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The case against assisted dying: reading between the lines.

Lord Falconer’s assisted dying (AD) Bill must overcome numerous hurdles before it becomes law and, as a supporter of Dignity in Dying (DiD) and of Healthcare Professionals for Assisted Dying (HPAD), I decided that in the meantime I might do more to help than simply telling others why AD is a good idea.

“we believe that as rational autonomous beings we should have this choice”

Support for the legalisation of AD is based on simple principles: when we die we hope to do so peacefully, with dignity, free from distressing symptoms and ideally with friends and family close by. But if a combination of care strategies fail to relieve our distress we would want the option to achieve our aim with the indirect assistance of a doctor (AD). Our aspirations, , are broadly shared by more than 80% of the British public and we believe that as rational autonomous beings we should have this choice and that it is unjust for it to be denied.

Many just causes are implemented without public dissent but assisted dying (AD) is opposed by vociferous minority groups – some religious leaders, the British Medical Association (BMA), and a small section of the press which, holding privileged positions in society, wield disproportionate influence over the public perception of the rights and wrongs of AD. Consequently, successful campaigning for AD requires more than just explaining why it is the right strategy in a civilised society: It is equally important to critically examine the arguments presented by these opposition groups and to expose any shortcomings we find in their claims – if we don’t, they will win the debate by default.

Opposition groups present a common front against AD, notably “the slippery slope” argument but also the BMA refer to medical codes of practice to bolster their case and faith groups quote their religious beliefs. In these situations it is unfortunately easier to assume that there may be “no smoke without fire” than to look for the objective evidence on which their claims are based.

“Because of Oregon’s example more people are realising that the slippery slope is not standing up as an argument of any real value”

The “slippery slope” argument claims that the legalisation of AD in Oregon and elsewhere has led to the elderly, the infirm, the disabled and members of other vulnerable groups being subjected to involuntary euthanasia, that this trend will inevitably increase and that the same will happen in the UK. Against the background of frequent reports of the abuse and neglect of vulnerable groups in hospitals and care homes, it is worrying that this could be uncritically accepted by some members of the public. But the claim is facile: the Oregon Death with Dignity legislation “explicitly rejects active euthanasia” as do Lord Falconer’s proposals and the law in Oregon has never been extended from the criteria of a terminal illness.

Because of Oregon’s example more people are realising that the slippery slope is not standing up as an argument of any real value. This is why most disabled people are in fact supportive of legislation here.

It is also claimed that AD would lead to deterioration in the doctor/patient relationship and would adversely affect palliative care services. In reality, in each jurisdiction in which AD has been legalised the reverse has been the case.

“Most doctors either support AD or take a neutral stance”

Most doctors either support AD or take a neutral stance. Despite this the BMA, which claims that “We are the voice for doctors and medical students throughout the UK ”, maintains its opposition, stating: “The principle purpose of medicine is to improve patients’ quality of life (QOL) not to foreshorten it.” At first sight this is a succinct and catchy definition of good clinical practice but in fact adds nothing to the needs of the terminally ill: It is a truism. Of more concern is the implication that the practice of medicine is either good (improving the QOL) or bad (foreshortening it.) But in the real world many clinical decisions are not as clear cut as the BMA would have us believe. It may for example be impossible to perform a curative operation in a cancer patient but the patient isn’t abandoned.Instead an operation which only improves the QOL,e.g. by relieving distressing symptoms, is substituted which in some cases may carry a significant risk. Compromise and hard decisions are an integral part of good medicine.

The BMA are well aware that this is how good clinicians work and to accept it in principle but then to exclude patients whose symptoms are, by general agreement unresponsive to all conventional treatment is a resort to double standards simply to publicise their message. And to proclaim that improving the QOL is the principle purpose of medicine but at the same time oppose the only means of improving it in a selected small group of the terminally ill ( by legalising AD) is hypocritical.

In attempting to impose their idiosyncratic interpretation of the tenets of good clinical practice on the medical profession the BMA is effectively saying that for some patients the prolongation of life is paramount and that improving the QOL is of secondary importance. This is more in keeping with a religious, dogmatic interpretation of the sanctity of life than with recognising the need for a reasoned evidence- based debate on issues related to AD: Compassion and compromise sometimes requires that when there is conflict between striving to prolong life and to improve its quality, the latter should take precedence.

Some theologians argue that god created man in his own image and is uniquely entitled to terminate it. This is important to a deeply religious minority but irrelevant to the vast majority of the UK population. And it is a concern if in a civilised de facto secular society a small unrepresentative group is allowed to impose its will on the majority when an important issue such as AD is at stake.

“…the slippery slope argument lacks evidence and is illogical”

Briefly, from what I have read the arguments against AD are vacuous: the slippery slope argument lacks evidence and is illogical and the BMA s case may be based on double standards and duplicity. The faith-based case is, by definition, irrational and relevant only to the religious which is fine but others who do not share these beliefs should be able to make their own choices too.

Last year I attended a lecture at which a speaker opposed to AD likened doctors who support our cause to murderers: He, and others who disagree with us, refuse to accept that those doctors, purely out of compassion, reluctantly agree with the patient’s own choice that the only way they can hope for a peaceful painless death is by means of assisted dying.