Assisted Dying – the more people know the less they like it

If you are being asked to consent to an operation you aren’t asked a single question: “Do you want an operation, yes or no?” It is explained to you what exactly the procedure is and what its likely benefits and possible risks are. And yet claims about massive public support for “assisted dying” are based on exactly that – a single question.

The situation is made worse by persistent evasiveness about exactly what it is that campaigners want legalised – right down to the practice of claiming it isn’t assisted suicide even while campaigning to have assisting suicide decriminalised. As a result of this evasiveness a 2021 poll conducted for the All Party Parliamentary Group on Dying Well found that only 43% of people knew that “assisted dying” was the same thing as assisted suicide, with many thinking it referred to a right to refuse active treatment (already legal) or that it was a synonym for palliative care.

A 2014 poll conducted by ComRes for the campaigning organisation CNK made clear the reasons for this vagueness – the more people know about assisted dying the less they like it. While 73% of respondents initially said they agreed with changing the law, when presented with some practical considerations in making the decision that approval rate fell to 43%.

Here are five questions every supporter of assisted dying should answer in detail before any support for their plans could be regarded as fully informed:

Q1: What exactly is the practice you want to see legalised?

A survey for Living and Dying Well published in July 2024 found that when the details of assisted dying were defined, the majority of respondents were not in favour of a change in the law. So clarity without euphemism is needed. The answer to this question must be either assisted suicide or euthanasia.  Most people imagine, when they have some notion of what assisted dying is, that a doctor will provide drugs that the individual then swallows – as in a typical suicidal overdose.  However both Liam McArthur’s Scotland bill and Lord Falconer’s bill of this year are compatible with a doctor establishing an intravenous infusion which the individual then starts running (with physical help if necessary). In other words a sort of patient controlled euthanasia. Going beyond the names –

Which drugs and what method of administration (oral or intravenous) are to be legalised?

A part of this question is:

What practice will be legal in the event of problems arising during the assisted death?

Supportive accounts invariably avoid the reality of how common problems are and good data are hard to come by: the best available review suggests – retching for hours (up to 10%), death delayed for hours or even days (up to 7%) and recovery of consciousness (up to 4%). What additional interventions can be made if these problems occur? In Canada, clinicians can administer additional lethal drugs “to complete the process”. Is that part of proposed legislation?

Q2: Who exactly will be eligible?

Each of the common reasons given for assisted dying has its problems. Imminent death is difficult to predict except in the last days or weeks of life, and death may be months or years after somebody is deemed “terminally ill”. Life-limiting and incurable illness is extremely common and raises a spectre of use far beyond what was originally envisaged (7% of all deaths in Quebec are now by lethal injection).  Intractable suffering is the banner under which euthanasia or assisted suicide have been introduced for mental illness, a widely opposed indication among the general public.

An example of the importance of being clear and specific about eligible groups is Liam McArthur’s assisted dying bill in Scotland which is described as being about people with terminal illness but is in fact about people with life-limiting and incurable illness. One way into this question is to ask:

Are examples specified of conditions other than advanced cancer that will be included and any that will be excluded?

Q3 What safeguards (clinical and social) will be in place?

The privileging of personal choice is a feature of much of the support for assisted dying.  Assessment then comes to be focused on factors that might impair personal choice (sometimes in this debate called autonomy) – mental capacity in decision making, and lack of coercion. The presence of subtle or implicit coercion can be hard to detect.

How will coercion be assessed? For example, who else other than the candidate will be interviewed?

However, personal choice for one person may lead to risk for others – drink-driving, smoking in public places for example. Many of the leading risks for wanting to end life in the presence of physical illness are social – loneliness, living alone, low income and lack of employment, and a lack of social support. A history of problems with alcohol or drugs is also common. So is a history of mental health problems – typically not psychotic illness but recurrent episodes of depression. Suicide in the face of these risks is a result of a powerless feeling there are no other options. Identifying these risks requires an extended and sensitive exploration of social and personal circumstances; simply establishing mental competence and a lack of coercion won’t do. What assisted dying legislation does is create the framework of practice that puts vulnerable people at risk.

How will vulnerability factors be assessed? Will it be a requirement to consult a next-of-kin? Will it be a requirement to consult the individual’s usual general practitioner or other clinician familiar with their condition?

Q4 What legal safeguards will be in place?

Assisted dying legislation aims to exempt healthcare professionals from prosecution for assisting suicide. This leaves a question about assisting suicide when it is undertaken by somebody else – a spouse for example. It is this sort of scenario that has led PM Keir Starmer to suggest that decriminalising assisted suicide will be compassionate.

Will exemption extend to anybody who assists the suicide of somebody with an eligible clinical condition? Or will it be decriminalised only if the assisting person is a clinician approved for the purpose?

Conflict arises when family members do not agree with the assisted suicide of their relative, about which they may not have been consulted until after the event. Legislation has been drafted to protect clinicians from legal action in this situation, for example by allowing the issue of a false death certificate that names the cause of death as the eligible medical condition or by specifically proscribing civil action. 

Are protections against legal action a part of proposed practice and if so exactly what are they? Do they limit the reasonable rights of interested others?

Q5 How will adverse events be monitored and responded to?

There are two main types of adverse event: so-called protocol violations and unintended problems or complications. Protocol violations involve deviation from the practice laid down in legislation – the individual does not meet eligibility criteria, or the prescribed assessment process is not followed for example. Unintended problems include those listed above – emergence of intolerable symptoms or greatly-extended time to death for example.

How will adverse events be monitored in a way that ensures rapid and effective oversight?

All healthcare systems and procedures (vaccination programmes, surgical procedures and so on) have an adverse event rate. In fact all human endeavours do – including running nuclear power stations or flying passenger planes. Adverse event rates are used to determine stopping rules – the point at which the rate of negative outcomes outweighs the benefits. Stopping rules might include withdrawing a certain drug from use or closing a hospital unit because of poor outcomes.

How will adverse events be responded to and what are the specified stopping rules for an assisted dying programme?

You won’t find the answers to all these questions in either the McArthur or the Falconer bills. Why should you? After all, it’s just about personal choice.  Isn’t it?