Living with the consequences of assisted dying

Letters: The issue is about people who are dying and in great pain being given the legal right to ask for assistance to die as quickly as possible

While we fully agree that the ease of pain and suffering should be the priority when a patient is nearing the end of life, and keeping a patient alive at all costs is not consistent with compassionate care, we would like to counter some of Professor John Ashton's assertions (Top doctor's assisted dying call,  2 July).

First, his comments on the use of sedative medications at the end of life suggested that the administration of doses that would end life in a dying patient would not represent a major departure from current end-of-life prescribing of medications given to ease suffering. There is no evidence to show that medications used for relief of distress and symptom control at the end of life shorten life, and are not prescribed with this intention. To be confident of ending a person's life with these drugs, prescribing practices would need to change radically. Second, Prof Ashton voices his support for assisted suicide for patients in the final days and weeks of life, but the clinical practice he describes appears to be more in line with voluntary euthanasia, which is excluded from the assisted dying bill. The experience in Oregon shows that the majority of people who avail themselves of the provisions of the Death with Dignity Act are the more 'vigourous' terminally ill who are not typically days from death. Reduced consciousness levels are common in the final days of life, and decision-making as well as the ability to take and swallow medication may be impaired.

We strongly advocate for compassionate end-of-life care, but argue that assisted suicide is not merely an extension of current practice and should not be construed as such.
Prof Matthew Hotopf
Professor of general hospital psychiatry, King's College London Institute of Psychiatry
Dr Ollie Minton
Locum consultant and honorary senior lecturer in palliative medicine, St Georges University of London
Dr Annabel Price
Consultant psychiatrist in liaison psychiatry for older people, Cambridge and Peterborough foundation mental health trust

• Prof Ashton suggests that the professional equivalent of midwives should help terminally ill patients and "if necessary shorten the end of their lives".

A midwife, literally "one who is with the mother", never ends a mother's life no matter how painful or distressing the birth. Prof Ashton, like many people, seems to be unaware of the large numbers of doctors, nurses and allied health professionals who have the privilege of being "with the patient" at the end of life, and so act as midwives to the dying  in helping to ease pain and suffering.

I am disappointed that there was virtually no media coverage of One Chance to Get it Right, the recent report of the Leadership Alliance for the Care of Dying People, in response to the Neuberger review More Care Less Pathway. The alliance report focuses on improving compassionate care at the end of life. It is this report that merits our attention rather than changing the law to allow euthanasia or assisted suicide.
David Jeffrey
Honorary lecturer in palliative medicine, University of Edinburgh

• I think the views of Andrea Williams of Christian Concern would not be supported by the majority of her fellow Christians, as most people, believers or not, do not want to see their nearest and dearest suffer a prolonged and painful death. This has been demonstrated in many pieces of research and surveys of public opinion.

While I don't claim to understand her religious beliefs, I tolerate them and accept that she has a right to hold them. What I expect from her – and other religions – is a tolerance of my beliefs, without resorting to claims that doctors will be "killing" patients. The issue is about people who are dying and in great pain being given the legal right to ask for assistance to die as quickly as possible. That assistance could, in theory, be given by someone other than a doctor.

If Ms Williams and her supporters are happy for their lives to be prolonged when they are dying and in great pain, that is their choice. But please don't impose your choice on people who have a different view at the end of their life.
Graham Ross

• It was misleading that your front page was headlined "Top doctor's assisted dying call" when Dr Ashton's full interview was a balanced account of the public health needs affecting this country. Assisted dying and the Falconer bill, due to be debated in the House of Lords later this month, are firmly resisted by the other medical royal colleges (Dr Ashton's group is a faculty of the Royal College of Physicians), and by many doctors who work in direct patient care of terminally ill patients (unlike public health specialists).

There are serious risks that this policy would be uncontrollable, leading to "incremental extension" (to other classes of person), and to implicit pressure on vulnerable people to accede to voluntary assisted dying. There is evidence that excellent palliative care, in which the NHS is a world leader, strongly mitigates calls for assisted suicide, which are commonly withdrawn when such care is experienced.

The present law works well, combining a firm steer against exploitation and abuse with permitted judicial leniency in the rare hard cases.
Peter D Campion
Emeritus professor of primary Care Medicine, University of Hull

• Giles Fraser has given the same sermon twice (Loose canon, 5 July 2014 and 3 May 2013). He is playing God. He knows we have a right to life but rules that we should not have a right to death. He confuses choices forced on us by thoughtless care staff with personal choices that we want to make ourselves. We can already make personal choices, all carefully qualified and countersigned, to refuse treatment to prolong life. The Mental Capacity Act 2005 provides for such advance decisions. This legal refusal of treatment can already lead to earlier death.
Chris Coghill

• As a doctor I find the accusation of trying to "play God" offensive. Looking after people who are suffering, especially at the end of their lives, I see no God that is compassionate or just.
Dr Jacinta Derks
Rowlands Castle, Hampshire

• As a retired GP I was pleased to see Prof Ashton's thoughtful support for assisted dying. I was unsure about this issue until it affected my family. Last year my mother, totally immobile, in end-stage heart failure and with severe and painful ulcers, decided she could not cope with her life any longer. he chose to starve herself to death. It took over two weeks and was horrendous for her and everyone caring for her. Surely a more humane approach would have been to support her choice and help her on her way.
Alex Booth

• The discussion around Lord Falconer's bill on assisted dying has been made even more difficult by the careless use of words which may be etymologically correct but have widely differing connotations. It would be helpful to assign more specific meanings to the terms assisted dying, assisted suicide, killing and euthanasia, so that we can at least agree on what we are talking about.

The word "kill" has no place in this debate – killing is what Dr Harold Shipman did. "Suicide" often has overtones of personal tragedy but does not apply to a timely end to a terminal illness. "Assisted suicide" is the appropriate term for a mentally competent individual with unbearable but non-terminal physical disability who seeks help to die. "Euthanasia" should be reserved for situations where the individual has never been, or is not now, competent to request and consent to assisted dying. The term "assisted dying" in Lord Falconer's bill refers only to adult individuals who know they are dying, and are competent to decide about and participate in active measures in ending their life. Neither "assisted suicide" nor "euthanasia" as defined here are envisaged in this bill.

Those opposing Lord Falconer's bill cite the difficulty of protecting vulnerable individuals but there would be more protection for patients if the legality or otherwise of helping a particular individual to die were to be established before that help is given, rather than after the death. Health professionals, and palliative care specialists in particular, would be protected from complaints by the deceased's relatives.

Lord Falconer's bill will result in a robust legal framework to replace the guidelines set out in 2010 by Keir Starmer, the then director of public prosecutions.
Professor Sir David Hall

• Andrea Williams appears to be missing the point. The patients concerned are not "being killed"; they are dying, and wish to cut short the suffering they are enduring. To do this they need access to drugs that doctors have chosen to make available only on medical prescription. Assisted dying is what it says: the patient self-administers medication that a doctor makes available to him or her.
Elizabeth Brown

• Professor John Ashton sums up the feelings and wishes of so many people living with cancer. How reassuring it would be to know that a kind doctor would be prepared to end the patient's suffering when close to death, without fear of prosecution. Having recently moved house, and been diagnosed with cancer, I hope to form such a relationship with my doctor. Even better would be change in the law.
Marguerite Christmas
Stamford, Lincolnshire

• It is about time medical leaders came off the fence and supported the view of the majority of doctors and the public (from polls) who feel the law on assisted dying should be made more humanitarian, and a right of the individual to determine.

It is really only since the Shipman case that doctors, particularly GPs, have been frightened to help their patients remain as comfortable as possible during their last weeks or days, whether or not this meant shortening their life. The result has been unnecessary suffering. If a patient's mind is sound and he or she wants to end their suffering by dying, and safeguards such as two independent clinicians authenticate the request, then a doctor should be able to assist the patient.

If over the last few centuries we have won rights over how we may live our lives , it seems illogical to suddenly take those rights away at the end of life, because of someone else's beliefs that we may not share.
Peter Brown
Newton Ferrers, Devon

• Professor Ashton's suggestion that doctors should assist in ending the life of terminally ill sufferers would accord well with a market based economy. I would not suggest that such an idea entered the professor's mind but it would assuredly enter that of others. Caring for the depressed and terminally ill is expensive both financially and emotionally and the easiest and cheapest response is to just dispose of such. That is not the mark of a civilised society.

We already have a government which has cut the NHS to, and sometimes beyond, the bone; and this in spite of evidence to show that it is by far the most cost-effective way to deliver health care. A civilised society should offer quality care to people in such need and not fob them off with cheap alternatives, even if it means, horror of horrors, that taxes need to be increased.

Beware also the law of unintended consequences, the elderly with low self-esteem who feel that they would be better "out of the way".
Alan Pentecost
Maidstone, Kent

• I read with great interest John Ashton's article. I agree with everything he has said. As a physiotherapist who has previously worked in a hospice, I recognised that a main function of healthcare professionals is to empower one's patients. Sometimes, the only empowerment left on offer is the decision of the where and when of death and this must be afforded to our patients in their best interest.

My mother died after asking for assistance in dying which was denied to her. Her last request to me was to help to change "this ridiculous law". From the change of law in Oregon, it is clear that adequate safeguards have ensured that no patient is coerced into assisted dying: quite the reverse. Patient opting for assisted dying are informed people who have also been causative in their own lives. Why deny them the option of being causative in their deaths? I hope that the House of Lords see fit to support Lord Falconer's bill on 18 July.
Lindsay Flower
Abbots Langley, Hertfordshire

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