Assisted suicide vs prolonging death: Is there a third way?

Three days before admission he had a fall that resulted in bruised ribs. He was unable to breathe deeply or cough properly – hence the pneumonia.

A trainee doctor admitted him and said that he wanted to insert a cannula so that intravenous antibiotics could be given.

Mr B declined, saying that he did not want antibiotics, but would prefer that “nature should take its course”. He wanted to be kept comfortable, nothing more.

The junior doctor was perplexed and reported Mr B’s refusal to the registrar. The registrar then went to Mr B’s bedside to try again: “Mr B, you’ve got pneumonia, and we want to get on top of it for you”, she said.

Again, politely, Mr B declined to have the cannula. This time the registrar informed the consultant, who rang Mr B.s daughter and asked her to come to the hospital.

READ MORE: Glasgow man backs right to die law change after father's cancer ordeal

The consultant briefed her and they approached Mr B together. The daughter urged him to accept treatment:“Dad, you need to do this. We all want you to get better”.

The collusion worked. Mr B conceded. The cannula was inserted and antibiotics were commenced. Mr B’s pneumonia gradually improved.

However, on day four, Mr B said that he wanted to be discharged - “to end his life at home”. This statement was interpreted as “suicidal ideation”.

Dr Robin Taylor is a consultant physician in the NHS (Image: RobinTaylor)

A referral was made to the Liaison Psychiatrist, and although Mr B was not considered clinically depressed, he was commenced on anti-depressant medication.

Then on day eight, out of the blue, Mr B had a major seizure. He did not recover consciousness and died. Parkinson’s disease is only rarely associated with seizures.

No post-mortem was undertaken. However, it was later speculated that Mr B had secretly stored his medications in his locker and had taken them all at once.

From every possible angle, this case is disturbing.

What was the dominant thinking of the trainee doctor, the registrar, the consultant, before they got Mr B’s daughter to apply emotional leverage?

What was the daughter’s reaction to her father’s wish: “I don’t want antibiotics. I just want to die”?

Was it right that what Mr B said was labelled as a psychiatric problem? What were Mr B’s inner thoughts during the days when he was improving? Was he angry that he was getting better?

Was he in despair that his wishes had been so constructively dismissed, that his perspectives had not been respected? How alienated and lonely had he been made to feel by those who were allegedly caring for him?

The philosopher Ivan Illich anticipated a case like Mr B’s in his book “Medical nemesis: the expropriation of health” (1976).

Illich describes the medical profession as being in a “total war” against death. He rails at the power of “the system” in which asserting autonomy is labelled as a form of deviance.

READ MORE: Dr Catherine Calderwood on giving Scotland a dose of 'realistic medicine'

Even more pertinently, in 'Illness and culture in the postmodern age' (2000), David Morris writes: “The modern deconstruction of mortality has led us to an impasse. Patients at the end of their lives are trapped between, on the one hand, health systems designed to keep bodies alive indefinitely, and on the other, understandable but reckless clamour for physician assisted-suicide as the only alternative to ignominious physician-assisted suffering.”

It seems obvious that Mr B’s wishes should have been accepted. Yet their legitimacy was denied.

This is not uncommon. NHS hospitals are, after all, vehicles for a prevailing cultural ethos: survival is everything.

We are a death-denying and death-defying society. But too often we are wilfully blind to the fact that eventually all treatments will be futile. In the end they will deliver more harms than benefits.

Our hospitals are where you go to get everything fixed. That was the priority of the clinicians looking after Mr B. Together with his daughter, everyone thought that they had Mr B’s best interests at heart. But they were mistaken.

Right now in Scotland, those who wish to go further than just “allow a natural death” are making their voices heard. That assisted dying should have been available to Mr B is now on the public radar.

Advocates champion two ideas. The first is the relief of suffering and the second is personal autonomy. I agree strongly that these are critical elements of good medical care.

Agreeing “What are we trying to achieve?” and “What should be done if things get worse?” should shape everyone’s priorities whenever someone is admitted acutely to hospital.

Paradoxically, by always striving to achieve survival - we have indirectly helped to justify assisted dying. “I wouldn’t do that to my dog” is a crude judgement about what happens when “fix it” medicine is out of control and doctors become complicit in contributing to a patient’s suffering.

This is wrong. Together with the society that we serve, doctors define success in narrow, biological terms. Fixing Mr B’s pneumonia was the priority for everyone except the patient.

Assisted Dying legislation is not the answer to these complexities. In the vast majority of patients palliative care makes “dying with dignity” entirely possible.

We must not abandon the restriction that wisely precludes doctors from colluding in the death of a patient. The present law provides a critical safeguard. It ensures that a patient can place watertight trust in a doctor’s motives and the integrity of their advice because death as a treatment is out of bounds.

The principles of the Hippocratic oath still govern how doctors practice, as well as how patients perceive our role. I quote: “Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course”.

READ MORE: Lawyers examine assisted dying plan to avoid gender-style clash with UK Govt

Do we somehow think that the wisdom of the 21st century is an improvement on what has been an anchor of medical ethics for 2400 years?

When someone is admitted to hospital, they are at their most vulnerable. They may meet upwards of 10 to 12 doctors in a matter of days.

Trust in all the medical practitioners they meet is a vital commodity and whatever their failings, it is understood that doctors are never going to be the agents or advocates of death as a treatment.

Advocates for Assisted Dying highlight that proposed legislation will have safeguards. But in countries where legislation is enacted, safeguards have frequently been eroded.

In Canada, five years after its introduction, medically assisted dying for those with unbearable suffering was changed into “the right to die”. The Canadian parliament is now considering that the “right to die” should be extended to those with mental illness and minors with disability.

No legislation can define “unbearable suffering”. Once granted to a few, it is illogical not to grant assisted dying to the many. The provisions of MSP Liam MacArthur’s Bill would currently preclude Mr B’s eligibility.

But who would stand in the way if Mr B pleaded for assisted dying and it were available behind the scenes? Who is going to enforce the proposed law’s safeguards?

Liam McArthur has stated publicly that doctors who do not wish to be involved in medically assisted dying will be “supported”. But the obligations that his Bill will impose, contradict his claim.

In 2015, the UK Supreme Court passed a judgment in a case entitled “Montgomery versus NHS Lanarkshire”. The Court ruled that the requirement for ‘informed choice’ or ‘informed consent’ for patients rests fundamentally on the duty of disclosure by medical practitioners of all reasonable treatment options.

Liam McArthur is bringing a third attempt to pass assisted dying legislation in Scotland (Image: PA)

Case law already indicates that there can be no freedom of conscience regarding assisted dying as a treatment option for terminally ill patients. In keeping with this, Liam McArthur’s Medical Advisory Group proposes that training in assisted dying conversations should be mandatory for all doctors. This too is wrong.

But there is a third way.

We must renounce our addiction to “fix-it medicine” and the needless harms and suffering that too often go with it. We cannot fix all of the people all of the time. And futile treatments often deliver harms.

“Dying with dignity” should indeed have been the priority for Mr B - experienced as shared decision-making, agreed goals of treatment, and, when he needed them, palliative treatments.

These things ought to be the norm for every patient. But equally we must avoid the perils of assisted dying.

Pursuing death as a treatment for human suffering is not the answer. The price will be far too high across the whole of the NHS.

D. Robin Taylor is a consultant physician working in the NHS in Scotland. He is writing in a personal capacity