Written 17 October 2024
The government has announced that Parliament will debate a private members’ bill on assisted dying in the coming session so as this is an issue I have taken quite an interest in for some time I thought it would be good to set down a few thoughts on it. None of these will be original, this is not definitive and I expect to change my views over the coming years (as my views have changed up till now).
First off I think people on both sides of the debate are almost without exception motivated by principle and honour. That should go without saying, it’s true of almost any political question, but given the state of our political debate over recent years I do expect that people will lose sight of this over the coming months: tempers will become frayed, impolitic comments will be made in the heat of the moment but we should all remember that we are arguing for what we think is best. Everybody has seen loved ones die of painful and distressing diseases, we’re all going to die, we all have skin in the game.
Secondly I am not a philosopher or ethicist. Thankfully. Now philosophy and ethics are important and it goes without saying that there is an ethical and philosophical dimension to this debate as indeed there is to any other. But I do not see politics and our political and regulatory settlement as primarily questions of philosophy or ethics. To be honest, they’re not fields I’m particularly interested in, they’re certainly not ones I’m qualified to opine on and I don’t think the heart of the debate lies here.
Jolly good. Starting at the end, it seems inevitable to me that we will eventually have legislation on the books that allows assisted dying in this country. The public seems to be strongly in favour of it1 and there have been any number of (thus far unsuccessful) attempts through both the Commons and the Lords. We also have a new Government whose majority in the Commons is built on a younger generation of MPs who I believe will be more supportive and campaigners aren’t going to give up. Unless there is a significant cultural shift over coming years the train has left the station. I am of course assuming of course that history really works in one direction, which I don’t believe, but for my purposes here I’ll assume in this case it does.
Our health and care systems
Britain’s health and care systems are not good (though they are revered, see below). I don’t think this is a particularly controversial take: most people in the country seem to agree though there is of course a lot of disagreement on the reasons for it. Generally those on the left regard the issue as one of funding, while those on the right point more to structural factors. The truth in my view lies somewhere in between: our demographics demand that we direct more resources towards health and care and this should be done in conjunction with profound and far reaching reform, especially bringing together state provision of care into an expanded health and care system. This inevitably means a bigger NHS which in my view will likely exacerbate structural issues but I’m not going to go there: the British public are nowhere near voting for serious reform of the NHS but will support incorporating care into it. Good, let’s get on with it, and let’s also expect that this will improve end of life care (while also noting that hospices, which specialise in delivering quality end of life care while receiving about a third of their funding from the NHS are managerially separate from it and generally wish to remain so). This must be a priority and if improvements to end of life care in the UK are possible then we should see results quickly.
Current practice and proposals
Like most people I have seen assisted dying in practice, it actually already exists in the UK. If you think it doesn’t you haven’t been paying attention. When my Dad died it was very quick: it turned out he’d been ill for some time with cancer2, my brothers and I got the call on a Sunday night that he wouldn’t make it through the night. Over eight hours in Newport Hospital my Dad was kept sedated through huge doses of drugs that the nurse told us, through nods and winks, would also have the beneficial side effect of bringing the end on sooner. It happens all the time, we all knew what was going on, the nurse (very experienced and very good) knew what he was doing (he’d clearly done it many times before), communicated well and we were all comfortable with the process which all took place in the course of a night.
We have yet to see the legislation to be brought before Parliament but clearly more is imagined than merely formalising the informal processes in place that took place with my Dad where the interventions were to keep him comfortable with a hastened death as an acceptable side effect. The details will matter: which prognoses will qualify? need there be a terminal condition? What oversight and safeguards will apply? etc etc etc.
I can understand the principled arguments in favour of assisted dying as an extension of providing well directed end of life care. Nevertheless I think the best that we can say at the moment about any proposed legislation is that it is premature: we have so much work to do on our healthcare and end of life care systems that is much more important and a much better use of our resources. This is not my principal concern however, these are all really centred around firstly the nature of our politics and culture, the nature of the progressive project which is inextricably entwined with a cause like assisted dying, and thirdly with our old friend the slippery slope. None stand in isolation, they are all related, but it’s as well to deal with them separately.
Our politics and culture
Two points really stand out to me regarding the state of our politics. The first is pretty general, the second really concerns the NHS. I despair at the state of debate and political discourse in our country: it’s shallow, shrill and infantile. I think a large part of the blame lies with the emergence of political communication and spin, particularly through TV, as an increasingly central plank of political operations in the country under and since New Labour but that’s by the by. It has served to trivialise debate and meant that the most dysfunctional personalities are hugely over represented in the political sphere (by which I include media and other fields within the penumbra of parliament). With the remorseless rise of TV and now social media we find that media celebrities appear to be accorded a weight and importance that is entirely unmerited, further degrading the standard of discourse. I don’t know what is to be done about this, and it obviously has repercussions well beyond this question in particular, but it does seem to me to bode badly for the debate to come.
Secondly I think that the UK has a uniquely odd relationship with its system of state healthcare. Other countries simply do not revere their systems as we do (they are in all cases designed along very different lines to our own NHS anyway). In the recent pandemic, the fact that lockdowns could be imposed so successfully by an appeal to “protect the NHS” is something I found genuinely weird. As a nation we are in thrall to a government system that does not deliver particularly impressive results but believe we are uniquely blessed among civilised nations in having. As Nigel Lawson said, the NHS is the closest thing the English have to a religion. This is a cultural factor that is important to the debate in the UK in particular.
The Progressive Project
Progress is a good thing and I regard myself as a progressive and as a liberal. Progress and liberalism have delivered tremendous benefits to humankind over the last few centuries. Who’d want to be without universal suffrage, a welfare state or the rises in living standards and life expectancy driven by the adoption of science?
In the modern West we see an acceleration towards a political self-described progressivism that is very much not the same thing as a project to achieve genuine, worthwhile progress in our societies. When I speak of the Progressive Project I am referring to what I see as (at best) a subset of the historical Left, prone to a legalistic outlook, hubris, arrogance and a lack of empathy with those who do not share their views. The Progressive Project has won, I say this not to bemoan the fact but rather as an inescapable fact. However, within its presumptions I think there lie enormous dangers for assisted dying legislation.
One thing that has become increasingly clear to me over the last couple of decades is that liberalism and progressivism by themselves in their current forms and without any sense of boundaries which they must respect and operate within have led to high levels of dissatisfaction and unhappiness in Western societies. Slower, measured progress over longer periods of time following long periods of argument and campaigning has given way to what feels to many like me as a machine, a rotovator acting on and within history, having no regard to any tradition and wholly deaf to voices in opposition (which are generally regarded as at best uneducated but more often as mere echoes of atavism which progressives have risen above). Once cultural norms are breached we have a second rate replacement in the form of technocratic safeguards administered by bureaucracies that are themselves staffed disproportionately by liberals and progressives.
To repeat, the Progressive Project has won. I say this not to bemoan the fact, though I think it impoverishes our society in untold different ways, but it simply seems beyond doubt to me. It won’t be a forever victory, its inherent contradictions are too obvious and run too strongly counter to what is really necessary for genuine flourishing. The West though has no effective immunity against it for the time being and this looks set to be the case some time to come. Its demise will not be in the form of some sort of return to an idealised past, it will be superseded by something else, something that may well be a lot worse, but speculating on that here is not the point.
The importance of boundaries really can’t be overstated and this is where I think we really start running into problems. Liberalism and Progress are good things, but I think they can only deliver genuine sustainable advance in our society if they operate within boundaries and I think a real problem for these political outlooks is that they are by themselves incapable of articulating or defending boundaries in any way other than the shallowly technocratic. Both operate with a vision of a better tomorrow in one hand and a political rand reforming ratchet in the other. One victory is simply never enough. Once one boundary is breached attention inevitably turns to the next one: probably a weaker one, because it hasn’t been there for very long and is most likely a highly technocratic/bureaucratic safeguard rather than something rooted in anything deeper or less transient.
Conclusion
Taking the three broad points above together, where are we likely to get to? I think it is certain that any legislation will not be a one off reform to tidy up and improve end of life care and management. It should be seen as the start of a process of reforms that will have a momentum and internal logic all of their own and whose practical effects I can’t welcome. Though Kim Leadbeater assures us there will be no “slippery slope”3 there are clear indications that many MPs and campaigners see the proposed legislation as significantly underpowered and that its scope must be increased. This is inherent in the politics of the Progressive Project. Where this leads is not difficult to imagine. Indications from Canada and the Netherlands are that any safeguards are likely to be weak in practice and degrade over time and if you’ve got this far you’ll be aware of how assisted dying has developed to undermine welfare and the care of the most vulnerable members of society (the mentally ill, the homeless etc) . This is inherent in their nature. Thinking that slippery slopes don’t exist can only be described as naive in the extreme.
Given I don’t really see how assisted dying legislation isn’t passed at some point in the future, what is the point in opposition? Well, firstly I think it is important to nail the proponents of these changes and extract commitments as to their future conduct and also how they expect the environment around death to be improved over the coming years. We can extract promises of “this far but no further”. These of course will not be binding and in time will be disregarded but nevertheless, this will serve a purpose in informing future debate and not just about assisted dying. Receipts of this nature are of absolutely no use in a tactical sense but serve to throw light on the nature of the Progressive Project and its use of policy ratchets. This is something that our politicians have been entirely useless at doing over the last thirty years but there are some glimmers of hope that a newer generation are beginning to cop on.
We’re going to just have to grit our teeth, accept that this is coming in one form or another (quite likely through this private bill) and dust ourselves down. Proponents of assisted dying, once you get beyond the spin, seem so terribly defeatist to me and indicative of a diminished sense of what human life is but there we are. As scandals and unintended consequences reveal themselves over the coming years there will be tweaks to regulations, constitutional changes to regulatory bodies but I think at some point as Western societies chase the illusion of fulfilment and meaning through materialism, health, rights and individual choice the poverty of this outlook will become more obvious to more people. Then we can make genuine progress towards something better.
- YouGov polling here (download): https://yougov.co.uk/health/articles/37358-three-quarters-britons-support-doctor-assisted-sui. The difference across generations is not really noticeable on the first question regarding terminal disease but on “painful,incurable but not terminal diseases” it is, which may be important for future directions in policy. ↩︎
- The less said about standards of NHS communication generally and on diagnoses/prognoses here the better: long story but it ain’t good in this case. ↩︎
- Here at around 1:30 https://www.youtube.com/watch?v=35lU-SnGTpk ↩︎