The slippery slope to death by doctor’s order

The Royal College of Physicians’ decision to end its opposition to assisted dying is morally indefensible and gives a green light to activists

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Medical associations are losing their opposition to euthanasia (© Jessica Rinaldi/The Boston Globe via Getty Images)

Imagine (if you will) a progressive movement, a modernising trend, opposed by the majority, supported by an enlightened minority. Imagine (it won’t be difficult) the radical minority to be full of passionate intensity, certain that their view must prevail. They call a vote. The electorate gets it wrong and rejects them. The electorate is instructed to vote again. They get it wrong again. Now what? You cannot stop the march of history! Obviously there must be a third election, but too much is being left to chance. So you make two innovative and imaginative changes. First, you don’t so much shift as walk away with the goalposts; and second, announce the result in advance. So another vote is called, and simultaneously the outcome declared. Unless two-thirds oppose your change, the new, progressive position will now be adopted. Simple!

Now open your eyes.

This is precisely what has recently unfolded, not in some newly-assembled underground rabble of revolutionaries, but within one of the largest and most influential medical institutions in the world, the Royal College of Physicians of London. The “progressive” issue in question is assisted dying, in particular the College’s longheld stance of opposing legalisation. The RCP’s third poll since 2006, complete with its novel approach to democracy, has been completed after a minor adjustment: the RCP Council initially decreed that a two-thirds majority of the vote would be needed to stop them changing the College position to non-opposition; following vigorous protestation, this was massaged downwards to a mere 60 per cent.

The result showed (again) that the largest proportion of members (43.4 per cent) wanted the RCP to maintain its opposition to assisted dying. But the 60 per cent figure to stop the change was, inevitably, not reached. The percentage supporting assisted dying increased from 24.6 per cent in 2014 to 31.6 per cent, while a quarter preferred that the RCP remain neutral. 

“With a virtually guaranteed outcome, this is a sham poll with a rigged outcome,” wrote the former chair of the College’s own ethics committee, while the current chair, Professor Albert Weale, resigned over the issue, along with two other members (so far). Undaunted, the RCP has declared its new position: it is no longer opposed to “assisted dying”, it is “neutral” on the issue and henceforth will not engage in public debate.

And so another medical body has flipped on assisted dying by dropping its longstanding opposition. The means may have been extraordinary, but the outcome is common. Even though the World Medical Association and the American Medical Association recently rejected rather more conventional attempts to change their anti-euthanasia positions, the number of medical bodies no longer opposed steadily rises. The list now includes the Royal College of Nursing in the UK, the Canadian Medical Association, the American Academy of Family Physicians and the state medical organisations in California, Oregon, Vermont and Massachusetts as well as other professional bodies around the world. It is true that bills to to legalise assisted dying have been rejected in Britain, South Australia, and the American states of  New Mexico, Maryland, Arizona, Arkansas and Virginia, and furthermore that American state referendums have more commonly failed than succeeded. But the sheer volume of physician-assisted suicide bills (PAS bills were rejected in 27 states in 2017 alone) is a measure of the pressure under which the historical position of opposing the practice is now subjected. Assisted suicide is now legal in eight US states (soon to be nine with the addition of New Jersey), and in Canada, the Netherlands and Belgium, Luxembourg, Switzerland, Germany and Colombia. In Australia, legalisation will come into effect in the state of Victoria in a few months.

But 25 years ago, not a single one of these legislatures or medical associations supported assisted dying. Indeed, the only organisations in favour were the Voluntary Euthanasia Society in Britain and the Hemlock Society in the US (now respectively Dignity in Dying and Compassion & Choices). Clearly euphemisms work. Indeed, “assisted dying” itself is a relatively recent term for “physician-assisted suicide” (PAS)—or more brutally, to paraphrase Lord Bingham, assisting in killing: “There is no substantial moral distinction of principle between assisting someone to kill themselves (assisted suicide) and killing them with their consent as in voluntary euthanasia.”

In PAS, doctors prescribe and provide, and if necessary help administer, lethal drugs to those patients whose wish for
suicide we approve of, with the deliberate intent to cause their deaths. Doctors carry on attempting to rescue those whose wish for suicide we deem unsatisfactory (the majority, at least so far), even if that is explicitly against the patient’s wishes.

When so articulated, the arbitrariness and subjectivity, and hence the dangers and the unsustainability, of the concept become apparent—as they have been since the ethics of medicine were first considered. Hippocrates saw no need for neutrality on euthanasia. He swore: “I will use treatment to help the sick  . . .  but never with a view to injury and wrong-doing. Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course.” Swearing by Apollo (not to mention Asclepius, Hygieia and Panacea) might rankle with even the less progressive among us, but physician-assisted suicide remains opposed by the World Medical Association, the Declaration of Geneva, the British Medical Association and the American Medical Association. In the UK, more than 80 per cent of those doctors most intimately involved in the end of life—palliative care physicians—are opposed to PAS.

Without going into a detailed discussion of the ethics of PAS, it’s fair to say its proponents argue first that individual autonomy trumps all other considerations, including those of society in general and its most vulnerable in particular (ironically, a pseudo-Thatcherite “me, me, me” position). Second, they insist there is no “slippery slope”,  the extension of PAS far beyond those for whose “benefit” it was initially intended.

But observing the practice where it has formally been adopted  longest shows this slippery slope can no longer be dismissed as alarmist, reactionary rhetoric, but has become incontrovertible, documented fact. Originally introduced only for competent, consenting adults who were in the final stages of terminal illness, the list of those deemed suitable for euthanasia now includes infants in the Netherlands, through the rather sinister-sounding Groningen Protocol, by which with vicarious consent, babies who are not terminally ill may be despatched, if a “poor quality of life is predicted”. Though fear not, all shall be well!—since “after the decision has been made and the child has died, an outside legal body should determine whether the decision was justified”. In Belgium, doctors are authorised to end the lives of children requesting to be killed. But again, the same reassurances!—“once any euthanasia—for a child or an adult—has occurred, a six-member commission examines the case file to make sure everything was done properly”.

And what of autonomy? Studies a decade ago in the Netherlands reported 400 deaths a year where “the ending of life [was] without an explicit request by the patient”. In Belgium, where 5 per cent of all deaths are now by euthanasia, 32 per cent of deaths recorded as PAS were “without explicit request by the patient”. Latterly, the “service” in several regions has been extended to the demented, the depressed, and even those with autism spectrum disorder and Borderline Personality Disorder.

Indeed, how could it not be so extended? As psychiatrist Mark Komrad has written, “Principles of justice have made it very difficult to limit such procedures to [one] category of people . . . It is unjust, and therefore impossible, in a democratic society, to limit these procedures to some—like the terminally ill—but refuse it to others—like those with chronic physical and psychiatric disabilities.”

No group is more alarmed by these trends than the disabled—physically, intellectually or psychologically. The clamour in favour of assisted suicide telegraphs a message, to quote the prominent ethicist Daniel Sulmasy, of “social sanction of the idea that lives characterised by incontinence, cognitive incapacity, and dependence on others are unworthy of life and so can be ended by direct killing”. In Britain, the wheelchair-using Baroness Campbell wrote: “Disabled peoples’ lives are invariably seen as less worthwhile than those of non-disabled people.” This is hardly paranoia—witness the unguarded writings of journalists such as the Guardian’s Polly Toynbee: “Another bad argument is that the frail will be intimidated into hastening the end of their lives so as not to be a burden on their children. Well, why not?” Or philosophers such as the late Baroness Warnock: “If you are demented, you are wasting people’s lives, your family’s lives, and you are wasting the resources of the National Health Service.” The annual data report published since Oregon passed its Death With Dignity Act shows a marked increase in the number of people citing fear of becoming a burden on family, friends or caregivers as a reason for seeking death—from just over one-third in the first five-year period, to nearly two-thirds by 2018.

As to the RCP’s new stance of “neutrality”, both ethicists and physicians point out that it is untenable. Doctors are central to PAS: they are both judge and (forgive the metaphor) executioner. Daniel Sulmasy and Baroness Finlay, professor of palliative medicine, recently wrote: “Professions have a positive ethical responsibility to take public stances on issues that are central to the meaning of their work. Neutrality on PAS, in this light, seems an abdication of professional responsibility. Doctors helping patients to kill themselves is either problematic, or not.

These changes matter. They have impact. As Dr William Toffler, professor of family medicine in Oregon and a GP for 35 years, has written, “Since the voters of Oregon narrowly legalised physician-assisted suicide 20 years ago, there has been a profound shift in attitude toward medical care—new fear and secrecy, and a fixation on death.” When various jurisdictions legalise the procedure, and influential bodies drop their opposition, society is influenced.

“Popular indifference, justification by experts and elites, judicial sanction and legislative endorsement change the cultural view of life . . . This is no slippery slope. This is the way cultures change,” wrote Jeffrey Riley, professor of ethics at New Orleans Baptist Theological Seminary.

The recent muddled reporting of the sad death of a Dutch girl with a history of rape, PTSD and severe anorexia is informative. Initially paraded by many media outlets as another euthanasia death, subsequent reports indicated that her formal request for euthanasia (at the age of 16, and unbeknown to her parents) had in fact been rejected. Rather, she was allowed to die at home having for days or weeks refused food and water. For many, the issue is not the initial misreporting, but a culture that now permits the suicidal death of a deeply-troubled 17-year-old by voluntary stopping of eating and drinking. (Another bleak outcome was that the Dutch euthanasia clinic named in the “fake news”—the Levenseindekliniek—subsequently reported a surge in calls from individuals requesting euthanasia.)

The Royal College of Physicians, and other “neutral” bodies, argue that their position accommodates the varied opinions held by members—though there is no other policy issue on which the RCP has required unanimity, none even where a “super-majority” has been required.

“To change from opposition to neutrality represents a substantive shift in a professional, ethical, and political position, declaring a policy no longer morally unacceptable; the political effect is to give it a green light.” Certainly, this is how such a change is perceived in the press—“RCP no longer opposed” was a standard headline. The pro-euthanasia groups find both encouragement and ammunition in medical bodies’ abandonment of opposition, and society is changed. By fair means or foul, the tide now appears to flow clearly with the assisted suicide lobby.