Let’s talk about (assisted) dying

(Updated 30 November)

The House of Commons today voted in favour of the bill to legalise assisted dying. This is an area on which I find it very difficult to decide one way or the other, and when the general principle last came before General Synod in July 2022, I abstained. For that debate, we were asked to make a decision about ‘assisted suicide’ rather than ‘assisted dying’ – words matter – and, in contrast to today’s parliamentary vote, the motion was overwhelmingly defeated. The present bill is very specific; limited to people over 18, with terminal conditions meaning that they probably have less than six months to live. But I fully hear the ‘slippery slope’ concerns expressed by disabled people and the parents of disabled children that, as became clear during Covid, it is all too easy to conclude that some lives are more valuable than others. There are also important discussions to be had around the effect of race; I just saw that ethnic minority MPs were less likely to vote in favour of this bill and I’d like to know more about that.

We all bring personal experiences to this debate. Many years ago, when my mother was in hospital with a feeding tube, she asked me to end her life. It was painful to hear that question, and I knew that, regardless of the law, there was no way I could do such a thing. And, a few days on, she was feeling much better. When I told her later what she had said, she had no recollection of it; and she found it hard to believe that she would have asked that. The present bill would not have applied to her; she had no terminal condition, and in any case the bill includes a ‘cooling off period’ after which one would have to confirm one’s decision. I have also heard people, both within my family and friends and in care homes I have visited, saying very firmly that they wanted to die, and in their case this has been to do with their quality of life rather than fear of the process of dying. The frustrations of age, and of disability, affect us all differently. I have found interesting the point that we do so much to extend life, yet feel we can’t shorten the process of dying. Many of us have said at some time “I would rather die than…” but when that thing happens to us, we may find we feel differently. 

I’ve also spoken in a hospice, and was very impressed by everything I saw there, but am also aware that, even with modern drugs, it isn’t always easy to control pain. For that talk, my theme was ‘the history of pain’. Because, as ever, there’s history, both of pain relief and of the concept of a ‘good death’. 

Before today’s vote, I went to an online seminar on the topic to hear some other views. In the chat feature, somebody asked ‘What about the Hippocratic Oath?’ And then I found that Tim Farron MP had said something similar on Premier Christianity writing, “Do no harm. It is also the basis of the Hippocratic oath taken by the medical profession”.

So let’s look at that. The Oath has played an important role in medical ethics. In 1913, in The Evolution of Modern Medicine, William Osler referred to it as ‘the high-water mark of professional morality’. In a 1995 article, Vivian Nutton definitively demolished two myths: first, that the Oath is a ‘fixed and unalterable document of medical ethics’ and, second, that all doctors in the Western medical tradition have taken, and continue to take, it. It isn’t, they haven’t, and they don’t. Yet we seem to need an ideal from the past against which to measure our response to our own ethical issues, even if that ideal never existed. As Vivian Nutton wrote of the Oath, ‘far from the Oath imposing its values on society, it has always been society that has imposed its interpretation and values on what that Oath is and means, and it has been constantly changed to accommodate the demands, the concerns, and, at times, the prejudices of society at large’.

That chat comment in the seminar was presumably a reference to the clause in the Oath sometimes translated as ‘I will give no deadly medicine to anyone if asked, nor suggest any such counsel’, sometimes as ‘I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan’. The thing is, this is not relevant to assisted dying. There is no discussion of the ethics of such an action in the various ‘Hippocratic’ texts, and there is no evidence to suggest that ancient Greek doctors practised assisted dying, by responding to patients who asked them to help them die. As for the word ‘euthanasia’, which seems to have been discarded in the recent debates – too technical? too foreign? – originally it meant nothing like its usage now; it is simply a ‘good death’, and the ancient Greeks regarded that as being the death of a young man fighting for his homeland. In contrast to all this, the clause in the Oath seems more likely to be about the fact that doctors had access to potentially powerful materials which could be used in murder, and that they needed to keep control of these. 

Some people think that the injunction ‘First do no harm’ comes from the Hippocratic Oath. It doesn’t. The nearest wording in the ‘Hippocratic’ texts comes not from the Oath but from Epidemics1.11, which includes ‘As to diseases, make a habit of two things – to help, or at least to do no harm.’ The problem with that today is simply that modern medicine relies on treatments which work precisely by ‘doing harm’ first.

I write here as someone who has written an entire book – Hippocrates Now – about how orthodox and alternative medicine, as well as the wider public, think about Hippocrates today. The publisher made it available on open access so anyone can read it all. But this question in the chat didn’t just irritate me because it reminded me of all the claims wrongly made for the Hippocratic Oath. There’s something going on here about how we don’t want to take full responsibility for our decisions; we don’t want to think through the issues properly, instead bringing in some text from the past as if it is entirely without its own historical context. Why is it that anyone thinks a document written two millennia ago, by someone who wasn’t even Hippocrates, should affect what we do today? Why can’t we make up our own minds, based on today’s knowledge of medicine and the body? Medicine changes: knowledge changes: our view of the body and how it works changes. We can’t rely on the past: we need to think within our own context.