As an emergency physician, I make agonising life or death decisions every day. When caring for a terminally-ill patient whose organs are failing, and who can’t recognise her own children, I work with colleagues and family members to decide whether to withdraw treatment. We do this when both evidence and experience suggest there is no hope left.
These decisions are incredibly sensitive. Yet compared to the intense controversy over Kim Leadbeater’s Terminally Ill Adults (End of Life) Bill, which Parliament will vote on tomorrow, the public doesn’t seem that concerned by end-of-life medical care. Critics of the Bill worry about doctors will be “playing God” by interfering in the workings of death. But trying to ensure our dying patients a dignified death is already part of the job. Not only do physicians determine the limits of care: we also choose when and whether to withdraw treatment. The question isn’t whether these decisions about death will be made, but how best to make them with dignity.
The Assisted Dying Bill would in fact reduce the role of doctors in the process of death. Currently, every significant end-of-life decision I make involves consultations with other physicians; discussions with family members; and respect for the patient’s wishes via an advance directive or “living will” that states a desire to refuse treatment — should he or she be unable to communicate. If it becomes law, the Bill would bolster these existing safeguards with additional layers of protection. And it would take decision-making out of the hands of medical professionals. Doctors would simply execute legally-sound protocols, as we currently do with Do Not Resuscitate (DNR) orders.
Let’s imagine how this would play out in practice. An adult patient with full mental capacity, who faces a terminal diagnosis or severe deterioration, and is in their final six months of life, could request an advance directive for assisted dying with the help of a doctor, who would ensure that the patient meets the eligibility criteria. This means, according to the Bill, that the person has a “clear, settled and informed wish to end their own life” and that they have come to the decision “voluntarily, without coercion or pressure”. If two doctors independently state that the eligibility criteria have been met, the patient may apply to the High Court for approval.
If the High Court approves the request, there would then be a 14-day reflection period (if the death is imminent, this would fall to 48 hours). After that, the applicant may make a second request for assistance to end their life. If their doctor still deems the patient eligible, a life-ending “approved substance” could be prescribed for self-administration. This is hardly a snap decision made in a moment of distress. At any point along the line, clinicians could decide that the criteria haven’t yet been met and defer action for review in three to six months’ time.
This multi-layered approach provides significantly more checks and balances than are in place for many current end-of-life decisions. When, for instance, I come across a terminally-ill patient with a perforated bowel at 3am in the emergency department, I am forced to make an immediate decision about the appropriate care limitations. While I always seek advice from my colleagues in such cases, I do not have much time. Every emergency physician can recall cases where treatment choices didn’t achieve the intended outcome — not due to negligence, or poor judgment, but simply because doctors are making complex decisions about the most intricate machine on Earth: the human body.
The proposed assisted dying framework would remove the element of time pressure, and take the decision-making burden away from doctors. I would focus instead, quite rightly, on patient autonomy and dignity. I cannot help but recall the tragic case of the judge, Sir Nicholas Wall, who at the age of 71, having been diagnosed with a rare case of fronto-temporal lobe dementia, “lost the will to live” and hanged himself in his care home in 2017. While I have no personal stake in the assisted dying bill, I do believe that those in positions like Sir Nicholas — who, in his own words, could find within himself “no hope for the future” — deserve the right to choose a dignified death.
Why would anyone be opposed to this? Part of the reason is that the debate over assisted dying has been cast as an existential battle between good and evil; between those who value the sanctity of life, and those who are willing to trample over it. And yet this Manichean way of thinking entirely misinterprets the reality of current medical practice. In his passionate critique of assisted dying legislation in UnHerd earlier this week, Giles Fraser argued that “fundamentally, the state should not be in the death business”. But the state, via the NHS, is already deeply involved in end-of-life decisions. The question isn’t whether these decisions will be made but how best to make them with humanity, clarity, and the appropriate safeguards.
There are many who argue that any system of assisted dying would be open to abuse by unscrupulous characters looking to exploit a patient’s lack of mental capacity. And yet our legal system is well versed in spotting subtle forms of coercion in many contexts — from contract law to criminal justice. It would be difficult for anyone to get around the proposed system, which promises an unprecedented level of scrutiny. I expect that any questionable death will be referred to the Coroner’s Court, the oldest in the land, for a thorough review, and, if necessary, criminal sanction. This level of oversight would be unimaginable in current end-of-life decisions.
Another factor to bear in mind is that the quality of an emergency department isn’t measured solely by how many lives we save. An equally important metric is how we care for the dying. Currently, I spend too much time with elderly patients who are shadows of their former selves — many are incontinent, confused, combative, and can no longer recognise their loved ones. Surely, people deserve a choice about their future suffering?
I’ve seen far too many bad deaths in my time — often in cases where doctors preserved biological function long past the point of meaningful life. The assisted dying bill offers a better way forward: not by empowering doctors to play God, but by enabling individuals to make informed choices about their own end-of-life care, supported by appropriate medical and legal safeguards. While death is an inevitable part of life, an undignified one need not be.
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Source: UnHerd Read the original article here: https://unherd.com/