Whatever else, arguments for and against assisted dying must include the notion of cruelty. And, in my view to refuse the request for advice on, or help in, dying (the legal requirement of doctors at present) when asked for help by patients of sound mind, who are competent to make decisions, who are suffering unbearably from a disabling disease for which there is no prospect of improvement and who have made it clear that they no longer wish to live, can be seen as little more than cruel. On grounds of cruelty alone therefore, doctors should be campaigning for change, for the introduction of laws that permit them to assist. Yet overall, as individuals they seem little interested in the fight and the same goes for the leading medical organisations, who all actively oppose change.
For me this all seems to suggest that doctors are institutionally, and all too often individually, cruel, and certainly that is borne out by history. As a doctor myself, I have been witness to and in some instances involved in behaviour that was unquestionably cruel. I well remember how teams of us (nurses included) would forcibly restrain (‘grapple with’) resistant (‘difficult’) patients to introduce a tube into the stomach to ‘wash out’ tablets taken in overdose. Committing suicide was then illegal and instructions to carry out a gastric ‘wash out’, were followed without a second thought. Our behaviour was quite horrible but was justified by those in the medical profession who took the ‘we-know-best’ position arguing that doctors were simply being ‘cruel to be kind’. Others will have used the ‘sanctity of life’ argument so that above all else life must be saved. Whatever the defence, nowadays forcefully washing out the stomach in this way would be unthinkable.
One might suppose that the assault of patients who had taken an overdose was an isolated example of cruelty but not so, after all, doctors were similarly involved in force feeding prisoners on hunger strike. In another example cruelty was seen with the introduction of law to permit abortion. Here change was driven by public pressure rather than by medical foresight, and against which there was actually opposition from at least two of the Royal Colleges. Remember too doctors’ treatment of patients with intractable pain. There was none of the modern idea of giving analgesics to prevent pain developing. In those good old (puritanical) days, it was not uncommon for patients to only get their pain relief when the pain had become unbearable and only then when they asked (sometimes begged!) for it – a relationship that was both cruel and demeaning.
But examples of cruel behaviour do not stop here, once one recognises that cruelty does not necessarily involve physical hurt. Although things have now changed, not long ago doctors routinely withheld from anxious patients the details of their diagnosis (as, for instance, a cancer), the names of their medicines and their results. And of course medical students were famously encouraged to undertake intimate examinations without permission while patients were anaesthetised. But these have changed as society has demanded that doctors re-evaluate their values and practice.
But now to the substantive point. The kindest, most humane, most compassionate response to (‘legitimate’) requests for help in dying would be for doctors to aid patients, helping them have a dignified death at a time a place of their convenience. Death is a natural and inevitable part of the human condition and for determined patients who want to end their lives an alternative to assisted dying is to use their own devices. This, as with the old ‘back street abortion’, simply serves to make their end squalid, risky, and undignified. Doctors should note how, in retrospect, the cruel behaviours they practised in the past are now seen as totally unacceptable. One day, the current practice in which doctors fail to help people dying will be seen in the same way. On grounds of cruelty alone, doctors and the public should be fighting to decriminalise assistance in dying. The criteria will need to be worked on very carefully, but for me at least, the reasons for the need for change are established.