under a week. Could any doctor really judge the pressures and problems a patient faces after only knowing them a week? In 2014, 59% of people asking for an assisted suicide stated as motivation the fear that they would be a burden on family, friends, or carers. This flies in the face of the common claim that assisted dying empowers the frail.

Euthanasia and assisted suicide are both famously legal in the Netherlands. In 2012, 3% of deaths in the Netherlands were the result of euthanasia or assisted suicide.  Of those, 7% were done without the explicit request of the patient. A lot of arguments for assisted suicide emphasise the will of the patient. But if an assisted suicide is truly in a patient’s best interests, it’s unclear why it should only be prescribed if he or she asks for it. In practice, the role of explicit consent can easily fade away. Furthermore, Dutch children aged 12-16 are able to request and be assisted in suicide if their parents agree. The Marris Bill is limited to those over 18. But again, why shouldn’t this eventually change to include children if there is nothing wrong with assisted suicide? Some Dutch patients have been granted an assisted suicide when they are simply ‘tired of living’. The safeguards in the Marris Bill aren’t safe – they have eroded everywhere that similar laws have been put in place.

In the news recently for extending euthanasia to children of any age, Belgium is a cautionary tale for a country deciding whether or not to legalise assisted suicide. For the most part, Belgian patients are not referred for an assisted suicide by a doctor who is a specialist in palliative care. In other words, they are referred by someone who does not have expert knowledge of ways to minimise suffering. To an unspecialised doctor, assisted suicide may seem like the best option because he/she does not know what else to offer. Assisted suicide is being prescribed in ignorance.

But you don’t even need to look at real-life consequences of physician-assisted suicide to see what’s wrong with it. If Parliament passes the Marris Bill, it will send the message that the lives of the terminally ill are worth less than the lives of the healthy, and that the state will no longer protect the sick in the same way. The law should not be making judgements about the value of people’s lives. All life is valuable, and deserves protection.

To write to your MP, go to http://notoassistedsuicide.org.uk/. Let them know that life is valuable.

Assisted suicide would change the way we respond to despair

Nathan Verhelst, a trans man from Belgium, had struggled with mental illness since childhood. At the age of 44, after a series of crises, he took his own life. Sadly, that is not so uncommon. What was unusual were the circumstances. Verhelst received a lethal injection from a doctor, as part of Belgium’s standard bureaucratic procedure for those in ‘unbearable suffering’. The doctor explained that Verhelst’s suffering qualified as unbearable because after six months of counselling he was still suicidal. If that kind of reasoning makes you uncomfortable – if you wonder whether six months of counselling amounts to everything that might have helped Nathan Verhelst – then look away now, because it could be coming to the UK.

 
If Rob Marris’s assisted suicide bill is passed on 11 September, and survives the rest of its progress through Parliament, this country will become more dangerous for the elderly, the ill, the disabled and the depressed. So say the British Medical Association, Disability Rights UK, and the Royal College of GPs. At the very least, the principle of caution should warn against this bill.

Everyone can feel the pull of the case for assisted suicide. Many people are in physical and psychological pain; they say, repeatedly, that they would rather be dead than alive. Who could possibly be indifferent to their distress, and their hope that it might end?

 
We experience a stab of guilt, hearing their stories. And guilt is not the worst motive. If it prompts us to help the people at the margins of our own community, or prompts government to improve palliative care, guilt can do a lot of good. But it is a poor basis on which to pass a law which will change the fabric of society. This law will not simply abolish a category of suffering: it will create new ones. The evidence everywhere suggests that the main result of assisted suicide laws is to surround unhappy, lonely people with exit signs.
In Oregon, the supposed paragon of such a law, the chief effect has not been on those in physical pain. Less than a quarter of those receiving poison say they are worried about pain, or even the possibility of pain; the main reasons are ‘loss of autonomy’ (91%) and ‘decreasing ability to participate in activities that made life enjoyable’ (89%). According to a high estimate, over 30% of recipients in a single year may have had their judgment impaired by undiagnosed depression.

Still, to give Oregon its due, there is a fundamental difference from Britain. Oregon Right to Die, the body behind the law, were from the beginning moderates. Their intention, according to one of their leading figures, Eli Stutsman, was to ‘campaign for the right to die and against Dr. Jack Kevorkian in the same breath’. They were, if you like, doves rather than hawks.

The British right-to-die movement is different. It is a flock of hawks with some official doves fluttering around in the vanguard. The doves assure us that this Bill will go no further than Oregon’s restrictions: it will apply only to the terminally ill. (An elastic category in any case, as the disabilities campaigner Baroness Campbell has pointed out.) But the hawks are more articulate and more consistent in applying the logic of total self-determination. Baroness Warnock, a leading intellectual light of the movement, predicts a future in which ‘you’d be licensing people to put others down’. Polly Toynbee, one of Fleet Street’s most influential voices for a change in the law (and for further changes down the line), concedes the possibility ‘that the frail will be intimidated into hastening the end of their lives so as not to be a burden on their children’. She comments, in a disturbing foretaste of things to come: ‘Well, why not?’ The Economist recently proposed that the opportunity for taking poison be extended to people with depression. Well, in Belgium they are already living the dream. Euthanasia is up 25% on last year, and the law becomes ever less discriminating in its effects.

There, as Rachel Aviv reported in a must-read article for the New Yorker, euthanasia has taken away people with ‘autism, anorexia, borderline personality disorder, chronic-fatigue syndrome, partial paralysis, blindness coupled with deafness, and manic depression’. This is scarcely the picture painted by the likes of Dignity in Dying.

In 1931, the great psychologist Carl Jung noted that many of his patients suffered from ‘the senselessness and aimlessness of their lives… I should not object if this were called the general neurosis of our age’. If anything, that diagnosis is truer today. Suicide is the biggest killer of young British men, and the UK is incubating a crisis of loneliness and mental illness. Usually, we try to build hope and solidarity against despair. But Belgium has discovered an alternative. “If the patient’s energy is gone,” one euthanasia doctor tells Aviv, “then it is not humane to say, ‘Well, maybe if you go to a hospital that specializes in your problem for two more years it will help.’ I think we have to respect when people say, ‘No – that is enough.’” Sorry, doctor, but running out of energy is a symptom of depression: a lot of people feel that they have ‘had enough’, are useless, and would be better off dead. It makes all the difference whether they are listened to and given support to carry on. In some places, that seems to be going out of fashion.

The testimony of doctors suggests that when suicide becomes institutionalised, a society becomes anaesthetised to the preciousness of human life. One Dutch doctor recalled the first time he administered euthanasia. The first case was ‘terrible’, he said. His team agonised all day before carrying it out. The next one, he said, was much easier. ‘The third case’, he concluded, ‘was a piece of cake’. That is a report from the bottom of the slippery slope, and it turns out to be quite a short slope. Assisted suicide will weaken the bonds of society. It will nudge towards the edge exactly the people we should be hauling back from it. One day we might be asked if anybody tried to stop it.

 
To write to your MP, go to http://notoassistedsuicide.org.uk/

Dan Hitchens is a former President of Oxford Students for Life.