Assisted suicide: the red flags from abroad

It is hardly surprising that in dismissing the reality of how some slopes truly are slipperyPolly Toynbee this week in the Guardian looked to the U.S. state of Oregon’s experience of assisted suicide to prove her point, asking skeptically, “How often will it be used? After 17 years of Oregon’s Death with Dignity Act 80 people out of 30,000 deaths used it last year.”

Oregon is  the jurisdiction where the legalisation of assisted suicide appears to have been least detrimental, making it the poster example for campaigners for a change in Britain’s law. Yet cultural, demographic, and geographic similarities mean that Britain’s near neighbours Netherlands and Belgium offer far more natural comparisons than distant, rural, thinly populated Oregon.

But even if Oregon were the comparison, it still offers a powerful warning of what happens once the law changes, as Lord Falconer proposes, to allow doctors to help people to take their lives. Since 1998, the first full year in which the Death with Dignity Act was in force, the annual rate of deaths from physician-assisted suicide has increased fivefold. Eighty deaths a year might not sound like a lot to Polly Toynbee, but barely four million people live in Oregon; such a death rate, if applied proportionately to England and Wales, would lead to more than 1100 annual deaths from physician-assisted suicide.

Consider, too, what happens in practice. Lord Falconer’s bill, as noted yesterday, leaves it to doctors to decide how public safety should be enforced, neither detailing criteria nor imposing safeguards for assessing patients’ eligibility for physician-assisted suicide. In Oregon between 1998 and 2009 the typical doctor-patient relationship for those who died through physician-assisted suicide was just ten weeks, and was often much shorter. It is hard to see how a doctor, however well-intentioned – and we will come on to this – could reliably assess a patient’s mental state and intention in so brief a period.

The brevity of so many doctor-patient relationships seems to be closely linked to the phenomenon known as “doctor shopping”: many doctors in Oregon, as in Britain, are strongly opposed to physician-assisted suicide, which means that those wanting a doctor to help take their lives have recourse to a small number of doctors. In 2013, for instance, following a similar pattern to 2012, a mere 62 doctors wrote 122 prescriptions for lethal drugs to enable patients to take their own lives. At least one of these doctors, as in the previous year, wrote ten prescriptions. These are doctors, naturally, who are very supportive of the idea of physician-assisted suicide.

‘Doctor shopping’, in this context, leads to patients seeking doctors who will give them the answers they want, which may not be in their best interests, as though ‘choice’ is the greatest good in medical care. It is hard to avoid comparisons with press stories these past years about British doctors who, rather than building relationships with their patients, were instead found to have signed abortion forms without even meeting the women for whom they ought to be caring.

Given Oregon’s experience, it is hardly surprising that the British Medical Association is concerned about how the introduction of physician-assisted suicide to the UK could undermine medical ethics, as well as endangering vulnerable individuals and – as Alice Maynard of Scope points out – undermining society’s attitudes to the weak. Similar views have been expressed by the Royal College of Surgeons, which recognises no circumstances in which physician-assisted suicide should be introduced, noting that a change in UK law would

fundamentally alter the role of the doctor and their relationship with their patient. Medical attendants should be present to preserve and improve life – if they are involved in the taking of life, this creates a conflict that is potentially very damaging.

Disturbing though the reality of Oregon’s physician-assisted suicide laws is, matters are decidedly worse in our densely-populated neighbors, Belgium and the Netherlands. They show just how laws on assisted suicide tend to be elastic: once we decide that it is in some people’s best interests to no longer be alive, we establish the principle that some lives are not worth living; once people get used to this notion, they naturally become willing to expand the range of people who can avail of physician-assisted suicide.

In Belgium, for instance, the number of deaths from physician-assisted euthanasia rose from 235 in 2003 to 1133 in 2011. And in February this year, despite public opposition from doctors including a group of 160 paediatricians, Belgium’s parliament voted to allow euthanasia for terminally ill children who request it and have parental support. Some slopes actually do slip.

Theo Boer, a Dutch former supporter of physician-assisted suicide, has spoken out against Lord Falconer’s bill based on the Dutch experience. He knows what he is talking about: he is a member of one of the Netherlands’ five regional review committees charged with assessing whether instances of euthanasia were conducted in accordance with the law.

Noting how assisted deaths have increased in number by about 15 per cent every year since 2006, such that physician-assisted euthanasia is now “on the way to being a default mode of dying for cancer patients,” Boer has noted that whereas the Netherlands’ law continues to see assisted suicide and euthanasia as exceptions, “public opinion is shifting towards considering them rights”, with corresponding duties on doctors to act. The parallels with Britain’s abortion law are, again, startling.

The law in the Netherlands presupposes an established doctor-patient relationship, but does not demand this, and this ambiguity has led to the Dutch Right to Die Society having founded a network of travelling doctors who typically see a patient just three times before administering drugs to end their life.

Boer has expressed concern about this development and about how the type of patients who are being ‘helped to die’.  Numbers of euthanised patients with dementia or psychiatric illnesses are now sharply on the rise, and there have been cases where a large part of the suffering of those given euthanasia or assisted suicide consisted in being aged, lonely or bereaved. These people could, with proper care and support, have lived for years if not decades.

Horrified by these developments, Boer’s warning to Britain is stark:

I used to be a supporter of legislation. But now, with twelve years of experience, I take a different view. At the very least, wait for an honest and intellectually satisfying analysis of the reasons behind the explosive increase in the numbers. Is it because the law should have had better safeguards? Or is it because the mere existence of such a law is an invitation to see assisted suicide and euthanasia as a normality instead of a last resort? Before those questions are answered, don’t go there. Once the genie is out of the bottle, it is not likely to ever go back in again.

[Greg Daly]

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