"Care given to them is a hymn to human dignity"

 The following extract from Pope Francis' Bull of Indiction for the 2025 Holy Year (n.11)appears particularly relevant following Friday's vote in favour of assisted dying in the House of Commons. I have added the italics to the last sentence. I was particularly struck by its reference to the part to be played by society as a whole, in addition to that of the individuals or teams who might be immediate care givers.

Signs of hope should also be shown to the sick, at home or in hospital. Their sufferings can be allayed by the closeness and affection of those who visit them. Works of mercy are also works of hope that give rise to immense gratitude. Gratitude should likewise be shown to all those healthcare workers who, often in precarious conditions, carry out their mission with constant care and concern for the sick and for those who are most vulnerable.

Inclusive attention should also be given to all those in particularly difficult situations, who experience their own weaknesses and limitations, especially those affected by illnesses or disabilities that severely restrict their personal independence and freedom. Care given to them is a hymn to human dignity, a song of hope that calls for the choral participation of society as a whole.

Assisted Dying - or living at the end of life?

When I reach the time where the end of my life is foreseeable, I really do hope that none of those around me will speak or think in terms like "dying". I would much prefer them to think in terms of my living at the end of my life or, indeed, living the end of my life.  I also hope that, if I ever find myself accompanying someone else who is approaching the end of their life, we would speak and live using the same terms. It strikes me as being how the human person manifests and receives in an existential way, at this last stage of their life, the virtue of hope.

Even the term "assisted dying" articulates the denial of hope; and, if the patient is themselves at the origin of that denial, asks of their medical team to affirm them in that denial. (This seems particularly acute if it is a nurse who immediately provides the necessary drugs to the patient rather than the prescribing doctor.) If the medical team are the origin of that denial - which is a foreseeable consequence should proposed legislation before the Houses of Commons and Lords enter into law - the term expresses the projection from the medical team on to the patient of a denial of hope and inevitably provides a pressure in favour of it.

The Assisted Dying (no.2) Bill is due for Second Reading in the House of Commons on 11th September. In preparing my letter to my MP on this subject, I used the following sources:

Britain's law on assisted suicide is not 'broken' and does not need ‘fixing’

Eight Reasons not to legalize Physician Assisted Suicide

Since writing it, I have referred to:

Assisted Suicide and Euthanasia: A Guide to the Evidence

According to the first source, the Commons private members bill is "almost identical" to the Bill introduced in the House of Lords, though a full text has yet to be published. One has only to look at the experience of legalized abortion to be able to foresee that legislation that does not in any way establish a right for a patient to be provided with assistance to commit suicide will in the event be interpreted in that way. Over time, doctors will sign off a patient's request precisely "on request", though that is not envisaged by the legislation. In particular - and I didn't include this in my letter - the second "independent doctor" is required by the proposed legislation to satisfy themselves of a range of factors, including the freedom of the patient from coercion. But I cannot see how a doctor can do this in genuine good faith without having a close knowledge of the patient's care, a knowledge that can only be achieved by having a significant presence in the patient's care.... and in that case a serious compromise of independence. Page 8 of the last source above indicates an aspect of this from experience in Oregon, where a small proportion of doctors sign off a majority of cases of assisted suicide.

If you want a summary of the substance of my letter - text below - it is that the experience of the practice of legalized abortion indicates that, if the proposed legislation were to make its way into law, all the safeguards around assisted suicide contained in the legislation will turn out to be utterly illusory.

I do not believe that the provision for medical professionals to provide patients with the means to kill themselves is in accord with the proper duty of care due to those who suffer serious illness. It would be much more in accord with that duty for there to be sufficient provision for end of life care on the model of hospice care. It should be possible today in countries such as England and Wales, for example, to ensure that pain relief, symptom relief and appropriate spiritual care are available to fully support a patient as they come to the end of their lives without making provision for them to commit suicide.

Whilst the Commons Bill has yet to be published, the similar Assisted Dying Bill in the House of Lords gives a close indication of the provisions in the Commons Bill. It is my view that the protections contained in that Bill, and, as I understand it, which will also be present in the Commons Bill are largely illusory. If these provisions were to become law, one can readily foresee that, as a doctor communicates a terminal diagnosis to a patient they will be expected by regulation or code of practice to also communicate the option of assistance from a medical professional to help them kill themselves. As soon as this happens, all the safeguards in the proposed legislation are compromised, most particularly the voluntary nature of the patients request which has inevitably become the subject of external influence.

One can also foresee that, whilst the debate in favour of the proposed legislation might suggest a (single) narrative of a free choice by a terminally ill patient to avoid overbearing suffering, the reality of the practice of such legislation would involve a variety of narratives on the part of patients. The published experiences of women with regard to legalized abortion, including those from writers supportive of legalized abortion, show very clearly that there are a variety of narratives, only a proportion of which can be fully characterized as a free choice on the part of the woman. This experience is instructive, I think, for what would be the experience of implementing legislation allowing medical professionals to assist their patients in killing themselves.

An afterthought that has occurred to me since writing my letter is the possibility that regulations and codes of practice might even expect the clinical staff in hospice settings to offer the option of assisted suicide to their patients - something totally alien to the ethical and clinical principles of hospice care.

Misrepresentation: continued debate about hope in The Times

I found very interesting the letter I copied in this post of two days ago. What I found interesting was the way in which it raised, in the context of the medical profession, the question of hope as part of the discussion of assisted suicide.

Yesterday further correspondence appeared in The Times, replying to Professor Morgan's letter. The first of these letters prompts two questions about the nature of the media, questions which apply to both electronic and print media.

Question 1: As a matter of media strategy, it is not unusual to try to respond to or criticise another writer or speaker without making any explicit reference to what they have said. This is based on the principle that many people might read or hear what you are saying without going to look at what your opponent wrote or said earlier ; you therefore get your point of view over without inadvertently communicating your opponent's point of at the same time. Now, one of the new letters contains the statement: "Professor Gethin Morgan (“Assisted dying and the suicidal state of mind”, letter, Aug 4) displays the assumption, too common among medics, that anyone wishing to die must be mentally ill." If you read Professor Morgan's letter, you will realise that he does no such thing. The letter writer has grossly misrepresented Professor Morgan's letter, so was it ethical for him to write such a letter for publication, even if we admit a legitimacy to the media strategy just described? I would suggest not.

Question 2: Given the possibly un-ethical nature of the letter itself, has the editor who decided to publish the letter also acted un-ethically? Should an editor publish a letter which, as I see it, so clearly mis-represents the contents of an earlier letter? Or does one detect a certain media bias on this question?

To reply to some of the points made in these new letters:

Surely desperate people do need hope? And, as Professor Morgan indicated in his letter, hope does extend beyond the realm of the physical, whereas yesterday's letters limit consideration of hope to just the physical.

Surely a rational thought process leading to a decision for suicide can be quite legitimately the subject of a discussion with a health care professional during an illness? That seems to be a part of the meaning of the word "rational".

The underlying principle of the second two letters appears to be that of respect for autonomy, for the right of an individual to make their own decision. What this avoids is the effect that one person's decision has on others - our decisions in a field such as this affect everyone, both those who might not want to commit suicide and medical professionals who might find themselves having to take part in decisions that they themselves find immoral.

The last paragraph of the third letter opposes considerations of "hope or despair" to those of "compassion and respect for my autonomy". Surely despair is an opposite of compassion, and the promotion of hope is profoundly compassionate?

Hope again

Having posted yesterday on the need for hope in the context of the debate about assisted suicide, I was very interested to read the following letter in The Times newspaper today.

Sir, With regard to the continuing debate about assisted suicide, there are certain points concerning the suicidal state of mind that are not given sufficient consideration.

To begin with, there is the problem of concluding that a person has irrevocably lost all hope to live. My experience in caring for suicidal individuals has taught me that it is hazardous to assume that hope has gone forever. What is more, hope in suicidal persons can vary in intensity from time to time, even from one moment to the next. It is sometimes possible to revive hope, which may apparently have disappeared. In general the techniques involved may be deceptively simple.

One important component is to listen for as long as it takes, with a realistic yet positive and reassuring attitude towards continuing with what life still has to offer. A gentle, fully explained refusal to agree with despair can itself be very helpful as a way of instilling confidence and encouraging the wish to go on living.

I acknowledge the particular problem posed by severe irreversible physical illness: yet even in this case the above points are relevant. Adequate care must address both physical and psychological issues, promoting confidence that intolerable suffering, the prospect of which is of course so frightening, may well not be inevitable.

These considerations are essential in any worthwhile debate concerning assisted suicide. They explain why any conclusion that hope has become irreversibly lost is a particularly unreliable judgment to make.

Professor Gethin Morgan
Emeritus Professor of Mental Health, University of Bristol

I have added the emphasis to the sentence about the refusal to agree with despair, which seems to me to reflect the pastoral need that might arise at the bed side of a patient.

Assisted Suicide: a round up

Fr Tim has posted, and provided links, about concern being expressed by Multiple Sclerosis charities after the recent Law Lords ruling in the Purdy case. "Although they are non-committal on the morality of assisted suicide, the charities are clearly not happy with the way that MS has been portrayed in the propaganda supporting this case." The quotations offered by Fr Tim clearly express a need to make provision to care for patients and families/carers affected by multiple sclerosis. I will come back to this point later in this post.

Another useful post to read is this one at Dophinarium, and its links. It brings out the role of the media in promoting euthanasia / assisted suicide in recent days. This article in The Times from Dominic Lawson also points out a media manipulation - of the determination of the actual judgement: Don't book a ticket to Dignitas just yet. Dominic Lawson also offers a useful presentation of what the Law Lords said, in particular with regard to an earlier explanation by the Director of Public Prosecutions about one of his decisions following a death at the Dignitas clinic in Switzerland. He ends his article by pointing out the utter contradiction in Debbie Purdy's claim that the judgement gave her her life back:

Yet when I saw her [Debbie Purdy] declare last Thursday, “I feel like I have my life back”, my stomach heaved. It is a sick society that regards assisted suicide as an affirmation of life.

As we have seen with the trivialisation of the grounds on which abortions are carried out, the legalisation of assisted suicide or euthanasia will have a mirror effect back on to how a range of medical conditions are considered. Indeed, even the discussion of such a legalisation is already affecting how chronic illness is viewed in society. How people view conditions which are chronic, but not terminal, will change.

Matthew Parris wrote a piece "Why I'm opposed to legalising assisted suicide" in The Times on Saturday 1st August. If I have understood the reason for his opposition correctly, it is expressed in his last paragraphs:

It is one thing for the State to decline, at its discretion, to prosecute someone who has killed without authority. It is quite another thing for the State to issue an authority to kill. We do best, I think, to stay on that first, more limited, ground. It may be messier, it may be cloudier; but it’s philosophically less dangerous.

But, in his first paragraphs, Matthew Parris sets up the arguments - not the ones that underpin his conclusion - in favour of assisted suicide.

... if Nature does not do the job in a timely manner I shall consider it a duty to take matters into my own hands. For me it would be wretched, self-defeating, selfish, irrational, inefficient and pointlessly extravagant to live beyond the time when I am useful, or life is fun.

And, from the next paragraph:

For me it would be wretched, self-defeating, selfish, irrational, inefficient and pointlessly extravagant to live beyond the time when I am useful, or life is fun....The knowledge that I’m here by choice, that every breath I take I take by choice, injects into my soul a transcendent joy. That we can let go whenever we want is for me the deepest sort of thrill.

Matthew Parris presents suicide as "the supreme act of defiance, the final raspberry". We might want to use another word to describe this: it is the supreme act of despair, which is why the Catholic Church viewed it so severely in the past and still teaches that it is a "grave offence" forbidden by the fifth commandment (cf Compendium of the Catechism of the Catholic Church Q.470).

Underlying all of this, though, is the question of the meaning of life. This question is not just one that is discussed in the hallowed halls of academia; it arises at the bed side of the person who is seriously ill or who is infirm as a result of age. It is a very practical question. The field of pastoral and spiritual care in hospitals is all about this. It is about trying to give patients who are seriously ill a sense of meaning to their present situation, and, as life come to its end, a sense of meaning to their earlier life. For some this is a religious meaning, but not for all.

Hope is the opposite of despair, and so is what one really wants to bring to the person who is seriously or chronically ill. To express the purpose or value of life in terms of "usefulness" or of "fun" is profoundly contrary to the promotion of hope - it limits the valuing of life to the situation of being able to be self-reliant and independent of the help of others. And we are all at different times in our lives going to be in situations where we depend on others for help and, indeed, in situations where others may depend on us for help. This is particularly true, though not exclusive to, situations of clincial illness. And there is nothing wrong with this; it is, in a certain sense, entirely natural.

A tremendous witness to this idea of hope is the number if situations where someone in hospital, particularly if they are elderly, is visited by their family. And, in some cases, a patient takes quite a pride in their visitors and will speak very highly of them. The last thing that these people need is the pressure of legalised euthanasia or assisted suicide. I sometimes meet older people, who may also be sick, who worry about the trouble they cause to other people. What I try to say to them is that, if they look back on their lives, they will probably be able to think of times when they helped other people - and that now it just happens to be their turn to be in need of help and that they have an entitlement to it. One could argue that the point of view presented by Matthew Parris is profoundly discriminatory against older people and against those suffering from chronic conditions since they are going to be disproportionately in need of help when compared to others in society.

Which brings me back to the first paragraph of this post. For a whole range of conditions, what is really needed is appropriate help and support for patients, families and carers. And support that is spiritual as well as physical. What is needed is hope not despair, a culture of life not a culture of death.