The assisted dying debate: supporting GPs in a changing landscape

Nearly a decade ago, in September 2015, an assisted dying bill was debated in the House of Commons. It was proposed as a private members bill by the backbench Labour MP Rob Marris and it would have enabled terminally ill, mentally competent adults to request assistance to end their own lives, subject to upfront safeguards. The bill was rejected at its second reading by 330 votes to 118.¹

That summer, a man called Bob Cole from Chester, who was dying with mesothelioma, had urged MPs to change the law. He was making this demand for himself, knowing any change would come too late for him to access it, but for terminally ill people who would come after him. Bob was able to exercise control over how his life ended at Dignitas a few weeks before the House of Commons vote. His final wish, to see assisted dying legalised across the UK, remains unfulfilled.²

On the surface little has changed since 2015. Remarkably, despite the attention this debate attracts, MPs have had no further opportunity to debate an assisted dying bill. Many more Britons like Bob have travelled to Switzerland for an assisted death; in fact, membership of Dignitas is at an all-time high.³ That option is of course only available to those who can afford it and who are well enough to travel. When it comes to the consequences of the blanket prohibition of assisted dying here, campaigners consider the outsourcing of difficult deaths to other jurisdictions just the tip of the iceberg, with reports of hundreds more dying people every year ending their own lives in this country,⁴ and thousands more suffering even when in receipt of high-quality palliative care.⁵

But look a little closer and it becomes clear that the landscape of the assisted dying debate has completely transformed in recent years.

Just before Christmas, Dame Esther Rantzen spoke out about her diagnosis of lung cancer and why she had made the decision to join the growing number of UK members of Dignitas.⁶ The subsequent flurry of media headlines prompted Sir Keir Starmer to declare his personal support of assisted dying and he has now indicated that a future Labour government could make time for a debate on legislation.⁷ Whereas once senior political figures hid behind the status quo, appetite for change now feels very real.

Things have changed outside of Parliament too. In the House of Commons debate in 2015, one Conservative MP made an impassioned speech against assisted dying: ‘most of us here in this House are not medical professionals’, he said, encouraging his colleagues to ‘have regard to what the BMA [British Medical Association] and the royal colleges have to say.’⁸ At the time, the BMA and others held policies of outright opposition to assisted dying and they had briefed MPs to vote against the bill. That is no longer the case. The BMA, Royal College of Physicians, and Royal College of Surgeons all dropped their opposition after surveys highlighted how such policies were out of touch with the views of their members. No MP who wants to vote against law change in the future will be able to cite the opposition of doctors as justification for doing so.

The Royal College of General Practitioners now remains the UK’s only medical Royal College to oppose law change, following a controversial decision by Council in 2020.⁹ Yet, in September last year the current Council adopted a more constructive approach and agreed to establish a working group to look at assisted dying in more detail. The group will not debate if assisted dying is a good idea or not but will instead apply its expertise and learning to the question of how the College might support all GPs whatever their beliefs, if the law does change.

One thing that appears to have remained constant since 2015 is public support. Polls suggest more than 80% of people want an assisted dying law.¹⁰ The National Centre for Social Research recently told the Health and Social Care Select Committee that there has been broad support for assisted dying for 20 years, notably commenting that the public want doctors to be involved.¹¹ This year the Nuffield Council on Bioethics will host a Citizens’ Jury on assisted dying to explore the public’s position in more depth.¹²

The public may have to wait until after the next general election for Westminster to change the law; however, things have progressed more rapidly in the rest of the British Isles: in 2021 Jersey approved the principle of law change and the government is now leading on the development of proposals; last autumn a bill in the Isle of Man — tabled by a GP — passed its second reading when it was backed by 70% of members of the House of Keys; and in 2021 a public consultation on proposals in Scotland broke the record for the number of positive responses, with draft legislation expected soon. Key debates and votes in these three jurisdictions are likely to happen within the next 12 months.

While it is a source of anger and frustration for many, those who fear we are taking a step into the unknown may take comfort in the fact that we have actually fallen behind much of the Anglosphere when it comes to end-of-life choice. The body of evidence of how laws in practice work grows year on year. Every state in Australia has now legalised assisted dying, so has New Zealand. They join ten states and Washington DC in the US. Residents in Oregon have had the option of assisted dying since 1997, where it is still only used by less than 1% of dying people, though more are reassured that it is there if they need it.

These jurisdictions have adopted a model of assisted dying strictly limited to those who are terminally ill and despite speculative fears none of those laws have extended beyond that initial scope. This is the model favoured in the proposals tabled in the UK, suggesting there is less appetite for the broader laws passed by legislators in Canada and a number of European countries.

Readers will no doubt have a variety of views on this issue. Some will feel strongly on one side or the other, perhaps informed by their own personal experiences and beliefs. Others may hold a more nuanced position or remain undecided. As doctors — as opposed to politicians — we will not have a final say in whether or not the law changes, but we will have a crucial role to play if it does. Perhaps, therefore, the most significant change in the debate is that it is now much easier for doctors to discuss assisted dying than it once was. That should be welcomed by all, and it is essential to informing how we might incorporate assisted dying into end-of-life care provision in this country, which, judging by recent events, may be sooner rather than later.

Provenance

Commissioned; not externally peer reviewed.

Competing interests

Supporter of the charity Dignity in Dying; Associate Director of NHS Resolution; Non-Executive Director of East London NHS Foundation Trust (Mental Health Trust) from 2020; Consultant to the National Academy of Social Prescribing; Fellow and Professor of Queen Mary University of London from 2015; Vice President of the Queen’s Nursing Institute from 2016; Vice President and Council Member of the College of Medicine; Council Member of the Royal College of General Practitioners in November; and Council Member of the British Medical Association.