In February 2020, the media reported the decision by 59-year-old Michael Askham to end his own life by deliberately starving himself to death to raise awareness of, and to make an appeal to change, UK assisted dying laws. The patient, who has motor neurone disease, is a former nurse (Lintern, 2020).
Background
Euthanasia is the act of deliberately ending a person's life to relieve suffering; assisted suicide is the act of deliberately assisting or encouraging another person to take their own life.
An example of euthanasia might be a doctor deliberately giving a patient, who had a terminal illness and was approaching the end of life, medication that they did not require such as an overdose of sedatives or muscle relaxant, with the sole aim of ending their life.
The Oxford Dictionary defines assisted suicide as a person killing himself/herself with the help of someone such as a doctor, especially because he/she is suffering from a disease that has no cure. For example, if a relative of such a patient were to acquire a fatal dose of an opioid drug, knowing that the patient in question would use the drug to end their own life, this would be considered as assisting suicide.
Both euthanasia and assisted suicide are illegal in the UK (NHS website, 2017).
Depending on the circumstances, euthanasia is regarded as either manslaughter or murder and carries a maximum penalty of life imprisonment. Assisted suicide is illegal under the terms of the Suicide Act (1961) and is punishable by up to 14 years' imprisonment. However, attempting suicide was declared legal by the same Act. Previously, suicide was classed as self-murder and anyone attempting to do so and not succeeding would have been prosecuted. Some 6507 people in the UK took their own lives by suicide in 2018 (Mental Health Foundation, 2019).
Although euthanasia is illegal in the UK, those who are terminally ill have the right to refuse treatment or to eat. Additionally, there is so-called ‘passive euthanasia’, which is also legal. An example would be stopping treatments that are keeping someone alive such as respiratory support from a ventilator. This happened in the case of Charlie Gard, a child with a life-threating condition. After a lengthy court case, judges ruled that the doctors providing care for the child could remove treatment, thus precipitating his death (Gayle, 2017).
Although euthanasia and assisted suicide are illegal in the UK, this is not the case in some other countries. Currently, voluntary euthanasia and/or doctor-assisted suicide is legally available in parts of Australia, Belgium, Canada, Colombia, Luxembourg, the Netherlands and Switzerland (My Death, My Decision, 2020). It is also legal in 10 states in the USA, including California and Oregon. The Oregon Death with Dignity Act allows terminally ill patients to receive a prescription for lethal medications, which they administer themselves after completing the consent process (Oregon Health Authority, 2020).
The role of organisations such as Dignitas
Assisted suicide in Switzerland is not illegal but euthanasia is punishable by the law. The Swiss penal code allows assisted suicide provided it is not undertaken for motives other than the patient's personal wishes. The liberal attitude of the Swiss government has led to the development of organisations that help individuals with untreatable disease to die with dignity, Exit and Dignitas being the most well known. Exit provides assistance for citizens or long-term residents of Switzerland, while Dignitas provides services to people from other countries (Mills, 2018; Dignitas, 2020).
All such organisations must undertake meticulous checks to ensure that the individual seeking assisted suicide has full mental capacity (NHS website, 2019). Someone lacking capacity because of, for example, a mental health problem, may not be able to make a decision to end their life if they are unable to:
Checks are made by the Swiss organisations to ensure that the person requesting the assisted suicide is mentally competent, not suffering from depression, and is acting on their own wishes, rather than being persuaded by others.
Clearly this would make it very difficult for someone with an enduring mental problem to access assisted suicide. There has, however, been one instance where a person with a long-term and untreatable mental health condition was allowed to access assisted suicide: Aurelia Brouwers, a 29-year-old Dutch lady with a long history of psychiatric illnesses. She had been declared eligible for euthanasia under the Netherlands 2002 Termination of Life on Request and Assisted Suicide Act, which allows people to end their life where there is ‘unbearable suffering’ without hope of relief. Her death in 2018 was controversial because, unlike many assisted suicide cases, she did not have a terminal illness (Sherwood, 2018).
Although establishments such as Dignitas are not-for-profit organisations, they are not free. It is beyond the reach of most people to access assisted suicide in Switzerland. The costs are prohibitive and the full cost of travelling to Dignitas and accessing an assisted death can be up to £15 000. This denies the option of an assisted death to the bulk of the UK population.
Legal implications in the UK
Although euthanasia and assisted suicide are illegal in the UK, there are both lay and professional people who are supporters of allowing assisted suicide. Parliament has debated allowing assisted suicide on a number of occasions, the last being in 2014 when Lord Falconer tabled a Bill in the House of Lords to change the law to allow doctors to help certain groups of patients in the final stages of incurable illness to end their lives peacefully. After much debate the Bill was defeated in 2015 by MPs despite Sir Keir Starmer, the former Director of Public Prosecutions (DPP) giving a key address to the commons supporting the Bill. However, the Assisted Dying Bill [HL] 2019-21 introduced by Lord Falconer is once more making progress through Parliament and its first reading took place in the House of Lords on 28 January 2020.The second reading has yet to be announced and given the current crisis relating to COVID-19, it is not clear when this will be. However there is a degree of optimism that an assisted suicide bill might be passed eventually by parliament (https://services.parliament.uk/bills/2019-21/assisteddying.html).
In July 2009, the Royal College of Nursing's (RCN) governing council voted to move to a neutral stance in relation to assisted dying for people who have a terminal illness. The RCN recognises that nurses and other healthcare workers will have a part to play in ensuring that they are able to have difficult conversations with the people they care for, especially those who have terminal illnesses (RCN, 2014).
The British Medical Association's (BMA) present policy is to oppose physician-assisted dying in all its forms, but the organisation is currently polling its membership to ascertain whether it should change this stance to adopt a neutral position (BMA, 2020).
The Royal College of Physicians (RCP) has already adopted a neutral position on assisted dying following a survey of its UK fellows and members (RCP, 2019).
The well-publicised case of Daniel James has added to the ongoing debate about allowing assisted suicide. Daniel had been a keen rugby player and sustained a spinal fracture that left him paralysed from the chest down and with no independent hand movement. At 23, he was one of youngest Britons to seek assisted suicide. Before going to Dignitas in 2008, he had attempted suicide on three occasions, although he was found to be rational, not depressed and with the mental capacity to make decisions by psychiatrists each time (Laurance, 2011).
Although his parents clearly wanted Daniel to live and tried to discourage him from taking his own life, his continued pleas to be allowed to go to Dignitas to end his life persuaded them. After their son's assisted suicide, the parents found themselves the subject of a potential criminal charge by the Crown Prosecution Service led by the DPP Starmer.
Professor of Health Care Law at the University of Southampton Jonathan Montgomery discussed the case of Daniel James, and the role played by Starmer. Starmer fully investigated this case and concluded that it would have passed the evidential test for prosecuting the parents on a number of elements. First, the parents had assisted Daniel to send documentation to the Swiss organisation and they transferred funds to it from their joint bank account. They subsequently made the travel arrangements and they accompanied him on the flight. Although the parents did not assist in the act of suicide itself, Starmer concluded that there was a ‘realistic prospect of convicting the parents under the Code for Crown Prosecutors, unless there were public interest factors tending against prosecution’. Starmer decided against prosecuting the parents (Montgomery, 2011).
Discussion
Dyer (2013) reports that up to 200 Britons, most diagnosed with terminal illnesses, have chosen to end their lives in Switzerland. Furthermore polls indicate that a majority of UK citizens support the legalisation of doctor-assisted dying. The RCN recognises there is a clear distinction between end-of-life decisions taken as part of palliative care, thinking ahead (advance care planning), and the concept of acting to end life, which is a feature of assisted suicide. Assisted dying remains a highly contentious and much debated topic with genuine concerns about the potential for coercion and abuse and the vulnerability of people with disabilities (RCN, 2016).
However, Lord Falconer's Private Member's Bill offers hope for the future for those who support this change in the law.