By Helen Watt

The Terminally Ill Adults (End of Life) Bill would permit assisted suicide in England and Wales for mentally capable adults reasonably expected to die within 6 months. Progress on the Bill has met a roadblock:  we now wait as the House of Lords begins committee-stage consideration.  After vigorous debate in the Lords, during which opponents of the Bill – at least in its current form – outweighed supporters two to one, a House of Lords Committee will now hear evidence from office-holders and professional groups.

Before the Lords debate, I watched a Belgian documentary on euthanasia, where during a leisurely and gentle series of interview clips, oncologist Catherine Dopchie spoke of a colleague in palliative care whom she described as very competent and close to her patients.  When one patient wanted euthanasia, her colleague spoke of loyalty to that patient, saying “I don’t want to do that, I don’t think it’s good, it’s not palliative care, but I am erasing myself, I no longer exist, and I am becoming a hand that euthanises her.”

Dr Dopchie commented,

“But for me, what my hand does, my heart does. I cannot dissociate an act that I produce from what this act will do inside of me.”

The “heart” – meaning here, the moral core of the person – cannot be split from the “hands” carrying out another’s wishes.  A doctor is not a robot, not a tool.  And this applies not just to hands that give lethal injections but to hands that write suicide prescriptions, help patients take suicide drugs or sign off on applications.  Suicide is not something to encourage, not something to assist.  It does not treat and it does not heal.

There are important distinctions in “cooperation” in wrongdoing or even perceived wrongdoing – above all, the distinction between “formal” cooperation (such as where the assister shares the intention of the patient and colleagues that suicide occur) and “material” cooperation (where someone assists in effect but not in intention).  Yet important as this distinction is – and very relevant to conscientious objection –  “material” cooperation can also be unacceptably “close”  in various ways to the wrong done by the main actor or actors.  When double effect principles are applied, unintended harms may be in no way outweighed by any benefits:  cooperation may send out a strongly complicit message to main actors and others, destroying opportunities to witness to a wrong or even to protect a vulnerable person.  For example, a pharmacist in training who helps prepare suicide drugs, not with the intention anyone die, but with the intention of pleasing his trainer is closely and “scandalously” implicated in the suicides he assists. His very obvious causal involvement in the patient’s death strongly suggests absent or lacklustre moral objections or even outright approval.

What about cooperation using not one’s hands but “merely” speech or silence?   Silence or vague words about a planned assisted suicide a health care professional is not intending to enable would be material cooperation.  Again, this may be justified or otherwise depending on the goods at stake, including the possibility that the patient or colleagues could still be dissuaded.  But if the health care professional has the specific intention the patient access assisted suicide, she “formally” cooperates in assisted suicide.  The professional intends whether by speech or silence to facilitate the patient receiving assistance to take his own life.

What of a doctor who engages in a “preliminary discussion” with the patient, of the kind referred to in the current Bill?  Such a doctor may again intend – even if conditionally – that the patient take suicide drugs, if found to be eligible.  Alternatively, the doctor may not intend this, but may simply want to have the conversation, because they see responding to suicidality as part of their normal work and/or because they do not want such discussions restricted to doctors who favour assisted suicide.

Whether the Bill’s  “preliminary discussions” can be reasonably engaged in by doctors opposed to assisted suicide will depend on the details.  What will they be expected, in any final law or guidelines, to say to the patient or report to others?   A quick generic recital of legal facts may perhaps be compatible – albeit with some strains – with the normal protective response to patient suicidality.  But it may transpire that any doctor agreeing to a preliminary discussion will be expected to provide, or refer for, precise details of assisted suicide “care” and how to obtain it.  Giving similar details would be inconceivable with “private” suicide (as with information on high buildings, lethal doses of over-the-counter drugs or Swiss suicide providers).  And if doctors do not want to provide, or refer for,  details on how to access assisted suicide, and are therefore recusing themselves from the Bill’s “preliminary discussions”,  they may also not want to signpost, as the current Bill requires, to those with fewer qualms.  If risking patient suicide is harmful, it is harmful both for colleagues and those who point in their direction.

The Royal College of Psychiatrists has expressed serious concerns about the Bill, not least because its provisions are difficult to reconcile with their normal response to suicidal patients. Such patients include those who would not in any case be eligible for assisted suicide but may ask for information on how to access it.  Will doctors seeking to protect a patient precisely against suicide be pressed to have – or signpost for – a how-to consultation that may be exactly what he or she does not need?

A change in the law is not inevitable, and seems less likely after the Lords debate. As we continue to discuss the Bill, we need to consider not only conscientious objection but the nature of health care in terms of protecting – or at least respecting – functionality and palliating unpleasant symptoms.  Suicide assistance does none of that:  it is not health care but has the reverse aim and effect. On that ground alone, no person, and no organisation, should be pressed – or arguably, permitted – to join a suicide-enabling chain.

Author: Helen Watt

Affiliations: Senior Research Fellow, Bios Centre, London

Research Fellow, Blackfriars Hall, Oxford

Competing interests: None declared

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