I was invited to give a talk to a meeting on assisted death at a German resort town on the Baltic. I have no qualifications to lecture on such a topic and hesitated to accept. Even so, I had written about the ethical problems arising in the use of animals in research and how agreement can sometimes be won between people who had been deeply opposed to each other. Could a similar approach be used in the debates about whether or not people should be helped to die? With that question in mind, I agreed to talk at the meeting in Germany.
Most people who have pets have to deal with the issue of what they should do when their animal companions reach the end of their lives. It is unusual for the pet to be subjected to a series of invasive procedures when it is obviously suffering. Most commonly the pet will be “put to sleep” humanely before it endures more suffering. In my lecture, I posed the question of why fellow humans are treated differently from pets. As expected, I encountered strongly held views on both sides about assisted death, but I sensed that agreement might be achieved between at least some of those whose opinions differed so radically.
The moral dilemmas faced by whether or not it should be acceptable to help someone to die are not trivial. Conflicts between people with deeply opposed views are common enough. Consider, for example, the conflict between maintaining fish stocks and caring for the people in fishing villages; or the conflict between having pure air and providing sources of energy from fossil fuels; or the conflict between farming and the conservation of habitats. Unwillingness to compromise can end up with outcomes that are regarded as undesirable by everybody: no fish and no fishing villages; dirty air and devastated sources of energy; dead waterways, unproductive land and massive reductions in biological diversity. Will intransigence block the legalising of assisted death?
Humans know that they must eventually die and many, at least, wish to put off the moment of death for as long as possible. The very rich and self absorbed may even ask that they be frozen immediately after death in the hope that at some future date, the technology might be available to resuscitate them. Nevertheless, many people with progressive and incurable diseases want to die before they are totally incapable. In most countries it is illegal to help people to die. In the UK you can go, as a member of the family or as a friend of the person who wishes to die, to the Dignitas clinic in Zurich where assisted death is legal. But the procedure is expensive and, disagreeably, the person who wishes to die has to self-administer the fatal cocktail. Moreover, if the friends or family members are from the UK, they risk prosecution when they return home.
The author, Sir Terry Pratchett was diagnosed with early onset Alzheimer’s disease. The disease is inexorable and he would like to be able to seek help in choosing the moment when he might end his own life. In his 2010 BBC Dimbleby lecture, Pratchett suggested that a tribunal could establish the facts of the case well before the assisted death might take place. The members of the tribunal would ensure the person wishing to die was of sound and informed mind, firm in their purpose, suffering from a life threatening and incurable disease and not coerced by a third party. He suggested that the tribunal should include a lawyer with good listening skills and expertise in family affairs and a medical practitioner experienced in dealing with the complexities of serious long-term illnesses. Pratchett added that: “The tribunal would also have to be a check on those seeking death for reasons that reasonable people may consider trivial or transient distress. I dare say that quite a few people have contemplated death for reasons that much later seemed to them to be quite minor. If we are to live in a world where a socially acceptable ‘early death’ can be allowed, it must be allowed as a result of careful consideration.”
The tabloid press ridiculed Pratchett’s idea of what they called “Death Committees”. More thoughtful critics said that any legalization of assisted death could play into the hands of unscrupulous people who wished to get rid of an aged relative. The relative causing them trouble might, when he or she died, also leave them wealth and possessions. Others thought that effort should be made to improve palliative care focused on providing patients with relief from the symptoms, pain and stress of a serious illness — whatever the prognosis. Recently, Tim Montgomerie wrote in the London Times: “… assisted dying laws would soon become lethal tools in the hands of activist judges, greedy relatives and financially stretched health services.” Is that pessimism justified? Marcia Angell, a distinguished medical journalist, thinks not.
In an article in the New York Review of Books Angell wrote about the effects of the Death with Dignity Act passed by the Oregon legislature in 1994. Concerns about an ethical “slippery slope” have not been borne out. Good palliative care has increased. The law is not used disproportionately by the poor or the uninsured. It is used by people like Pratchett who value independence and their ability to control what happens to them. Above all, no evidence exists of coercion by unscrupulous family members. Despite that experience, profound differences of opinion about assisted death persist. An attempt to introduce a Death with Dignity Act in Massachusetts in 2012 was defeated by nearly 52% of those voting. The Catholic Archbishop of Boston, Cardinal Seán O’Malley, described assisted dying not as compassionate, but as an act of “sheer brutality.”
What would a Pratchett tribunal have to consider? Most obviously it would have to assess the individual’s wishes and those of the friends and family. If both are strongly in favour then no problem arises other things being equal and conversely, if both parties are against, the decision not to proceed is clear. How would the tribunal draw the line between what is acceptable and what is not? Those who favour assisted death suggest that pre-eminence should be given to the subject’s own wishes. Many will argue, however, that the prevailing ethics of society might be strongly opposed to assisted death. Some will state that it is God’s choice when a human will die. In a secular society, on the other hand, others will argue that a God’s wishes cannot be determined by rational inquiry. Plenty of examples exist where the scruples of a conservative religious minority have been over-ridden by the wishes of the majority. Contraception, abortion and stem cell research are three cases in point. In the UK suicide was decriminalised in 1961.
The three assessments required by the tribunal depend on the wishes of the patient, the wishes of family and friends, and the prevailing consensus in society as a whole. The decision space in which a tribunal would have to agree to an assisted death is not absolute and, in any particular case, the outcome is contingent on the assessments made along the three different dimensions of the space. Some of the moral tensions are not easily resolved in the abstract since the position that people adopt will be swayed by the choices they are offered. Social psychologists have often noticed the contextual effects that can arise when different forms of assessment are used. This tendency to base judgments on the last assessment that has been considered can be met in part by ensuring that the different dimensions on which the final choice depends are made independently and only then are they brought together for the overall decision.
The decision is not a cost-benefit piece of accountancy since it does not depend on a common currency or on balancing incommensurable properties. It is a pragmatic approach that can be helpful in determining whether or not a decision to assist the death of a person should be taken. It is similar to the weighing carried out by a judge faced with conflicts in a court of law. The ultimate judgment requires a consensus acceptable to the majority of the public. When I have discussed the issue with medical doctors, some admit that if a patient is dying at home, they have quietly assisted death by withholding treatment or actively administering a lethal dose of a drug. In a hospital, doctors behave differently, even when their judgment is that the patient will never recover. Typically they operate in teams. If they took a unilateral decision, they may fear that their actions will be reported and that they will then risk prosecution. That seems wrong. My sense is that when people understand the humanity of what is being proposed they would accept that a Death with Dignity Law is justified. Euthanasia when the patient is unable to give his or her consent raises another issue. If the patient has written beforehand that they wish to be helped to die in specific circumstances, such as prolonged coma, that would be evidence that the Pratchett tribunal could take into account. If not, other guidance would be required.
The reasons why humans are often treated less well than their pets are understandable. A frightened person who is dying may grasp at all offers of medical help. Unfortunately, those offers are not always disinterested or compassionate. The doctors involved might have research interests in the proposed treatment, they might have financial interests arising from prolonging intensive care, or they might simply have a strong commitment to prolonging life irrespective of cost or the individual patient’s suffering. Whatever the reason, medical attitudes are crucial.
In a study of terminally ill cancer patients, two-thirds of them reported having had no discussion with their doctors about their goals for end-of-life care, despite being, on average, just four months from death. The remaining third who did have such discussions were far less likely to undergo cardiopulmonary resuscitation or be put on a ventilator or end up in an intensive-care unit. Patients who seriously discussed with their doctors the care they would receive before they finally died ended up suffering less. They were far more likely to die at peace. Also their families were spared much anguish.
The finding does not necessarily prove a causal link since patients who were temperamentally more likely to have serious talks with their doctors might also be more likely to accept the reality of their impending deaths. Even so, the conclusion of the study links up with the well-known benefits of palliative care. The Oregon experience suggests that an opportunity to choose the moment of death has led to expanded palliative care and all round greater compassion. If a Death with Dignity Bill came before Parliament, I have no doubt where my sympathy would lie.