Wes Streeting’s scheme to shame NHS Trusts shows you exactly why he is the Blairites’ crown prince. But that means that if he made it clear that he would resign rather than accept the statutory duty that the Assisted Dying Bill would impose on the Health Secretary, then that Bill could not be given Government time, thereby guaranteeing that it would fail. As Dan Hitchens writes:
There is a popular image of assisted suicide: a swift, straightforward procedure, backed by the awesome authority of modern science, sure to send you off in a comfortable doze. Dignity in Dying, for instance, claim that assisted suicide can “guarantee” a calm and peaceful death. Terry Pratchett expressed his wish to die “sitting in a chair in my own garden with a glass of brandy in my hand and Thomas Tallis on the iPod”.
Now compare the experience of Linda van Zandt. In 2016, on the day of her aunt’s assisted suicide in California, an Uber arrived bearing thousands of dollars worth of lethal medication. That included 100 capsules which had to be crushed, dissolved and swallowed within the hour. Wearing latex gloves and wielding toothpicks, the family frantically scraped the white powder from the capsules, combining it with a sugar syrup to make a bitter sludge so “vile” that van Zandt broke down in tears. Afterwards, she sat at her kitchen table wondering: “Who wrote this law?”
That, to be clear, isn’t everyone’s experience — but then nor is the romanticised picture presented by assisted-suicide advocates. The vision of people like Pratchett “is not the clinical reality”, says Mark Taubert, palliative care consultant and professor of medicine at Cardiff University. Claud Regnard, a retired consultant, points out that only two studies have compared “quality of death” by assisted suicide and by nature taking its course. Both studies, one in Oregon, one in the Netherlands, concluded that they were as good, or bad, as each other.
Assisted suicide relies on lethal drugs. But how reliable are the medications themselves? An article in a leading medical law journal remarks: “The pervasive belief that these, or any, noxious drugs are guaranteed to provide for a peaceful and painless death must be dispelled; modern medicine cannot yet achieve this.” On every point — the supply chain, the means of administration, the risk of complications — the reality is far from straightforward. But that reality is about to hit Britain as the Leadbeater Bill on assisted tying is being debated by MPs on 29 November.
Take Mehdi Alavi’s Dream Pharma — which operated out of the Elgone Driving Academy in Acton. In 2011, this one-man firm was suddenly placed under the spotlight of an international human rights story, as it emerged that it was supplying Arizona’s death penalty system with deadly chemicals.
Why did Arizona have to rely on a man at a driving school in Acton? Welcome to the strange world of lethal drugs, a shadow world largely unmonitored by health authorities, where supply chains can suddenly disappear, where new experimental mixtures come and go, and where best practice remains decidedly unclear.
When it comes to the physical stuff doctors depend on, assisted suicide and the death penalty are entwined. In the early 2010s, European companies launched tough new restrictions on the export of certain drugs to the US because the drugs were being used for capital punishment. That explains the emergence of individual suppliers such as Mehdi Alavi. But these small-scale alternatives were soon banned by American courts too. US pharma companies also stopped making the drugs used in assisted suicide — possibly because there are few other medical uses for them.
“US pharma companies also stopped making the drugs used in assisted suicide — possibly because there are few other medical uses for them.”
The shortage caused problems for penitentiaries and assisted-suicide clinics alike. One chemical, until then a popular choice in assisted-suicide states, practically disappeared from the market. Assisted-suicide doctors’ groups scoured America looking for the drug, but to no avail. Next they turned to another chemical which was supplied by a company called Valeant. The company was plagued by scandal and investigated for price gouging; the price of the drug rose from around $400 to almost $3,000 per lethal dose between 2010 and 2016.
In the end, American assisted-suicide doctors had to come up with their own solutions. But the blend of toxic substances caused “severe pain” , so physicians tried out other combinations, tweaking the formula half-a-dozen times. Across the globe, meanwhile, there are countless variations: more than 30 chemicals are used in the different forms of oral or intravenous assisted suicide.
As with death penalty procedures, then, there is no gold standard, but rather a great variety of options, none of which has established itself as the most appropriate. According to an article in The Lancet, complication rates with assisted suicide may be even more frequent than those with the death penalty.
How serious are those complications? The data is extremely patchy, but some have attempted statistical estimates. With oral methods, a third of assisted suicides take between 90 minutes and 30 hours. Up to 9% have trouble swallowing the dose; up to 10% vomit it up; up to 2% re-emerge from their coma. There are also horror stories, such as the Dutch woman with Alzheimer’s who recovered consciousness and was held down by her daughter and husband while a doctor finally euthanised her.
Then there are the unknowns. Baroness Finlay, a palliative care specialist, told the parliamentary committee on assisted suicide last year that during executions by lethal injection, “four-fifths probably regained a degree of consciousness”. Finlay said that though there is an obvious need for more research on consciousness in euthanasia and assisted suicide, nobody has ever done a proper study.
Not everyone is so sceptical. As Silvan Luley of Dignitas has claimed: “There has been not one case that did not work, in the sense of the person not reaching the goal in a dignified way.” Dr Lonny Shavelson, of Bay Area End of Life Options, has made similar claims. “These,” he says, “are lovely deaths.”
But every claim and counterclaim should be qualified by the fundamental point: the evidence base is inadequate. No drug regulatory authority anywhere has approved any drugs for use in assisted suicide. The 2019 protocol from the Canadian Association of MAiD Assessors and Providers acknowledged that there had been “little to no research” on their recommended combinations, and “no peer-reviewed literature to guide best practice”.
In the British context, meanwhile, supporters of assisted suicide seem conscious of the need for more research. Dignity in Dying told me in a statement that assisted-suicide drugs “are under constant review amongst clinicians and that best practice is constantly developing”, and that the UK procedure would depend on “engagement with healthcare bodies and regulators”, drawing on other jurisdictions “where they are confident that the drugs used are safe, effective and provide dying people with a dignified death”.
Which drugs might a future UK assisted suicide programme adopt? The Leadbeater Bill mentions none specifically, simply stating that the “Secretary of State must, by regulations, specify one or more drugs or other substances”. Leadbeater has not given any view on the subject; her chief of staff Lance Price tells me that it would be a matter for NICE and other regulators. NICE didn’t respond to a request for comment. For their part, UK doctors themselves seem unaware of the challenges. As a 2016 report by the British Medical Association found, some physicians were “surprised” to learn that assisted suicide could come with complications.
Dr Regnard, who is not against assisted dying per se told me that the introduction of such unevidenced drug combinations would be completely unprecedented. “I think it puts us back 100 years to when there was no regulation, basically people could do pretty well what they wanted.”
In the end, the assisted suicide debate will hinge less on these questions, though, and more on the familiar trade-offs between personal autonomy and threats to the vulnerable. Yet that shadow world of lethal drugs suggests a broader point: that taking life is, at the very least, an awkward fit with healthcare — and that when these cocktails are introduced into a medical system, the system itself inevitably changes. You can call Kim Leadbeater’s proposal brave or reckless. But it would surely be the biggest experiment ever conducted on the NHS.
Yuan Yi Zhu writes:
Labour MP’s Kim Leadbeater’s assisted dying bill has the “strictest safeguards anywhere in the world”, according to Labour MP Kim Leadbeater. In fact, the safeguards are so strong that Leadbeater could not even tell us what they were when she published those words at the weekend.
At least now we have the safeguards, such as they are, in print. The 38-page-long private member’s bill has been published just over two weeks before MPs are permitted five hours to discuss it and then decide whether to legalise state-sponsored suicide.
And what of these famous safeguards? Two doctors are required to sign off on an assisted suicide request, but the first doctor gets to pick the second (the “independent doctor”, allegedly). And if the second, “independent doctor” doesn’t like the look of the application, the first doctor gets to choose another “independent doctor”, a practice known as doctor-shopping, which has led to no end of abuse in places such as Canada — whose experience of euthanasia, by the way, is not relevant according to Leadbeater because it’s a very big country.
Then, the High Court must approve the request. Proponents of the bill have made much of this. There are 18 judges in the Family Division of the High Court. Proponents of the bill estimate that there might be 1,000 requests per year, which comes to about 50 applications per judge each year. Yet if we use Oregon — America is also a very big country, but assisted suicide promoters like to use Oregon as the best-case scenario — as a baseline, we are talking about more than 400 applications per judge a year.
Mind you, these 18 judges have other things to do as well: divorces, child custody, and the rest. At eight cases per week per judge, they cannot be anything but rubber stamps. Alternatively, cases could be passed to judges lower in the family courts hierarchy, which would mean that a big-money divorce case, say, will be dealt with by a more senior judge than an assisted suicide application.
Doctors are supposed to satisfy themselves that the applicant has not been coerced into making the request. But doctors are explicitly allowed to broach the subject of assisted suicide with their patients. Put yourself in the shoes of a patient on their sickbed. The doctor comes in and says, sotto voce: “Have you considered… making a dignified exit? We are very short of beds, you know.” Is this coercion? Not according to the Leadbeater bill, which proposes that killing yourself is healthcare, so why not discuss it with your favourite medical professional?
How would doctors detect signs of coercion, since they are not trained in spotting coercive control? Christine Jardine, a Scottish Liberal Democrat MP and a co-sponsor of the bill, had a fun time on Newsnight, when presenter Victoria Derbyshire asked her this exact question.
“I think we are talking about people who are in a heart-breaking situation,” began the hapless MP for Edinburgh West. “Hopefully, there would be questions, hopefully they would examine the person”. Pressed again for an answer, Jardine mumbled something about sincerity on the deathbed, then said that safeguards would be put in place if the bill is passed. “I thought this bill had the strictest safeguards in the world,” said the incredulous interviewer.
If, after watching the excruciating nine-minute clip, you still have trust in the bill’s safeguards, you are made of sterner stuff. Or perhaps you have your eye on Granny’s bungalow in a nice postcode. In any case, not even the bill’s boosters really believe what they say about the safeguards. This week, Humanists UK told MPs to vote for the bill even if they “are concerned about the practicalities” therein, which does not sound like a vote of confidence in the “strictest safeguards in the world”.
Meanwhile, Leadbeater has been telling MPs to vote in favour even if they are undecided about the issue, simply because it could be a long time before they get another chance at legalising assisted suicide.
She needn’t worry: Parliament has debated or voted on the issue in 2021, 2015, 2014, 2009, 2008, 2006, 2005, 2004, 2003, and 1997. And if Leadbeater and her backers have their way, Parliament will continue to do so year after year, until they get the outcome they want, at which point it becomes a “settled question”, sacrilegious even to question.
But this is not a settled question. In a world of collapsing healthcare and social care systems, of strained NHS budgets, and of greedy relatives, there is no way to legalise assisted suicide safely. Parliamentarians knew this, which is why they rejected it 10 times in the last 30 years. They must now do so again.
And Professor Kevin Yuill writes:
The controversial Terminally Ill Adults (End of Life) Bill was published late on Monday night. This private members’ bill (PMB) is being brought forward by Labour MP Kim Leadbeater and will be debated and voted on in the House of Commons at the end of this month. That gives MPs just over two weeks to make up their minds on whether assisted dying should be legalised in England and Wales.
At almost 40 pages, this is one of the longest PMBs ever. MPs will have until just 29 November to scrutinise the bill’s opaque, ambiguous and often contradictory language. They will also only have five hours to actually debate it in the Commons. Compare this with Brexit, which prompted more than 500 hours of debate in parliament – even after the public had already made up their minds in the EU referendum.
There are certainly a lot of disturbing points in the bill that warrant serious scrutiny. First, it would make it legal for a doctor to suggest assisted suicide to a patient who hasn’t previously expressed interest in it. At the same time, it would not allow a doctor to refuse to have any part in facilitating an assisted suicide on the grounds of conscience. Even if a doctor objects to approving a patient’s death, he must recommend another physician who might. For all the pro-assisted-dying camp’s talk of this bill responding to public opinion, polls actually show that most Brits don’t want doctors to be coerced into facilitating the deaths of their patients.
A lot also hinges on a patient being considered ‘terminally ill’. Any patient expected to die within six months would be eligible for assisted suicide. But doctors can get these kinds of prognoses very wrong. In fact, studies have shown that doctors are more often wrong than right when they predict that a patient will die within six months.
Moreover, the phrasing of the bill is ludicrously vague. It specifies that a patient must have ‘an inevitably progressive illness, disease or medical condition which cannot be reversed by treatment’. In theory, this could in future include those with Type 1 diabetes, since insulin does not ‘reverse’ the primary condition.
The bill’s definitions are also confusing and misleading. It defines terminal illness as a ‘medical condition which cannot be reversed by treatment’. But at the same time, it states that a person cannot be ‘considered to be terminally ill by reason only of the person having… a disability’ – something that, by definition, is terminal and irreversible. Similarly, the doctor can ‘assist’ a patient to take lethal drugs, but not cause the patient’s death by directly administering those drugs. The doctor must remain with the person until death occurs, but need not necessarily ‘be in the same room as the person to whom the assistance is provided’. This makes no sense at all.
Many aspects of the bill are simply not practical, either. It calls for the High Court to approve all assisted-suicide applications. Judges would have to hear from at least one of the doctors who approved the patient’s application and could potentially also question the dying person. If assisted suicides occur in England and Wales at roughly the same rate as they do in the US state of Oregon, where it has been legal since 1997, we would be looking at around 5,000 applications every year. There are just 18 High Court judges in the family division who would be expected to deal with these cases. Plus, as Justice Munby, former president of the High Court family division, has pointed out, it is not at all clear the role the judge is supposed to play. ‘To what extent is the judge expected to exercise a discretion?’, he asks. You can’t help but suspect their role will be to rubber stamp doctors’ decisions.
Other aspects of the bill are bafflingly slipshod. For example, patients may give their consent to assisted suicide by electing a ‘proxy’. The proxy can sign forms on the patient’s behalf for ‘reason of physical impairment, being unable to read or for any other reason’. Any other reason? This is a loophole begging to be exploited by abusive family members or carers.
Astonishingly, some still don’t think the bill goes far enough. Esther Rantzen, broadcaster and assisted-dying advocate, suggests it should be extended to people with ‘chronic illnesses that can cause months of unbearable pain and distress’. She is not alone in thinking this. According to the Telegraph, 54 cross-party MPs are also demanding the criteria of the bill be expanded.
Interestingly, prime minister Keir Starmer, who earlier this year promised Rantzen to give MPs a vote on assisted dying, did not back the bill immediately. Instead, he said that he ‘will study the details’ because ‘safeguards have always been extremely important to me’. Assisted dying is one of the few issues Starmer has shown some consistency on during his career. Could the bill really be so bad that it could change his mind?
Sam Leith, literary editor at the Spectator and supporter of assisted dying, is also not convinced by Leadbeater’s bill. He called it a ‘botch job’, a ‘disappointment’ and a ‘danger’.
Hopefully, the shoddiness of the assisted-dying bill will give MPs pause for thought. Beyond its botched drafting, it would fundamentally change the relationship between state and citizen. It would alter the NHS’s ‘cradle to grave’ ethos and the relationship between doctor and patient. It would remove our moral sanction against suicide, and would divide the population between those whose suicides we try to prevent and those who we offer a push as they teeter on the proverbial ledge.
I hope MPs have the sense and courage to reject this bill.
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