Thought To The Consequences

The very, very, very liberal Kelvin Holdsworth writes:

The time has come to admit it. I’ve changed my mind about assisted dying. As a priest, the presumption is generally made that I’m against it for religious reasons. Recent aggressive campaigning by those in favour of allowing doctors to help people to end their lives has been relentlessly dismissive of religious reasons for being against it. As though religious people have no consciences worth respecting, no bodies of their own, no pain and no right to be heard.

The truth is, though I am very obviously religious, I do not have any religious reasons for objecting to the proposed law in principle but the longer that I’ve spent time with those who are actually dying the more I find myself unable to support a change in the law. My concerns are not religious but practical.

For a long time I was fairly uncommitted in this debate. My tendency would be to think that the alleviation of pain was the ultimate goal for anyone at the end of life and to take the view that preventing pain might well be a justification for allowing someone to end their life early. More recently though experience has suggested to me that the question is a good deal more complicated than that. And so I find that I’ve changed my mind. From being moderately supportive of a change in the law, I now find myself fully opposed to the new legislation.

I remember the day when I changed my mind very well too. I had been called to the deathbed of someone whom I did not know. Before I could get into the room with the dying person, their family met me in the corridor. They asked me whether I could help them as things were very difficult. “We were just wondering whether you could ask the doctors to speed things up a bit.” I replied that I couldn’t as the law wouldn’t allow such a thing. And I asked why. What was it? Did they need me to help them to speak to the doctors about trying to get some better pain regulation? “No” came the answer, “No – the thing is we’ve a skiing holiday booked and we leave on Monday – we just need this to be over so we can get away”. That was the moment that I realised that not everyone dies with people close to them who have their best interests at heart.

Those who are dying are some of the most vulnerable people in our society. They are losing their power to make independent choices. They are vulnerable to the attitudes of everyone they encounter. And almost everyone whom they encounter may have a financial or other interest not only in their death but in its timing. Spending time with the dying, I’ve also realised that those at the end of life are particularly vulnerable to societal assumptions about being a burden and causing a fuss.

Increasingly, funeral directors are making good money from ghoulishly promoting Direct Cremations – the disposing of bodies without ceremony or the presence of loved ones. To do so, they repeat again and again in their advertising, suggests that it is better to face death without causing a fuss. Yet everyone who grieves knows that death in itself is disruptive. Death and grief change lives. They are not to be dismissed. No amount of trying not to cause a fuss changes that.  It has all made me realise that when I die, I want everyone to know that I want plenty of fuss. Fuss is how we show one another that we love them. The desire to cause others no fuss at all though is one of the greatest pressures that the dying feel.

If it were the case that all people had access to the finest palliative care at the end of their lives and were all surrounded by those who had their best interests at heart in institutions where there is no financial pressure on managers and medics then I might be able to get to a position where I might support the assisted dying proposals. However, we don’t live or die in that world. And until then, the best way to assist people to die is by investing in those studying pain management, better funding hospitals and hospices and by listening to the stories of those who sit alongside those who are dying. I’ve sat in those rooms many times.

All of us should be in the presence of those who love and care for us when we die. Not all of us will be. The law, as it stands, is the best way to protect the interests of all of us when we die. For these reasons, I hope that our parliamentarians have the courage to vote no when the final vote is taken on this bill. It is legislation that would fundamentally change the relationship between the individual and the state. The principle of alleviating pain is a godly one but the reality is that the devil is in all manner of practical detail.

In similar vein is Iain Macwhirter:

The Scottish parliament is often criticised for passing politically correct bills without giving sufficient thought to the consequences — the Gender Recognition Reform (Scotland) Bill being a case in point. However, I don’t think MSPs can be accused of failing to consider the issues surrounding assisted dying, or elective euthanasia as some call it. After 300 amendments and nearly five years of consultations and debate since the Liberal Democrat MSP Liam McArthur first lodged his Assisted Dying for Terminally Ill Adults (Scotland) Bill in September 2021, MSPs have had enough time to think — and rethink — state-sponsored suicide. Increasingly they’ve found it wanting.

So, Tuesday’s final Stage 3 vote is on a knife-edge. But the Scottish bill has already failed in a moral sense. If it squeaks through on a handful of votes it will have been fatally undermined. You cannot have an issue of this weight decided by a split vote. MSPs to vote on assisted dying despite legal uncertainty. Yet until recently, McArthur’s bill seemed a slam-dunk. Eighty per cent of voters support the right to die. Most party leaders seemed to favour the principle. Prominent media figures such as Dame Esther Rantzen campaigned for it. The Labour MP Kim Leadbeater tabled a similar bill in Westminster with the approval of Sir Keir Starmer. Progressive opinion formers seemed agreed that this was about freedom of choice. People with painful and incurable diseases should not be forced to endure them just because of moral objections from “reactionary” religious groups, who tended to be the ones who initially opposed assisted dying. After all, we put down dogs, don’t we?

But after consideration most politicians in Scotland and England now realise that humans aren’t dumb animals. The Terminally Ill Adults (End of Life) Bill is failing in the House of Lords, weighed down by reasoned and reasonable amendments about safeguards. The tectonic plates started to shift in Holyrood after Nicola Sturgeon first expressed her doubts last year. The main Scottish party leaders have now all shuffled into the opposition camp, joining Labour’s Anas Sarwar, who was already there. The first minister, John Swinney, eventually came out against the bill and the Scottish Conservative leader Russell Findlay changed his mind only last week, citing worries over coercion. Apart from Mr McArthur’s Liberal Democrat boss, only the Scottish Green co-leader Ross Greer remains in the assisted dying camp. It is a free vote, however, and many MSPs in all parties still support the bill, which makes Tuesday’s vote difficult to call, though judging by Friday’s marathon debate many are moving rapidly against.

This is because the case for assisted dying has crumbled. I used to support the right to die. It was one of the progressive causes — like abortion, LGBT rights and equal pay — that appealed to people of my generation. It was really only when I witnessed my parents age and die — or “transition”, as they say in America — that I realised my mistake. It is impossible to ignore just how much old people worry about being a burden on society and, in particular, on their own families. We no longer respect old people in the way we did. They hear media figures and politicians forever complaining that the older generation has, in some way, grasped the wealth of the nation in their wrinkled hands. The row over the pension triple lock is largely based on this claim of intergenerational unfairness. The endless social care debate, with its talk of elderly people “bed-blocking” in hospital wards, has added to their sense of being in the way. Given the lack of resources for palliative care, there is an obvious risk that old people, especially those with embarrassing conditions, will try to make up for the inadequacies of the NHS by “doing the right thing”. Assisted dying could become the final solution to the social care crisis.

Much attention has been given to the slippery slope argument and how elective euthanasia in other jurisdictions, like the Netherlands, has led to young people with mental illness being allowed medically assisted suicide. That may be reason enough to oppose the bill. But the really big issue is the “granny factor”. The parental urge to care for their offspring, even after death and even when they don’t need or even want it, is incredibly strong. The fact that their children often cannot afford a home weighs on many elderly parents’ minds. Faced with the prospect of going into care and having the family home sold to pay for it, many may think that the right thing to do is to go sooner rather than later to protect the inheritance.

Coercion is not the point, though there’s a myriad of ways in which the younger generation can inflict subtle pressure on elderly parents. They may even do so unconsciously merely expressing their understandable grievance at not being able to afford a mortgage. No legal safeguards can prevent this. All it takes is two medics to agree that granny has a sound mind and a condition that is probably incurable. Then it’s off to your friendly private euthanasia clinic. The old don’t figure in the hierarchy of minority identities which are supposed to be valued. Elderly folk are often difficult. They have views on race and immigration that younger adults find “problematic”. It is also often subtly suggested that old people with chronic medical conditions are in some way to blame because they didn’t “look after themselves” — as if that mattered.

But many younger people with disabilities also fear that they’ll be exposed to subtle pressure to end their lives. And given our human rights culture, people with depression and other mental illnesses will surely claim that they should also have the right to kill themselves. Why should assisted dying only be available to people with observable ailments? That’s what they said in Holland, and last year 219 people with mental health issues were given lethal injections, some under 30 years of age. The numbers have risen year-on-year. So this apparently simple question of individual choice becomes highly complex, as MSPs have, to their credit, discovered. Voters may endorse the principle, but ask them about coercion and safeguards and they rapidly lose enthusiasm for elective euthanasia. So have many MSPs. This bill is over whatever happens on Tuesday. It should be helped to die humanely.

Jenny Lindsay (not so far as I know, but we are a clan) writes:

As soon as something is possible due to medical advancement, then allowed by law, it automatically becomes something a person will consider should circumstances permit it. Endless such leaps have allowed us to tinker with our fates, whether undergoing life-saving treatments to prolong life, fertility treatments to create it; or undertaking non-essential but desired cosmetic surgeries and procedures.

Some may raise an eyebrow at my grouping these things together – evidently life-prolonging or life-saving operations can be viewed as a universal good. But all new advances in medicine walk a tightrope between the individual’s wishes versus social norms, medical possibility versus medical ethics; with all including the possibility of disappointment, things not working, or having unintended consequences.

In our current era, non-essential but life-enhancing treatments are usually argued for in terms of ‘autonomy’ and ‘choice.’ But tomorrow, MSPs will make a decision far greater than any of these, which flips the question, while using the same appeal to both: whether a person - able to make the decision autonomously - has the right to choose the manner and time of their own death. Within the inevitably emotional debate, and bickering over legislative minutiae, it can often be lost how monumental – and society-changing - a decision this would be.

Death can be frightening to contemplate. A majority – while not necessarily receiving a terminal diagnosis – will face decline and/or serious illness before our inevitable end. For those with degenerative conditions this can be especially frightening. Should it pass tomorrow, The Assisted Dying for Terminally Ill Adults (Scotland) Bill would limit assisted death to those who are terminally ill. It’s not difficult to foresee, however, that the definition of ‘terminal’ may change, which is just one problem with the Bill as it stands.

The proposed legislation has been fraught with controversy, including despair at the limited time for adequate Stage 3 discussions. Last week, MSPs debated hundreds of amendments in marathon sessions, including rare sittings extending late into evenings - and on Friday - to complete the process.

On Friday, the Royal College of Psychiatrists was the latest medical organisation to state its opposition, saying it “poses an unacceptable risk to the public and the psychiatric workforce”. Additionally, religious objections have been raised, most notably from the Bishops’ Conference of Scotland. Alarmed by MSPs failure to pass amendments ensuring organisations can conscientiously object, they point out this means Catholic care homes, for example, would be “forced to decide between acting contrary to their foundational values or closing.”

Like most, I’ve witnessed loved ones suffer in their final days. Most painful was that of my paternal grandmother, Isabel Lindsay. Though she didn’t officially have a ‘terminal’ diagnosis, she lived for years knowing her incurable, degenerative lung condition would likely, eventually, end her life. In 2017, she was rushed to hospital for the final time, over a fortnight before she died. When she did, she was surrounded by her family. Each was deeply affected by that experience. I believe my grandmother – as was her character, after a lifetime of putting everyone else first, including a late husband who gave her little choice in that – felt some guilt at circumstances completely outwith her control.

Which is but one reason I’m opposed not only to what I perceive to be a flawed bill; but to the principle of medically-assisted dying of any kind. Once it is an option, I am unconvinced coercion can ever be fully ruled out. This includes self-coercion, brought about by being made to feel as if ‘being a burden’ is something one must always avoid. But burdens can be borne; they should be by a caring society. Idealistic, perhaps. But a principle worth defending.

In Canada, their Medical Assistance In Dying (MAID) legislation has seen precisely the ‘slippery slope’ critics of all assisted-death legislation forewarn of. Within a few years, MAID has been expanded to those without a terminal diagnosis, including those with depression and other manageable conditions.

Subsequently, the social discussion has rapidly moved far beyond the question of whether the state should help those suffering at the end of life. Instead, the question has become, “should we assist someone to die if they find life intolerable?” That is a fundamental reframing. Also: no.

I worry, too, about the assumptions inherent in the slogans of campaign groups like Dignity in Dying. My grandmother suffered, certainly, as all of us might. But being reliant on others, whether loved ones or palliative care professionals, isn’t ‘undignified.’ This framing is wrong. Other placard messages from the influential lobby group include: “So my family remembers my strength, not my suffering.” “So I can be remembered as I lived, not as I died.” I do not wish to sound harsh, nor to diminish such deeply-held worries. But neither of those is in an individual’s control.

When I think of my grandmother, I remember her laugh, her advice, her company. I picture us on those long walks around Lanark Loch. Her yellow dress. Her dancing with my brother. That day with the blackberry pies. I remember the pleasures she took from her quiet life. It is only secondary to remember that small hospital room. Its sadness – but also its love. That my grandmother may have thought herself a burden that final fortnight is something I’ll never know. But it’s something both family – and the palliative care nurses of Wishaw hospital - did our best to dispel. I empathise with those living with terminal illness. But I fear if this Bill is passed, the cost to us all will be too high. I too hope my last experience of my fellow humans won’t be to feel burdensome. A society where people feel that way is one to avoid, not ensure.

And James Bundy writes:

Legislation regulating assisted dying raises profound ethical, legal, and clinical questions. Where a legislature chooses to regulate an issue of such gravity, the safeguards governing the operation of the law must be subject to the highest level of democratic scrutiny. In Scotland’s devolved constitutional framework, reliance on a Section 104 order under the Scotland Act 1998 to determine key safeguards risks undermining that scrutiny. Although Section 104 orders serve an important technical purpose within the devolution settlement, using them to establish substantive protections in assisted dying legislation would represent a problematic constitutional approach.

A Section 104 order is a mechanism provided for in the Scotland Act that allows the UK government to make secondary legislation at Westminster to adjust reserved law so that an act of the Scottish Parliament can function properly. These orders exist because legislation passed by the Scottish Parliament may interact with areas of law that remain reserved to the UK Parliament. In such cases, changes to UK-wide legal provisions may be required to ensure that Scottish legislation operates coherently across the wider legal system.

The procedural features of Section 104 orders are significant. They are drafted by the UK government and laid before the UK Parliament as secondary legislation. While they are normally subject to the affirmative procedure, meaning that MPs and peers must approve them before they take effect, they cannot be amended during the parliamentary process. Legislators may only approve or reject the instrument in its entirety. Importantly, the Scottish Parliament itself does not vote on the order. These procedural characteristics reflect the intended purpose of Section 104 orders: they are designed to make technical or consequential adjustments necessary to implement devolved legislation, rather than to create substantive policy safeguards.

Using this mechanism to determine critical protections within assisted dying legislation raises several constitutional concerns. First, democratic accountability is weakened if essential safeguards are determined through a Section 104 order. In such circumstances, MSPs would be unable to amend the provisions governing those safeguards. Decisions central to the operation of a devolved statute would effectively shift from Holyrood to Westminster. For legislation as ethically sensitive as assisted dying, the safeguards that determine how the law functions in practice should be debated and decided by the legislature responsible for passing the statute.

Secondly, reliance on a Section 104 order effectively reduces core safeguards to matters of secondary legislation. Protections such as conscientious objection for health professionals and the minimum qualifications required of participating clinicians are not technical matters. They are fundamental components of any assisted dying framework. However, secondary legislation receives a significantly lower level of scrutiny than primary legislation. As a result, the procedural safeguards normally associated with primary legislation are absent.

Thirdly, reliance on a future Section 104 order creates uncertainty during the legislative process itself. Questions about the scope of conscientious objection, the professional categories covered by such protections, and the training and experience required of clinicians may remain unresolved. In effect, the legislature would be asked to enact legislation without full clarity about how the system will operate in practice.

Finally, reliance on Section 104 orders raises concerns about the long-term stability of safeguards. Once protections are established through secondary legislation at Westminster, future amendments could also be made through secondary legislation. In such circumstances, the Scottish Parliament would have limited direct control over the evolution of safeguards governing a regime that it originally legislated for. This risks weakening the ongoing democratic oversight of the system.

These concerns are particularly acute in the context of assisted dying. Safeguards relating to conscientious objection and clinical expertise lie at the heart of any safe and ethically defensible framework. Health professionals must have clear, robust, and enforceable protections if they do not wish to participate in assisted dying. Similarly, the safety of any regime depends heavily on the training, qualifications, and experience of clinicians responsible for assessing eligibility, prognosis, mental capacity, and potential coercion.

For legislation of such gravity, these safeguards must either appear directly in the bill itself or be established through regulations subject to full scrutiny by the Scottish Parliament. Delegating their design to a Section 104 order risks reducing democratic accountability, lowering the level of scrutiny applied to core protections, and creating uncertainty about how the law will ultimately operate.

As Stephen Daisley puts it:

The stakes are seldom high when the Scottish parliament meets, but Tuesday's debate will be a matter of life and death. Liam McArthur’s Assisted Dying Bill will be put to a final vote. If passed, it will allow the NHS to hand out suicide drugs to vulnerable patients so that they can kill themselves. On paper, eligibility will be limited to those with terminal illnesses, though if other jurisdictions are anything to go by it won’t be long before this is watered down to include chronic physical and mental health problems.

As for ‘voluntary’, it is true enough that the final decision rests with the patient, but we all know someone who feels like a burden on their family or fears ending up in a care home. Someone – usually, it must be said, a woman – who has been taught since infancy to put her family before herself and to defer to the authority of a doctor. Maybe it would be better off if she wasn’t in the way and, besides, it must be the right thing to do, otherwise the GP or hospital consultant wouldn’t have raised it with her.

It works in other countries, the euthanasia lobby crows. Oh, it works all right. It works only too well. Canada was once the very model of a modern euthanasia system, held up by assisted suicide advocates as an exemplar of dignity and safety. They don’t hold it up anymore. When Canada introduced its Medical Assistance In Death (MAID) regime in 2016, the annual number of people availing themselves of it was 1,015. By 2024, the most recent year for which statistics are available, that number had spiralled to 16,499. That’s an almost unfathomable 1,526 per cent increase in the space of just eight years. MAID is now so commonplace it accounts for one in every 20 deaths in Canada. Imagine, if you will, walking through your local cemetery and every row you pass contains at least one person killed by their doctor. If assisted dying becomes law here, Scotland faces the prospect of becoming another Canada, a global by-word for the industrial-scale killing of the desperate and the vulnerable.

I understand the passion of sincere people on the other side. They dread a slow, undignified death. They have perhaps sat at the bedside of a loved one, wishing dearly for their suffering to end. And if it was possible to devise a foolproof assisted suicide system, I could see why they might think that the answer, even though I would continue to disagree in principle. Unfortunately, there is no such thing as a foolproof system. There will always be risks. There will always be loopholes. Not only will some people fall through those loopholes, some will be pushed. The abused wife whose husband gaslights her into ending it all. The patient first encouraged to consider suicide by a doctor who secretly resents elderly or disabled people as a burden on his time and society’s resources.

And that is before we consider the issue of unsuccessful assisted deaths. It’s a medical procedure after all and medical procedures don’t always work. What if the drugs don’t have the desired effect? What if they cause grave damage to the body but don’t stop the heart? There is no clarity on what would happen in this situation, and whether the doctor should try to bring the patient back round or kill him off with a lethal injection or some similar method. None of this is pleasant to read – it’s certainly not pleasant to write – but we have to face up to the realities of euthanasia.

Especially since one safeguard after another has been jettisoned, along with the right of institutions to refuse to have anything to do with it. Supporters of the Bill voted down an amendment that would have guaranteed an institutional conscientious objection. What that will mean in practice is that a care home or hospice run by a Christian order will not be allowed to opt out.  The Catholic Church has already said its hospices and care homes might have to close down altogether. Another conversation we would rather avoid: the all-too-obvious risk, especially with elderly people in understaffed care homes, that the wrong patient is accidentally dispensed suicide drugs.

Holyrood has not distinguished itself as a great legislative body. The Gender Recognition Bill had to be blocked by Westminster for straying into UK-wide equalities law. When the SNP government challenged this decision in court, it got sent away with a flea in its ear. The Gender Representation on Public Boards, intended to add more women to boardrooms, tried to define ‘women’ to include trans-identifying men. This eventually brought us the Supreme Court’s landmark gender ruling. The Referendum Bill saw Holyrood attempted to legislate beyond its powers and required MSPs to be set right in another key judgment by the Supreme Court.

The courts put a stop to the unlawful Named Persons Scheme and the blanket ban on public worship during the pandemic. Each violated a provision of the European Convention on Human Rights. Westminster had to step in and halt the disastrous deposit return scheme while ministers were forced to rewrite two Bills incorporating the UN Convention on the Rights of the Child and the European Charter of Local Self-Government after the Supreme Court pointed out they were ultra vires. One piece of legislation, the Offensive Behaviour Act, had to be repealed just six years after it was passed, so vague were its terms and noxious its effects.

These Bills and policies were either ill-conceived or injurious, but the Assisted Dying Bill is another species entirely. This is not a Bill where little legislative boo-boos can be highlighted by a judge and tidied up by Holyrood.  Where this Bill is inadequate – and it is inadequate in a great many respects – it will carry the risk of people losing their lives. No amount of tidying up can undo that. The stakes are indeed high. If the Bill becomes law, and nothing ever goes wrong, it will still mean vulnerable people being helped to end their lives and doctors who trained for a caring profession going into the killing profession. Instead of investing in palliative care so people can live out their final weeks in dignity, the state will supply them with taxpayer-funded suicides. If the Bill becomes law, and just one thing does wrong, it will mean people who wanted to live, who could have lived, cajoled or guilted into an involuntary self-destruction. MSPs who support it might not be the ones who dole out the killer drugs, but their fingerprints will be on each and every prescription.

Twenty-seven years on from the opening of the Scottish parliament, is this really the best devolution has to offer? ‘Sorry, we can’t teach your child to read, but we can hurry along her granny’s death.’ Nearly 30 years and this is what devolution looks like. Tasked with making Scotland more democratic, it has embedded an untouchable elite pursuing its own priorities with no regard for the popular will. Entrusted to improve and strengthen our public services, it has done untold damage, not least to education and health. Empowered to make life better in Scotland, it prefers to make it easier to take life away from elderly, disabled and other vulnerable people. Should the Assisted Dying Bill pass, should this act of moral and ethical vandalism makes it onto the statute books, it will put beyond any doubt that the devolution experiment has failed. And not only failed, but turned rancid.