Arun Bhaskar: The inescapable truth: palliative care is not enough—we can and should legislate for assisted dying

The standard of palliative care in the UK is exemplary. We are able to provide expert, compassionate care to a great many terminally ill people and we rightly hold our hospices and their workers in high regard. We bemoan the fact they are under funded and that access is still patchy, as is the case with many areas of medicine. But this should not prevent us from taking an honest look at palliative care, examining its limits or investigating whether assisted dying can or should be a viable part of it. 

Recent research from Dignity in Dying has done that. Their report makes for uncomfortable reading. New data from the Office of Health Economics finds that even if every dying person who needed it had access to the level of care currently provided in hospices, 6,394 people a year, or 17 a day, would still have no relief of their pain in the final three months of their life. This estimate does not include those who receive only partial pain relief or who suffer with other equally distressing symptoms. This chimes with polling commissioned for this report which finds that more than four in ten healthcare professionals (43% out of 1,008 asked) have experience of caring for someone who has suffered at the end of life despite receiving high quality palliative care.

These new data debunk the oft-cited argument that better funding or access to palliative care negates the need for assisted dying. The reality we must accept is that there is a significant minority of terminally ill patients whose suffering cannot be controlled by even world-class palliative care. Can we not consider providing those patients with another option that would allow them to determine their limit and decide to shorten their suffering in a dignified, swift, and painless way?

The report also examines current end of life practices, such as voluntary stopping eating and drinking, palliative sedation, withdrawal of treatment and the doctrine of double effect (whereby medication can be administered to relieve a patient’s symptoms in the knowledge that it could also hasten their death, so long as that is not the primary motivation). These options can provide many dying people with good deaths, but they can also result in unnecessarily prolonged and distressing ones. They involve careful judgments by healthcare professionals about prognosis and mental capacity and are no less ethically complex than assisted dying. According to this new polling, fewer than a quarter (24%) of healthcare professionals think refusing treatment to bring about death is more ethical than giving people the option of an assisted death. It is also worth noting that current options involve fewer checks and balances than the proposed assisted dying legislation (two independent doctors and a high court judge would need to sign off on a request, among other safeguards). 

The report makes the case for a change in the law to allow assisted dying for terminally ill, mentally competent adults alongside improvements to existing palliative care. I consider this as a serious and welcome suggestion. As a consultant in pain medicine with a background in anaesthetics and significant experience in treating cancer pain, I acknowledge that there are limits to what we can offer some dying patients who are suffering unbearably. And others appear to feel the same: only one in ten (13%) healthcare professionals think that without an 

assisted dying law there are sufficient options to give dying people meaningful control over their deaths. 

In lieu of meaningful choice, many dying people are forced to take matters into their own hands by travelling abroad for a legal assisted death or ending their own life at home. Doctors are also stepping in to fill the voidmore than six in ten (62%) healthcare professionals believe doctors or nurses have intentionally hastened death as a compassionate response to a patient’s request to end their suffering. It would be far safer for all involved to have a transparent assisted dying law with clear, upfront safeguards and monitoring. 

This report suggests that I am not alone in believing palliative care is not the panacea it is often purported to be. And yet there appears to be a collusion of silence in the sector, as if questioning its limits or suggesting that assisted dying could be part of it is simply a matter of far fetched opinion rather than anything based on hard evidence. Five palliative care consultants wrote in The BMJ in March about this stifling of open and honest debate. It is telling that they only felt able to air their views anonymously. 

Access to healthcare is a basic human right, but I feel that by denying our patients the choice of assisted dying we are disrespecting them as individuals and disregarding their rights. To force someone to suffer against their wishes and endure a drawn-out death is torture. This is not acceptable in a civilised society. In my view, a change in the law to allow assisted dying in limited circumstances and with robust protections is the only appropriate response to the findings of this report.

Arun Bhaskar is a consultant in pain medicine and President of the British Pain Society.

Competing interests: None declared