A Lot More Clarity

Dr Cajetan Skowronski writes:

“In extreme cases I would be willing to kill a patient to help them escape unbearable suffering, if they had come to that decision after serious consideration,” says a colleague of mine, in the windowless, unventilated cupboard that serves as a doctors’ office, “But there is no way in hell that the NHS can be trusted with such a role.”

Those who deal with life and death each day recognise that giving patients lethal drugs to end their life is active killing, not passive dying. I happen to think that we should not kill ourselves or others. My colleague takes a different view on the principle. But we don’t shy away from what it is we are actually discussing, so our conversation benefits from a lot more clarity than when politicians emotionalised and euphemised to limp Kim Leadbeater’s assisted suicide bill through the Commons.

We discuss the systemic chaos that we see affecting patients every day, and imagine what the effects of introducing a new therapeutic option of being killed would be. US-style privatised medicine has a perverse incentive to keep the patient alive with increasingly extreme and expensive (but ultimately futile) interventions — a quarter of all Americans die in intensive care.

UK-style socialised medicine has an equal and opposite perverse incentive to reduce the number of patients, especially in times of crisis. And the NHS is broken, as everyone from government to general practice states openly.

Facilitating the suicide of privileged elites who are used to having things their way and see their mode of death as a final opportunity for exercising autonomy is one matter, but if that requires suicide to be offered to all of our patients, including the vulnerable, the lonely, and the abused, the real cost appears to outweigh any idealised benefits. How do we tell a homeless patient with a new metastatic cancer diagnosis that they could wait months for a nursing home placement, or they could be scheduled for an assisted suicide in as little as nine days, without it sounding like a tacit recommendation?

What will this do to the doctor-patient relationship? When I encourage frail patients to think about realistic ceilings of care so that they don’t suffer distressing and futile therapies, the conversation is usually welcomed. But will they still trust me if I combine this with an offer to poison them? As doctors, we are allowed to opt out of direct involvement, but we cannot hide the option from our patients once it is the law.

How do we square it with our work in suicide recovery and prevention? The prospect of saving a patient from a suicidal overdose they took at home, only to end up prescribing them a lethal dose of drugs at their request weeks later, will be a new reality.

How will institutions such as hospices, for which there is no opt-out under the Leadbeater bill, negotiate that without compromising their true purpose and the care of their patients?

What drugs are we supposed to actually use to kill our patients? The bill does not specify. Other countries use a mixture of sedatives, respiratory depressants and paralytics to stop muscles required for breathing, to cause a cardiac arrest by starving the heart of oxygen. Would that be a peaceful way to go? At least it would look peaceful to an observer; paralysed patients don’t protest.

Our discussion is cut short by an emergency bleeping from our ancient pagers, but it feels like we have covered more ground regarding practical considerations in a matter of minutes than a lot of our MPs did during the bill’s passage through the Commons.

Lord Falconer and Kim Leadbeater are continuing to spread the falsehood that the Lords have the right to scrutinise the bill, but not to block it from becoming law.

This is simply wrong. Under the Salisbury Convention, only government bills which were clear manifesto commitments would command this level of docile acquiescence from peers. Lord Falconer himself has voted against even government bills in the past, but now, a Private Members’ bill which scraped through the Commons by just 23 votes (its majority halved from Second to Third Reading) and was never part of the Labour manifesto is supposed to be waved through. The Shadow Attorney General, Lord Wolfson of Tredegar KC, speaking for the Official Opposition at the close of the Second Reading debate in the House of Lords, expertly put this argument to the sword, concluding “the idea that we should uncritically defer to the House of Commons seems to be the parliamentary equivalent of ‘heads I win, tails you lose’”. Quite.

Falconer and Leadbeater have the air of estate agents, implying that once you have had your offer accepted on a house after a single viewing, it is a done deal and there is no pulling out, even if your survey uncovers Japanese knotweed on the patio and asbestos in the walls.

Of course, the Lords can reject or amend to death a Private Members’ bill which has not been thought through. That is why the Lords exist — as a meaningful safeguard against dangerous law. For myself and my colleagues, we are trained to listen to patients, to question and assess and reassess, and to apply our expertise to each patient rigorously, lest through failure to forensically and thoughtfully consider likely outcomes and unintended consequences we render our patients ineffectually cared for and denied the opportunity to improve, recover or receive comfort. The worst thing we can do is to simply take at face value everything we are told and uncritically plough on. The Lords can and must do likewise.