On 11 September, the Second Reading of the Assisted Dying (AD) Bill will take place in the House of Commons. If eventually passed, it will allow a terminally ill adult (prognosis less than 6 months) resident in England or Wales to be supplied with a lethal prescription to be self-administered under the supervision of ‘an attending health professional’ (doctor or nurse). Before the prescription is issued, a High Court Judge will have to be satisfied that the person has (mental) capacity, and that the desire to hasten death is voluntary, settled and informed. The key criterion is short prognosis; the patient does not have to be ‘suffering unbearably’.

Nurses will inevitably be involved, most probably as the ‘attending health professional’. This would mean delivering the lethal prescription and staying with the patient for several hours while it takes effect. The main justification for such a fundamental change is the right to self-determination (individual autonomy).

However, restrictions on individual autonomy are legitimate if other people would be endangered. Thus, the debate about AD revolves around the question: can we devise a law that would allow terminally ill people to end their lives (should they wish to) without endangering others (who do not want to)? Advocates for AD claim that it should be possible, whereas others (including most palliative care doctors and nurses) claim that a change in the law would cause more harm than good.

The common denominator in patients who desire to hasten death is despair—a sense of hopelessness, helplessness, lack of control, isolation and endlessness—related to actual or anticipated:

• Severe pain or other physical distress, for example, breathlessness, choking, vomiting

• Increasing dependence

• Slow deterioration over many months

• Being a burden on family and friends

• Being kept alive with machines and tubes when quality of life is unacceptably low or when in coma.1

Despair also stems from:

• A short-term adjustment disorder on discovering one has a fatal disease with limited life expectancy

• Demoralisation (‘no point in struggling on’)

• Depression (meaning a depressive illness, not just sadness or demoralisation).

In nearly 400 palliative care patients with cancer, a ‘genuine’ desire for death was present in 12%, over half of whom had an identifiable psychiatric disorder, mostly depression.2 In a study of Dutch patients who had requested AD, it was found that, without hopelessness, there is no perception of unbearable suffering, and that a constant feeling of unbearable suffering was invariably associated with depression.3 That said, one does occasionally meet patients who have a constant feeling of hopelessness not related to depression. This possibly stems from a world view in which self-worth depends on being robustly healthy and ‘in control’, and anything less is intolerable.4

However, the everyday lived experience of palliative care clinicians demonstrates that unconditional positive regard for patients (respect), good communication, goal-setting, holistic support, a sense of urgency, high-quality pain and symptom management, and an enduring commitment (non-abandonment) together provide a powerful contrasting set of positives. This typically results in renewed hope, which, in turn, allows people to ‘live until they die’, complete unfinished (psychosocial) business and to die peacefully (‘with dignity’) with no need for AD.

There is also justifiable concern that patients will be coerced into requesting AD by various subliminal influences. Further, some people already fear (and refuse) palliative care because they believe that they will be ‘done away with’. And this would surely increase if AD became lawful, enhancing the perception of clinicians as potential killers.

Many publications confirm that, once the barrier of legislation is passed, AD tends to take on a dynamic of its own, and extends beyond the agreed restrictions despite earlier explicit assurances that this would not happen.5 At present, the law in the UK provides a clear ‘bright line’; it may occasionally be crossed by doctors (and others) but it remains unambiguous.

It is perfectly consistent to argue that, ethically speaking, AD is permissible in some extreme cases but that it would be unwise to change the law. Law is a blunt instrument for dealing with ethical complexities. As at present, it could be better to allow hard cases to be taken care of by various expedients than to introduce new legislation that most likely would become too permissive.