Physician-assisted death should be available to people with MS – No

No one doubts that multiple sclerosis (MS) can be a uniquely awful disease. But it is not unique in relation to assisted dying. An argument attempting to justify physician-assisted death only for people with MS is unsustainable. And so this ‘Controversy’ is in fact whether physician-assisted death should be available at all. I will argue that the ‘goods’ supporting physician-assisted death are substantially less clear-cut than they might appear and that the harmful consequences – for patients, for society and for medicine – are as predictable as they are entirely unpreventable.

The arguments in favour are clearly well-intentioned. They are essentially two: autonomy, the right of an individual to make independent decisions; and the prevention of suffering. Autonomy is clearly a ‘good’. But can it extend to a ‘right to die’? Can a right to die mean anything other than a general right to suicide – a right that logically must extend to anyone with capacity? (How would that affect Emergency Department (ED) staff, for example, dealing with Friday night overdoses?) In truth, we do not recognise a right to suicide: in the United Kingdom, the 1961 Suicide Act made attempted suicide no longer a criminal act but, as has been repeatedly stressed, ‘conferred no right on anyone to commit or attempt to commit suicide’ ¹ [my emphasis]. The key principle is that while autonomy is a good, it is not a moral absolute, trumping all other considerations. Some ‘freedoms’ and personal choices, from not wearing a seat-belt to the sale and purchase of drugs between consenting adults, are legally constrained in the interests of society or for the greater good.

As for the relief of suffering, the question must be asked, is intentionally ending the life of the individual an appropriate response to suffering? And is euthanasia, in any of its formulations, really necessary for this purpose? Palliative care does work, in the great majority of cases. And altering the law, reversing a fundamental tenet of medicine, for the sake of the small number of individuals in whom it has not sufficiently helped, no matter how emotional their stories may be, carries too many risks.

Proponents of assisted dying argue that there need be no ‘slippery slope’, and there are no dangers of legalisation that could not be prevented. But this is no longer a live argument. Assisted dying having been introduced – and monitored – in various countries or states, the evidence is in. The results are not ambiguous: despite the best intentions, and the best possible regulation, assisted dying always extends beyond those for whom it was originally intended, often dramatically.

Oregon, it is often claimed, is watertight in its controls, with a ‘quadruple lock’ to prevent any hint of a ‘slippery slope’. But the lock is no such thing: every one of the four components is fragile:

It is then no surprise that, in approving states, numbers continue steadily to increase. Belgium – where a population-based survey found that almost a third of cases ‘were without explicit request by the patient’ ² – has legalised assisted dying for minors and more recently for clinically depressed and/or psychiatrically ill individuals. The Netherlands accepts euthanasia for infants (the ‘Groningen protocol’) ³ – not just the terminally ill, but babies for whom a ‘poor quality of life is predicted’.

What of the wider implications? Self-evidently, assisted dying undermines palliative care – virtually all medical bodies have majorities against the procedure, but that majority is highest among palliative care specialists. But more than this, it undermines the practice of medicine. As the General Medical Council (GMC) has said,

physician-assisted dying would have profound implications for the role and responsibilities of doctors and their relationships with patients. Acting with the primary intention to hasten a patient’s death would be difficult to reconcile with the medical ethical principles of beneficence and non-maleficence. (Select Committee on Assisted Dying for the Terminally Ill Bill Minutes of Evidence)

Medicine cannot be properly practiced unless patients trust doctors, and doctors cannot inspire and do not deserve that trust unless patients believe that doctors have neither the inclination nor a legal requirement to ask if the patient is the kind of human being who is worth caring for or instead is suitable for assisted dying. Those who most fear and who are most opposed to assisted dying are the elderly, and the physically and mentally ill (those most likely to support are White, male, wealthy, educated, and in good health – aside from ‘progressive’ philosophers such as Baroness Warnock: ‘If you’re demented, you’re wasting people’s lives – your family’s lives – and you’re wasting the resources of the National Health Service’ ⁴ ).

This is a difficult and emotionally charged debate. The vast majority of those campaigning in favour of assisted dying obviously intend nothing but kindness, and the relief of suffering. But, to quote Milton Friedman, ‘one of the great mistakes is to judge policies and programmes by their intentions rather than their results’. The results of making physician-assisted death available to people with MS would be truly regrettable.