The BMJ editorial team have taken a bold move in strongly supporting Lord Falconers Bill, due for its second reading later this month (1). Whilst a number of colleagues have criticised the editorial team for ‘flexing their muscles’ on the issue, it is important to remind ourselves that a fruitful debate can only occur once individuals articulate their opinions on the subject in a frank manner. Had the BMJ chosen to publish a more neutral article on the issue, I doubt it would have had the same response.
That being said, I am against Lord Falconer’s Bill, and as such, I find myself disagreeing with much of the editorial. The principle argument put forward in the article is that the Bill would preserve a terminally ill patient’s right to autonomy at the end-stages of their illness by putting them in control to end their suffering. In order to exercise the right to choose death, an individual must have the appropriate mental capacity. Thus, if this bill is passed, the right to choose assisted suicide would only be available for patients who have capacity. But aren’t terminally ill patients who lack mental capacity just as likely to experience unbearable suffering, and therefore have just as much right as those who possess capacity to have their suffering eased?
Although the idea of offering an assisted death to someone without their consent may at present seem absurd, we must note that in both Belgium and the Netherlands there have been instances where an assisted death was carried out without a patient’s consent (2,3). Indeed, Belgium has recently passed a law legalising euthanasia for terminally ill children without any age limit (4). This is precisely the slippery slope that those against assisted suicide worry about, and while the editors have naively played this down in their article, the experience of our European neighbours suggests that widening the net of assisted suicide to vulnerable individuals at some point in the future already has a precedent.
Furthermore, on the issue of slippery slopes and misuse of law, there are numerous examples when a statute has been introduced for a particular purpose, only for it to have been manipulated and misused in later years. Take the Terrorism Act 2000, which coincidentally was introduced by Lord Falconer. When David Miranda was detained in Britain under Schedule 7 of the act, Lord Falconer himself stated: ‘I am very clear that this does not apply, either on its terms or in its spirit, to Mr Miranda’ (5). Whilst the misapplication of his anti-terror legislation resulted in a brief inconvenience to an individual, the misapplication of his assisted suicide bill would have far more serious repercussions: the unnecessary loss of human life.
On the topic of assisted suicide only being offered to those with a life expectancy of six months, then what is the basis for this particular time frame? No evidence or robust reasoning is provided for this timeframe. Moreover, whilst the Commission on Assisted Dying (headed by Lord Falconer) suggest that assisted suicide should be offered to individuals with a life expectancy of twelve months (6), the Bill puts forward a life expectancy of six months without providing a reason as to why the time limits were altered for the Bill. Surely there must be more science to this than merely plucking out random numbers?
The editors cite evidence in the form of a systematic review to suggest that whilst doctors are poor at providing a predicting life expectancy, they usually overestimate prognosis (7). Though the paper provides strong evidence for this assertion, there are a couple of issues. Firstly, this study is limited to terminally ill cancer patients, what about patients with other terminal illnesses? Are clinicians in other specialities equally buoyant about the prognosis of their patients as oncologists? Secondly, the paper they cite is over a decade old, when there was a different culture amongst clinicians. Perhaps back then doctors knowingly offered an optimistic prognosis on the basis of providing hope to their patients? After all, these were mere ‘guestimates’ that conceivably didn’t have the same importance as they do today.
Finally, we must consider the long-term societal impact of legalising assisted suicide and how it will change our perception of death. The decriminalisation of assisted suicide will signal to society that some lives have greater worth than others, and subtle pressure by wider society has the potential to coerce the vulnerable by making them feel that they are a burden. I agree with the editors that our lawmakers must rise to the challenge; they must ensure that the most vulnerable members of our society remain protected for generations to come.
1. Delamothe T, Snow R, Godlee F: Why the Assisted Dying Bill should become law in England and Wales. BMJ 2014;349:g4349
2. Chambaere K. et al., ‘Physician-assisted deaths under the euthansia law in Belgium: a population-based survey’, CMAJ, June 15, 2010, 182(9). 1
3. van der Heide A. et al., ‘End-of-Life Practices in the Netherlands under the Euthanasia Act’, N Engl J Med 2007; 356:1957-1965.
6. “The current legal status of assisted dying is inadequate and incoherent…”. The Commision on Assisted Dying (2011).
7. Glare P, Virik K, Jones M, Hudson M, Eychmuller S, Simes J, Christakis N. A systematic review of physicians’ survival predictions in terminally ill cancer patients. BMJ2003;327:195
The article was originally published on the BMJ here.