Whatever else, arguments for and against assisted dying must include the notion of cruelty. In my view there can be little more cruel than to decline the request for help in, or advice on, dying from patients of sound mind, who are competent to make decisions, who are suffering unbearably from a disabling disease for which there is no prospect of improvement, and who have made it clear that they no longer wish to live. On grounds of cruelty alone, we as doctors should be campaigning for change, for the introduction of laws that permit us to assist. Yet overall as individuals there seems little interest in the fight, while our leading medical organisations (British Medical Association, Royal College of General Practitioners, Royal Society of Medicine, Royal College of Physicians) actively oppose change.
For me, this all seems to suggest that doctors are institutionally, and all too often individually, cruel, and certainly there is evidence for this in our history. As a doctor I have been witness to, and in some instances involved in, behaviour that was unquestionably cruel. I well remember how teams of us (nurses included) would forcibly restrain (grapple with and hold down) resistant (‘difficult’) patients to introduce a gastric tube in order to wash out tablets taken in overdose. Committing suicide was then illegal and instructions to carry out gastric lavage were followed without a second thought. Our behaviour was quite horrible, but was justified by those in the medical profession who took the we-know-best position, and argued we were being ‘cruel to be kind’. Others will have taken the ‘sanctity of life’ position, arguing that above all else, life must be saved. Whatever the defence, nowadays forcefully washing out the stomach in this way would be unthinkable.
One might suppose that the assault of patients who had taken an overdose was an isolated example of cruelty but not so, after all, doctors were similarly involved in force-feeding prisoners on hunger strike. In another example cruelty was seen with the introduction of law to permit abortion. Here change was driven by public pressure rather than by medical foresight, and against which there was actually opposition from at least two of the Royal Colleges. Remember too our treatment of patients with intractable pain. There was none of the modern idea of giving analgesics to prevent pain developing. In those old (more puritanical) days, it was not uncommon for patients to be given their analgesia once the pain was intolerable and then only when they asked (sometimes begged!) for it – a relationship that was both cruel and demeaning. And in a much smaller way this still goes on. It hurts a lot when an artery is punctured but this can easily be prevented by injecting local anaesthetic around the vessel. At present such prophylaxis is rarely used leaving patients to ‘grin and bear it’.
Examples of cruel (demeaning) behaviour do not stop here once one recognises that cruelty does not necessarily involve physical hurt. Not so long ago, and in the face of questioning, doctors routinely withheld from patients the details of their diagnosis (as, for instance, a cancer), the names of their medicines, and their results. And of course medical students were famously encouraged to undertake intimate examinations without permission while patients were anaesthetised. But these have changed as society has demanded that we look at ourselves and re-evaluate our practice.
But now to the substantive point. The kindest, most humane, most compassionate response to (‘legitimate’) requests for help in dying would be for doctors to aid patients, helping them have a dignified death at a time and place of their convenience. Death is a natural and inevitable part of the human condition, and for determined patients who want to end their lives, the alternative to assisted dying is to use their own devices. This, as with the old ‘back street abortion’, simply serves to make their end squalid, risky, and undignified. We should note how, in retrospect, the cruel behaviours we practised in the past are now seen as totally unacceptable. One day, the current practice whereby we deny people help in dying will be seen in the same way. On grounds of cruelty alone, we as doctors should be fighting to decriminalise assistance in dying.
This blog is based on one first published for a lay readership in greyhares.org
Joe Collier is emeritus professor of medicines policy at St George’s, University of London