Dr Matthew Doré – Palliative Care Consultant
Northern Ireland Hospice & Belfast Trust
Hon Sec of APM and Co-lead Clin ECHO

This is the question weighing heavily on the hearts of many palliative care physicians. The numbers of palliative care physicians are clear (5 surveys over 10 years): roughly 80% oppose assisted dying, 15% remain neutral, and 5% support it. Now, that 5% faces a critical choice – do they stand in solidarity with their palliative care colleagues, or do they allow the system to evolve in a way that may erode their colleagues’ standpoint?

It is now incumbent upon the 5% and all proponents to make a choice. Will they facilitate a model where the majority of palliative care can coexist separately from assisted dying? Or will they compel involvement as a societal change? Much of this debate has centred on the imposition of one view over another. The victors are now the decision makers, and therefore, I speak to them.

Proponents of assisted dying often argue that palliative care and assisted dying can more than co-exist; they can have one and the same function. They describe palliative care as a speciality that excels in symptom control, psychological support, social and spiritual guidance – all of which is true. In their view, palliative care’s expertise in holistic symptom management naturally extends to facilitating the choice of an assisted death.

But I believe there is something deeper at the heart of palliative care – something beyond symptom relief or even choice. The true magic of our speciality lies in its unwavering affirmation of human worth. The phrase “welcomed into the embrace of the hospice” captures it perfectly. Often, we don’t rush to adjust medications; first, we simply welcome the patient into the hospice. And something remarkable happens – they relax. We show them, in word and deed, that they matter. That they are valued unconditionally.

This, to me, is the essence of the word ‘dignity’ – which is not a variable state, not something that can be measured or lost, but an inherent human truth. You can’t gain ‘dignity’ by what you do, nor can you lose ‘dignity’ by what has happened to you. It remains a constant. It is not about asking, “How much dignity do you have left?” but rather, “How do I honour your inherent dignity?” Everyone has the same invaluable innate dignity, whether you are rich or poor, a prisoner or a politician, disabled or with learning difficulties, suffering from a fungating wound or uncontrollable vomiting. You are infinitely valuable because you are you. As the Universal Declaration of Human Rights outlines, “recognition of the inherent dignity …[of the human family]”

This unshakable affirmation of worth is what palliative excels at. In the face of terminal illness, in moments of profound loss and self-doubt, our ethos whispers: You matter.

Some may argue that offering “choice” is itself an act of bestowing worth. And this is true until a point, but it becomes obvious that ‘individual choice’ is born out of an ‘individual’s innate human worth’ and not the master of it. It is when someone feels broken, when they question their very existence, when they feel a burden, that what they seek most is not choice – it is acceptance. It is love. For over sixty years, hospices have reassured patients: “We don’t kill you.” I personally don’t want this to change, because when the patient is admitted, they discover an even deeper truth: We cherish you.

The fundamental rock of the unshakable, unconditional, unwavering worth bestowed upon the person at their most vulnerable point is at huge risk of being broken when we say, “have you considered lethal medications?” No matter how kindly asked.  

I ask, sorry, no, I plead to my colleagues who advocate for assisted dying to separate these two out. I ask my colleagues to protect this old ethos of palliative care and not impose an ethos that dignity is synonymous with a complete individual autonomy. I ask for your support to strongly reconsider a complete opt-out for the hospices, care homes and indeed wider specialist palliative care organisations who hold to the above ethos. Please separate the two completely and utterly. Or else we risk the magic of palliative care being lost.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.