The tone of the conversation around assisted dying is changing in the UK, with bills on the matter making their way through Parliament and Keir Starmer having promised a free vote on the issue. While the public are in favour of being offered the option of assisted dying, there are still many who have concerns around the potential abuses of such a policy. Patricia Haitink and Emily Jackson suggest that looking at the counties where assisted dying is already available should respond to such concerns.
UK debates surrounding assisted dying are changing gear. The Nuffield Council on Bioethics has just published key findings from England’s first Citizens’ Jury on the issue, in which 71 per cent of jurors voted in favour of allowing both assisted suicide and euthanasia for terminally ill patients with capacity. On both sides of the debate, interventions from public figures – including Dame Esther Rantzen, Dame Diana Rigg and Liz Carr – have become commonplace. Jersey and the Isle of Man are in the process of changing their laws, and there are Assisted Dying Private Members Bills before both the UK and the Scottish parliaments. Since his election as Prime Minister, Sir Keir Starmer has reiterated that his government will allow parliamentary time for a free vote on the issue, and he has previously said that he is in favour of a change in the law.
Even if it might be premature to say that it is no longer “for or against” but “how and when”, the tone of discussions does seem to have pivoted from concerns about the sanctity of life towards more general acceptance that there might be circumstances in which people should be allowed to choose to end their lives, and an acknowledgement that a majority of the public wishes to be given that choice. At the same time, that acceptance is often tempered by a certain queasiness about what those circumstances might be, and what the consequences might be for society.
In reality, there is overwhelming public support for assisted dying in countries where it is lawful, bolstered by increasing numbers of people who have experienced their loved ones’ peaceful assisted deaths.
As more and more jurisdictions worldwide have taken the decision to legalise assisted dying – so that the UK is increasingly becoming an outlier – it is noteworthy that media coverage in the UK often focuses on exceptional and perhaps questionable instances of assisted dying, and on countries with particularly broad eligibility criteria. In reality, there is overwhelming public support for assisted dying in countries where it is lawful, bolstered by increasing numbers of people who have experienced their loved ones’ peaceful assisted deaths. If the UK were to legalise assisted dying, it could choose to enact restrictive or permissive legislation, and there are now a wide range of models from which it could borrow.
While it is common for opponents of assisted dying to claim that it would be impossible for safeguards to adequately protect people who are disabled, elderly, poor or receiving sub-standard palliative care, this narrative is not confined to those who believe assisted dying is always morally wrong. There are also commentators who are sympathetic to the idea that people might legitimately wish to opt for an assisted death, but who worry about insidious pressures on the vulnerable, and who question the effectiveness of any regulatory system. For example, Dr Rachel Clarke recently expressed the fear that a lack of decent palliative care might drive some to opt for an earlier death; Sonia Sodha doubts whether doctors would be able to identify coercion; and Josh Glancy is worried that it would be principally the poor, unable to sustain a reasonable standard of living and fearful of being a burden, who would opt for it.
Opponents of assisted dying often cite data from Canada and the Netherlands, which have relatively wide-ranging eligibility criteria, even though there are many other jurisdictions, including 11 US states and districts, New Zealand and most of Australia, with more restrictive legislation, and a growing body of evidence not only of how these laws work in practice, but also of widespread public support for them.
Although there are worries that the poor might be more likely to opt for an earlier death, the evidence points in the opposite direction: it is the well-off and well-educated who are most likely to make that choice.
A requirement to increase funding for palliative care has sometimes been included as a condition of the introduction of assisted dying legislation, and there is evidence from Belgium and Canada that palliative care has improved as a result. Anxieties about coercion, too, appear to be overstated, and in practice, families report having to try to come to terms with their loved one’s desire to die. Although Josh Glancy worries that the poor might be more likely to opt for an earlier death, the evidence points in the opposite direction: it is the well-off and well-educated who are most likely to make that choice.
For those who fear that the disabled might come to be viewed, or view themselves, as “better off dead”, Australian legislation specifically states that persons are ineligible by reason only of disability or mental illness, and access is confined to people with terminal physical conditions. The US jurisdictions do not specifically exclude those with a disability; however, their life expectancy requirement in effect rules them out, unless they also have a terminal condition likely to result in death within six months. Whether most disabled people would welcome these restrictions is another matter, given polling which suggests that a majority would prefer to have the choice. However, the point is that it is up to parliament to decide what sort of regulatory system, with what safeguards, would be most likely to work effectively in the UK.
A rush to include ever more safeguards is not without costs, however. In Australia, each successive State to legalise assisted dying has piled on more legal provisions in order to demonstrate ever greater toughness: Victoria, the first state to introduce legislation, has a statute with 118 sections, whereas the most recent New South Wales Act has 187. In the US and Australasia, legislation draws somewhat artificial lines in the sand about life-expectancy when defining “terminal illness”. Restricting access to people with six or 12 months’ life expectancy might reassure politicians and the public that only those who are already dying will be allowed to hasten their deaths, but as well as the inevitable imprecision of these predictions, it means that people suffering devastating but not yet terminal illnesses would continue to travel to Dignitas in Switzerland to end lives which, to them, have become unbearable, if they have the means and the physical ability to do so.
Legalisation can also involve a series of procedural safeguards, including palliative care needs assessments, second opinions and waiting periods, as well as formal approval mechanisms.
Canada’s introduction of Medical Aid in Dying (MAID) is often portrayed as a cautionary tale, in part because eligibility has been expanded since its introduction. In fact, the “expansion” to adults whose death was not imminent brought the legislation into line with the original Supreme Court decision that adults with a grievous and irremediable medical condition had a right to an assisted death, even if they were not terminally ill. The possible future expansion to people with mental illnesses has not yet happened, and will not do so until 2027 at the earliest. Increased uptake since legalisation in Canada, and in other jurisdictions as well, could be viewed as meeting an unmet need, and there is certainly evidence that the populations of Canada, the Netherlands and Belgium in which eligibility is wider than the US or Australasia, support their more liberal laws; it is mainly overseas commentators or those who have “in principle” objections to assisted dying who do not.
Each nation can define the scope of eligibility for assisted dying as broadly or as narrowly as it chooses. Given that opinion polls consistently show that a majority in the UK would like the choice to be available – if only to provide the “comfort blanket” of a hypothetical “off switch” if their suffering were to become unbearable – as well as evidence that there is broad public support for assisted dying in countries where it has been legalised, it seems improbable that the UK parliament would be uniquely incapable of drafting publicly acceptable legislation.
In practice, the important question for parliament may be how to ensure that safeguards which are capable of addressing people’s concerns are not so tough and restrictive that eligible patients struggle to access assisted dying.
In Australia, it is a criminal offence to coerce or induce anyone into requesting or accessing an assisted death, and the UK and Scottish Bills reproduce this provision. Legalisation can also involve a series of procedural safeguards, including palliative care needs assessments, second opinions and waiting periods, as well as formal approval mechanisms. In practice, the important question for parliament may be how to ensure that safeguards which are capable of addressing people’s concerns are not so tough and restrictive that eligible patients struggle to access assisted dying. For example, the requirement in Lord Falconer’s Assisted Dying for Terminal Ill Adults Bill that the consent of a High Court Judge is required in every case could prove impracticable, in the light of court backlogs and the fact that most of the people seeking an assisted death are likely to be in their last days or weeks.
It is also important to remember that we allow adults with mental capacity to make life-ending choices when we respect their refusals of life-prolonging medical treatment. A person who asks to be disconnected from a ventilator – with the result that they will die – might be vulnerable, disabled, or worry about being a burden, but we believe that we have robust mechanisms in place to ensure that doctors are able to tell if a patient’s decision is truly their own. If we think we can identify coercion and pressure in people who wish to refuse life-prolonging treatment, it is hard to see why we think it would be impossible to do exactly the same thing for someone who was seeking an assisted death.
All articles posted on this blog give the views of the author(s), and not the position of LSE British Politics and Policy, nor of the London School of Economics and Political Science.
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