There is a popular image of assisted suicide: a swift, straightforward procedure, backed by the awesome authority of modern science, sure to send you off in a comfortable doze. Dignity in Dying, for instance, claim that assisted suicide can “guarantee” a calm and peaceful death. Terry Pratchett expressed his wish to die “sitting in a chair in my own garden with a glass of brandy in my hand and Thomas Tallis on the iPod”.
Now compare the experience of Linda van Zandt. In 2016, on the day of her aunt’s assisted suicide in California, an Uber arrived bearing thousands of dollars worth of lethal medication. That included 100 capsules which had to be crushed, dissolved and swallowed within the hour. Wearing latex gloves and wielding toothpicks, the family frantically scraped the white powder from the capsules, combining it with a sugar syrup to make a bitter sludge so “vile” that van Zandt broke down in tears. Afterwards, she sat at her kitchen table wondering: “Who wrote this law?”
That, to be clear, isn’t everyone’s experience — but then nor is the romanticised picture presented by assisted-suicide advocates. The vision of people like Pratchett “is not the clinical reality”, says Mark Taubert, palliative care consultant and professor of medicine at Cardiff University. Claud Regnard, a retired consultant, points out that only two studies have compared “quality of death” by assisted suicide and by nature taking its course. Both studies, one in Oregon, one in the Netherlands, concluded that they were as good, or bad, as each other.
Assisted suicide relies on lethal drugs. But how reliable are the medications themselves? An article in a leading medical law journal remarks: “The pervasive belief that these, or any, noxious drugs are guaranteed to provide for a peaceful and painless death must be dispelled; modern medicine cannot yet achieve this.” On every point — the supply chain, the means of administration, the risk of complications — the reality is far from straightforward. But that reality is about to hit Britain as the Leadbeater Bill on assisted dying is being debated by MPs on 29 November.
Take Mehdi Alavi’s Dream Pharma — which operated out of the Elgone Driving Academy in Acton. In 2011, this one-man firm was suddenly placed under the spotlight of an international human rights story, as it emerged that it was supplying Arizona’s death penalty system with deadly chemicals.
Why did Arizona have to rely on a man at a driving school in Acton? Welcome to the strange world of lethal drugs, a shadow world largely unmonitored by health authorities, where supply chains can suddenly disappear, where new experimental mixtures come and go, and where best practice remains decidedly unclear.
When it comes to the physical stuff doctors depend on, assisted suicide and the death penalty are entwined. In the early 2010s, European companies launched tough new restrictions on the export of certain drugs to the US because the drugs were being used for capital punishment. That explains the emergence of individual suppliers such as Mehdi Alavi. But these small-scale alternatives were soon banned by American courts too. US pharma companies also stopped making the drugs used in assisted suicide — possibly because there are few other medical uses for them.
The shortage caused problems for penitentiaries and assisted-suicide clinics alike. One chemical, until then a popular choice in assisted-suicide states, practically disappeared from the market. Assisted-suicide doctors’ groups scoured America looking for the drug, but to no avail. Next they turned to another chemical which was supplied by a company called Valeant. The company was plagued by scandal and investigated for price gouging; the price of the drug rose from around $400 to almost $3,000 per lethal dose between 2010 and 2016.
In the end, American assisted-suicide doctors had to come up with their own solutions. But the blend of toxic substances caused “severe pain” , so physicians tried out other combinations, tweaking the formula half-a-dozen times. Across the globe, meanwhile, there are countless variations: more than 30 chemicals are used in the different forms of oral or intravenous assisted suicide.
As with death penalty procedures, then, there is no gold standard, but rather a great variety of options, none of which has established itself as the most appropriate. According to an article in The Lancet, complication rates with assisted suicide may be even more frequent than those with the death penalty.
How serious are those complications? The data is extremely patchy, but some have attempted statistical estimates. With oral methods, a third of assisted suicides take between 90 minutes and 30 hours. Up to 9% have trouble swallowing the dose; up to 10% vomit it up; up to 2% re-emerge from their coma. There are also horror stories, such as the Dutch woman with Alzheimer’s who recovered consciousness and was held down by her daughter and husband while a doctor finally euthanised her.
Then there are the unknowns. Baroness Finlay, a palliative care specialist, told the parliamentary committee on assisted suicide last year that during executions by lethal injection, “four-fifths probably regained a degree of consciousness”. Finlay said that though there is an obvious need for more research on consciousness in euthanasia and assisted suicide, nobody has ever done a proper study.
Not everyone is so sceptical. As Silvan Luley of Dignitas has claimed: “There has been not one case that did not work, in the sense of the person not reaching the goal in a dignified way.” Dr Lonny Shavelson, of Bay Area End of Life Options, has made similar claims. “These,” he says, “are lovely deaths.”
But every claim and counterclaim should be qualified by the fundamental point: the evidence base is inadequate. No drug regulatory authority anywhere has approved any drugs for use in assisted suicide. The 2019 protocol from the Canadian Association of MAiD Assessors and Providers acknowledged that there had been “little to no research” on their recommended combinations, and “no peer-reviewed literature to guide best practice”.
In the British context, meanwhile, supporters of assisted suicide seem conscious of the need for more research. Dignity in Dying told me in a statement that assisted-suicide drugs “are under constant review amongst clinicians and that best practice is constantly developing”, and that the UK procedure would depend on “engagement with healthcare bodies and regulators”, drawing on other jurisdictions “where they are confident that the drugs used are safe, effective and provide dying people with a dignified death”.
Which drugs might a future UK assisted suicide programme adopt? The Leadbeater Bill mentions none specifically, simply stating that the “Secretary of State must, by regulations, specify one or more drugs or other substances”. Leadbeater has not given any view on the subject; her chief of staff Lance Price tells me that it would be a matter for NICE and other regulators. NICE didn’t respond to a request for comment. For their part, UK doctors themselves seem unaware of the challenges. As a 2016 report by the British Medical Association found, some physicians were “surprised” to learn that assisted suicide could come with complications.
Dr Regnard, who is not against assisted dying per se, told me that the introduction of such unevidenced drug combinations would be completely unprecedented. “I think it puts us back 100 years to when there was no regulation, basically people could do pretty well what they wanted.”
In the end, the assisted suicide debate will hinge less on these questions, though, and more on the familiar trade-offs between personal autonomy and threats to the vulnerable. Yet that shadow world of lethal drugs suggests a broader point: that taking life is, at the very least, an awkward fit with healthcare — and that when these cocktails are introduced into a medical system, the system itself inevitably changes. You can call Kim Leadbeater’s proposal brave or reckless. But it would surely be the biggest experiment ever conducted on the NHS.
You can call Samaritans for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch.
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Source: UnHerd Read the original article here: https://unherd.com/