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THE PURPOSE OF THIS PAPER
The first version of this paper was written in Oct 2013 for ANVIL and is now much revised in this my eightieth year of March 2021. In it I put the case that it be recognised that everyone should be able to die painlessly (and safely) at a time of their own choosing as a basic human right and the law should be changed to facilitate this.

THE EVOLUTION OF RIGHTS
Human rights have developed as such issues as slavery, the treatment of women, racial, sexual, political and religious discrimination have been recognised at different times as violating the fundamental freedoms and respect due to every human being. So why at this time am I, along with many others, calling for this to be recognised first ethically and then legally as a basic human right? The short answer is look at what is happening when such a right is widely denied.

THE NHS. A GREAT ACHIEVEMENT, THANK YOU
We are lucky to live in Great Britain with the NHS, a service that provides out of taxation world class health carefree at the point of use. As someone who has had a heart attack, followed months later by a triple bypass operation, I would not be here without it. It treats everyone, as near as is possible, as being of equal value, old or young, rich or poor, responsible or feckless. Certainly, the treatment I received was excellent. It is an amazing achievement based on liberal values,(Beveridge) both Humanist and Christian. What is more it is operating at a time when medical science is making enormous strides allowing more and more of us to live longer so that to pass eighty is now the norm with an increasing number reaching ninety and 100, and this is set to increase.

UNINTENDED CONSEQUENCES
The problem with this great achievement, as often happens, is the unintended consequences. The proportion of the population over working age is increasing rapidly – both here and in “developed” countries across the globe. What is more here the proportion of those who are over sixty who have serious health problems and disabilities which require expensive and often frequent treatment has reached a third of those 65-74 and a half of those 75 or older. What is more while many,  who are older, particularly the better off, can enjoy healthy, active, autonomous lives, many more, particularly those who have had unskilled occupations, become increasingly dependent on state funded medical services and social care. This is already placing increasing strain on those who are younger and in work and pushing up the cost of running the country to what is increasingly seen as an unsustainable level.

THE U.S.
This problem however is not unique to the UK. It is happening across Europe and most tellingly in the US, so let us start by looking there. In the US – as is the case also here – the top few percent of earners are getting richer and richer and able to buy more and better private health and social care and live easier lives. In the US with no NHS the majority in the middle must buy expensive insurance which provides limited health care while those who develop long standing conditions such as a recurring heart problem can find themselves bankrupted.

(In 2015, the Kaiser Family Foundation found that medical bills made 1 million adults declare bankruptcy. Its survey found that 26% of Americans age 18 to 64 struggled to pay medical bills.¹⁰ According to the U.S. Census, that is 52 million adults. The survey found that 2%, or 1 million, said they declared bankruptcy that year. )

Those at the bottom, some 40 million Americans, have only inferior quality Medicare until Medicaid kicks in for those 65 and older. As a result, they die much younger.

AFFORDABLE CARE AND REPUBLICAN “FREEDOM”
Obama’s Affordable Care Act now provides quality health insurance, (stalled by Trump but now ratified by Biden (2021)) aims to make insurance cover both compulsory and available to all with the hope that everyone will be in a situation like that found in Europe and the UK. Covid will certainly test this.

The Republicans however claim that in the long term the costs of these liberal policies will grow, so forcing up an overall national debt which they claim cannot be sustained. Opposed to tax rises to pay for better universal health care they are prepared to allow the pre-Obama situation to continue in which millions will be eligible for no or very restricted health and social care and will die younger. Again, they are happy that an elite get the best care in the world and die much older. Is such a polarised, divided and inequitable society what we would like to see here?  I fear some think it is inevitable and preferable to them being taxed more in order to “squander money on the undeserving.”

A COMING HEALTH CARE CRISIS
Of the crisis health care presents the Economist (Oct 19 p 12 2013) had this to say, “Eventually, demography – and the huge tribe of baby-boomers who expect pensions and health care, will bankrupt the country. All this age-related spending needs a “fiscal adjustment” (i.e., a tax hike) of 11.7% of GDP.” You cannot get a plainer warning of the crisis than that.

A DEATH-DEFYING CULTURE
What then is causing this near global problem? Obviously, everyone wants to live long and well. Better diet and health care certainly are driving up life expectancy across the world, but we are also facing a cultural phenomenon particularly in the “developed world.”.

We need recognise we live in a culture which sees death as the enemy, the final foe. Every death is seen as an unspoken tragedy and it is seen as a tragedy that we cannot and do not live “for ever.”

 

THE FEAR OF DEATH
In a more secular culture where, even amongst the religious, belief in any form of life after death is waning, the fight is on to extend individual life even further. A spectacular example of this was a six-page article in Time magazine (Sept 30 -2013) extolling Google who are determined it seems “to treat aging as a disease rather than a fact of life” and are out to beat it by putting up a $33 million dollar Breakthrough Prize in Life Sciences “aimed at curing intractable diseases and extending human life.” Now in the biggest scientific award Google gives $3 million to 6 researchers every year and has financed a variety of important potentially life extending breakthroughs.

The difficulty however is that fear of a painful death and the fear that death may or will bring a wipe-out of individual consciousness has become confused with a fear and rejection of dying as inevitable and an avoidance of even thinking about death.

Of course, to find someone is facing death as a child or when young and inexperienced really is tragic. Those who find themselves severely disabled or facing life-limiting conditions while young for whatever reason deserve the support they need to make the most of what they have and can achieve – despite, as we must recognise, the extremely high costs this support can entail both publicly and privately.  Still there are cases when some are born with extreme conditions or suffer extreme illness where keeping them alive can become most inhumane.  This has been recognised in Belgium and the Netherlands.

APPROACHING MORTALITY POSITIVELY
Basically, what makes facing a premature death tragic is the awareness that conscious self-aware life is the most precious thing we have. If, however we have lived and experienced a good full life of some “three score years and ten” o more, Psalm 90 – while certainly not seeking to end it, we should have no fear of death and certainly no desire to “live forever” in any literal sense.  If we reflect we can see it is simply part of the deal. Life has a beginning, a middle and an end.

At the same time to fear a painful, drawn out, debilitating, undignified and often miserable end to our lives is quite reasonable and something we certainly should reject as unnecessary and demeaning when we now know exactly how this can quite easily be avoided. As Professor Stephen Hawking so graphically stated recently before he died, “We would not let it happen to our cat.”

TOWARDS A CULTURE CHANGE
What I wish to see then is not just a change in the law to legalise assisted dying, but a move towards a deep cultural and attitude change in society based on a realistic and positive attitude towards our mortality. Death is not a defeat for the elderly, but the inevitable and proper end to every life. Our bodies and brains have evolved to work well for but a limited period,  and while medical science and good care services can extend that period and enable us to function well physically and mentally for some years longer, the end of the process is, and always will be- whatever the Google prize-winners may find – the same. We die.

What is more we need to see that our mortality is a positive good which facilitates necessary changes as each generation makes way for the next. After a full life, our mortality is not something to be feared and fought against, but to be recognised as a necessary part of life, as necessary as breathing. Facing this in a mature and responsible way and planning for when it will happen is an essential part of being an aware, responsible person.

We need a culture change where a substantial proportion of the elderly choose to die when they are ready rather than hang on for years experiencing unhappiness, loneliness, discomfort and misery, just because they are frightened to die or because they have never had the chance to think about the option of a painless, dignified passing.

WHAT I WOULD LIKE

I ask for others what I want for myself. I want to live for as long as I judge the quality of my life makes living worth-while and satisfying.  This is something only I, and certainly no-one else, can decide for me. I also hope to be able to access on the NHS high quality medical care and good social care for as long as I need it to enable me to live comfortably. If however my health deteriorates to a point where I judge I have had enough of pain and discomfort, enough of feeling I am a useless burden on my family, or know that I am beginning to “lose my marbles” for dementia is setting in, then I wish to be able to die at a time of my choosing with loved ones and even in a spirit of celebration and gratitude for what I have received and achieved over the course of my life.

DEMENTIA
You can find no more shocking documents describing what we are in for as a country than The Alzheimer’s Research Trust’s report Dementia 2010 . and the LSE report prepared for them of 2019. These reveal that 885,000 people in the UK live with dementia and the numbers are set to double every twenty years. ( i.e., 1,640,000 by 2030) Caring for each dementia patient costs £27,647 per year: (2010 prices) more than the UK median salary (£24,700). By contrast, patients with cancer cost £5,999, stroke £4,770 and heart disease £3,455 per year.

The Trust’s 2019 report produced by the LSE adds that as it is estimated that there are now almost 885,000 older people with dementia in the UK, 84.7% (748,000 people) live in England, 7.5% (66,300 people) live in Scotland, 5.3% (46,800 people) live in Wales, and 2.5% (22,000 people) live in Northern Ireland. Of those 127,000 have mild dementia, 246,000 have medium dementia  and 511,000 have severe dementia.  The current overall cost of dementia is £34.7 billion per year and the report concludes that all four countries of the UK face very substantial rising costs for dementia in the next two decades. The number of people with severe dementia is projected to more than double, and the costs of social care are projected to nearly triple by 2040.

Because dementia sufferers gradually lose their capacity for autonomy and discernment they are excluded from most assisted dying schemes – though not in Holland and Belgium where advance directives are accepted. This is something that just must be grasped as this condition alone could imperil the whole of the NHS and the national economy.  There must be a way of allowing anyone who finds themselves on the dementia pathway to either choose an assisted death early on or to formerly pass the power to decide when they are to die to a trusted party, spouse, doctor, solicitor or even friend.

LEGACY
This seems to me the point to mention our legacy, what we leave behind. There are two parts to this, material and non-material. We could call the non-material the spiritual or mental legacy. Of course, a material inheritance can be important, for some very important – even if for some it turns out to be a mixed blessing. However, if you really think about it, it is the non-material “spiritual legacy” that is most important.  Think of what we pass on by example and discussion of our attitudes and values, memories and experiences. Think of the moments of love and sharing we have had, for whatever we may believe about any afterlife, we know that in many ways we live on in those closest to us, and we want our legacy in this sense to be a good one.

THE COST OF LIVING LONGER
What is different about what is happening now as compared to what happened in the past is just how long – often many years, the chronically sick, handicapped and demented can hang on. They hang on exhausting their families and using up all their resources both emotional and material or are left isolated and lonely, on their own or in care homes. As a result, by the time people die – after having lived good, useful, fulfilling lives, loved by their children and respected for their work and achievements, much of that legacy may be dissipated and forgotten so all that is left is a sense of relief that “the loved one” has finally “let go,” and “passed on.”

In the case of the many dementia patients whose condition ends up as “severe”, partners, children and grandchildren often have to see their loved one live on for years unable to recognise or relate to them.  Their legacy is to be left with the most painful memories and in many cases no other inheritance, it all having been spent on someone they once loved, but whose real personality has long disappeared. That is a high price to pay for medical advances. Is it necessary?

THE DANGERS FOR THE VULNERABLE. THE ANGLICAN RESPONSE
In making a response to the Joffee Bill  to allow assisted dying the C of E issued this careful statement, “. The question must be asked: on balance, might a change in the law place more vulnerable people at increased risk of neglect, marginalisation or abuse?  Unless the answer can be a demonstrable and convincing ‘no’ it would be negligent in the extreme to contemplate such a change.”

My response to this? First it is good to see the Church focus on the world as it is and make no reference to supernatural sanctions or the teaching that suicide might be, as was long taught by the Church to be the one “unforgivable sin.”  It seems to me however that the present law which forbids assisted dying is already – because of the medical advances and the shifting demographic – contributing to a situation where “more vulnerable people are placed at increased risk of neglect, marginalisation and abuse”.  Almost daily we read how the pressures on care homes and hospitals are growing, and growing to the point of breakdown – and this will not be put right – as some have recently suggested – by installing spy cameras.

In November 2012, the Church also put out a statement which said that personal autonomy and the protection of life were both important complementary principles, but that when in conflict the protection of life should take priority over personal autonomy since every human life is uniquely and equally valuable. I agree human life is uniquely valuable but note that nowhere is there any recognition in their statement that “personal autonomy” extends to the point where it is recognised that it would be right for someone to choose assisted death rather than suffer, and that I think is a serious omission.

In fact, saying that “the protection of life takes priority over personal autonomy” means  they are saying it is tough so many must suffer a miserable painful death, but better they suffer that than the current law which bans them choosing assisted dying be changed. Why? Because that might result in opening the floodgates to a variety of abuses which they list.  These are: new obligations on doctors and nurses, elastic interpretations, hidden pressures on patients and staff, an undermining of the doctor patient relationship and an overloading on palliative care staff. So, they are saying that patients should suffer now so that others might not suffer from potential abuses in the future. To commend such a compulsory sacrifice hardly seems ethical. Are they really saying that it is right to deny the choice of a person who wants help to end their own life to avoid suffering in order to reduce the opportunities of persons unknown to endanger the lives of others judged to be vulnerable? Surely the right answer is to put in place reasonable legal safeguards to reduce the opportunities for abuse rather than condemn people to suffer and deny them the opportunity to choose assisted dying.

Again, my response is that certainly the abuses they list and others such as what happened at the Mid Staffs Hospital (2004-2009) when hundreds died needlessly because some doctors, nurses and health administrators wished to stick to their budgets and keep down costs need to be guarded against. This scandal and the stories that are appearing regularly show that many abuses are already taking place in a situation where assisted dying is illegal because the whole health and social care system is seriously underfunded and badly overloaded.

 

WHAT WOULD HAPPEN IF THE THE NHS BECAME UNSUSTAINABLE?
I would add to this a point that the Church statements do not address.  If the NHS as it operates presently, was – because of the shifting demographic, another pandemic and the cuts planned for the future – to start to break down in a widespread way, what would that mean? The answer is look at America pre-Obama and the Third World and add to it the work of the Google inspired life extenders. The result? A situation where the rich elite live on in almost perpetual lock-down or lock out in their gated communities to be 120 or 150 years old with incredibly sophisticated health care while the majority outside who cannot afford comprehensive private care, suffer more and more and die young – just as they are doing in the slums and impoverished hospitals of Africa, South America, India and other “Third World” scenarios.

In speaking out like this without specialist medical or legal knowledge I may be underestimating the difficulties of setting up a legal, administrative and medical framework that would protect patients adequately from forms of abuse that the legalisation of assisted dying might make possible.  The point I would make is, it seems to me, that leaving the law unchanged underestimates the negative consequences that flow from the current situation and the failures and abuse it generates now and will continue to do.

CURRENT ASSISTED DYING LAWS AND THEIR CONSEQUENCES
See the accompanying Guardian article which summarises the current growing number of countries and states that have now adopted some form of assisted dying.  Many follow the Oregon model (facing a terminal condition you are provided with lethal tablets to self-medicate) but the Dutch and Belgium laws go significantly further. Switzerland’s 1942 law was the first and has run smoothly without controversy since. In all these places the laws are for those who are suffering (physically or mentally) and usually terminally ill, and in all of them the law includes a high wall of safeguards so that there have been very few reports of suspected abuse and none in most of them.

These schemes are working and to be welcomed and it would be great if something similar could be introduced here, but it is a step that currently only caters for the needs of a small, self-confident, well-educated and financially secure minority. This means it has currently little or no impact on the big problems, dementia and the aged who are chronically sick, disabled and miserable.

Nor is there much evidence that the existence of assisted dying has ushered in much of a culture change as regards attitudes towards dying. There is however the exceptions of the Netherlands and Belgium. In the Netherlands since their law was introduced in 2002, there has been a steadily increasing uptake with 6,585 cases of voluntary euthanasia or assisted suicide – 4.4% of the total number of deaths in 2019. About 96% of cases involved doctor administrated euthanasia, with less than 4% choosing assisted suicide, and the largest proportion of cases involved people with cancer.

COPING WELL AND THEN CHOOSING TO GO
Now of course I understand many if not most people who are chronically sick and disabled adapt incredibly well to their condition, are amazingly positive and enjoy their lives. They deserve our admiration and support. If disabled I would hope to be able to behave in that way. However, that does not mean that eventually they do not reach a point when they feel they have had enough of the struggle and would like some help to let go. This was done quite legally in the case of two of my friends who for years dealt amazingly well with kidney dialysis, but who in the end both chose to come off their machines and die rather than face leg amputation. Neither were in any sense suffering from depression.

One a retired nurse moved in with her daughter, also a nurse, explained her choice and invited all her friends and family to come and see her, showed a lively interest in them all until she slipped painlessly into a final coma. The other, a retired police officer, announced very publicly his decision, had a big party for all his friends and family and went off on a dialysis supporting cruise with his wife before retiring to a hospice where many visited him until he died peacefully with his wife present. I am sure many of us envied that they could choose to go as they both did and have their decision sympathetically received by their families and friends.

THE HOSPICE MOVEMENT AND THE LIVERPOOL PATHWAY
Since its inception because of the work of Dr Cicely Saunders opening St Christopher’s in 1967 the hospice movement and palliative care has grown immensely to focus on giving people the opportunity of a “good death” either at home with Macmillan nurses or in a hospice where excellent care focused on reducing pain and improving the quality of life for those facing “life-limiting” conditions is given.  It is hard to remember how recent this movement is and what a significant and welcome culture change it has brought about in attitudes to death and dying. Initially it faced prejudice and suspicion amongst medical and nursing staff and there were many breakdowns in communication and failures by GPs and hospitals to refer patients to these new services as they became available. Since then the hospice movement has been widely accepted and palliative care has become global.

Concentrating on cancer its achievements have been immense with its staff becoming specialists in this  whole new area of medicine, the use of analgesics and in this country, the use of diamorphine – (the medical term for heroin – typically banned in the US)  At the same time leaders of the hospice movement do not support assisted dying on the grounds that they do not think it is necessary and that they can manage virtually all cases without resorting to it. With their focus on cancer, they do not however deal with dementia patients at no risk of imminent death and their use of life limiting doses of analgesics can be hard to distinguish from crossing the line into assisted dying.  They are however largely dependent on charitable giving and shy away from controversy.  There have apparently been some changes recently with palliative care doctors agreeing that assisted dying could be right in hospices.

Working with the NHS in Liverpool the Marie Curie nursing foundation developed a programme of integrated care for those recognised to be facing death in NHS hospitals and this was widely taken up across the service by 2006.  The aim was to make sure that everyone involved recognised that the patient was dying and to see that they would be treated appropriately.  This was the first time a proper focus was given to the needs of the dying in NHS hospitals where the personal needs of a patient could be lost sight of as they were moved from department to department. I came across enthusiastic nurses and administrators who told me the “Liverpool Pathway” was greatly needed and provided a huge change in attitude in the NHS.  They went further and wanted GPs to place patients they thought were likely to die in the next 12 months on a list to be flagged up and their needs made explicit for both medical and social carers so everyone involved was informed. One problem I heard was that most people are now dying in hospital when they would prefer to die at home.  This blocks beds for others, is expensive and in many cases most inappropriate.  Much better to have the diamorphine and analgesics kept in the patient’s home fridge so they could be available to be administered by the family GP or a visiting nurse.

Sadly, the Liverpool Pathway became part of a bureaucratic system which resulted in some being very inappropriately treated. Some without the knowledge of themselves or their families were put on severe analgesics and given “nil by mouth” so they died or almost died months earlier than they would otherwise have done without their having had any choice in the matter.  This attracted the wrath of the Daily Mail and the “Liverpool Pathway” was “phased out” rather than reformed. It has however been more recently restored with changes in palliative care teaching and practice for nurses and doctors quietly introduced.  The arrival of COVID 19 has also brought about a huge change as so many in the NHS have had to deal with dying patients and their families on a scale never experienced before.

• SUICIDES
  While my thinking and focus in this article has been on the right to die being recognised for those nearing the end of their “natural” lives, no discussion of the matter can avoid looking at suicide. We need to look at the truly tragic cases of the 5,691 who committed suicide in 2019 in England and Wales. Three quarters were men. Suicide is the foremost cause of death for men under the age of 50 who the Samaritans say are facing “a perfect storm” with money, employment, relationship breakdown, alcohol and drug abuse “issues” leading them to feel useless, miserable and get deeply depressed.  Their deaths not only waste their lives but cause huge suffering to their families.

Those who succeed are however a tiny proportion of those who call the Samaritans or the Ambulance Service where in a high proportion of cases calls come after heavy drinking and or self-harming – These are often more cries for help than real attempts at suicide.  Still such men desperately need help, counselling and support services to enable them regain autonomy and a sense of purpose in their lives.  Providing such care is expensive and difficult to access. Should they while still so young have the right to legally choose death and have access to approved means to do so painlessly? Surely not. Assisted dying at the end of a good life or when facing a dire medical condition is quite different. Their need is surely support and care.

CHANGING ATTITUDES
Does the relatively small take-up of assisted dying we have noted mean when we also consider the hysterical media backlash against the Liverpool Pathway that the sort of culture change and shift in attitudes towards assisted dying I am advocating is highly unlikely to happen? And what of the idea that the introduction of assisted dying might make a difference to the future sustainability of the NHS?

As regards culture change I think there are grounds for optimism. Questionnaires given to the public persistently show backing on a large scale (around 80%) for the introduction of assisted dying and this is a growing trend.  Assisted dying groups are growing and now include subsections for medical professionals and the physically handicapped. What is more, culture changes can take place surprisingly quickly. Think of the culture change that has resulted in the legalisation and acceptance of Gay Marriage and the acceptance of a legal prohibition on smoking in public places and most recently the public acceptance of Covid lockdowns and vaccination. A few years ago, these changes were almost unimaginable.

As for the NHS that is much more problematic as it would entail an enormous early take-up of assisted dying by those not facing imminent death anyway to make a financial difference.  The arrival of the “dementia tsunami” before 2030 could however make that difference and bring about the culture and legal changes necessary to accept what I have suggested unless new miracle drugs are discovered to put off the problem for a few years. There may however be forces in our society that will reject such changes with hysterical fanaticism and prefer a British version of the Tea Party “solution”, i.e., be prepared to see the NHS collapse and its replacement by a diminished, selective, privately funded service for the well-off.

How might a change of attitudes and culture show itself?   In May 2014 Lord Falconer’s very restricted Assisted Dying Bill which would only have applied to those  with a terminal condition, failed to get through Parliament (330 against to 118 for) and assisted dying of any sort remains illegal in the UK.  Still, instead of the rather sad, lonely and quite expensive trips to Dignitas in Switzerland (now legally tolerated) a tiny minority are currently taking, we could see some unexpected changes evolving, and Falconer is backing a more restricted form of his bill as a start, aware that he has a great deal of public support for some form of assisted dying. .

 

SAYING GOODBYE

Alongside conventional post death funerals we might see the growth of End-of-Life Events.  These are apparently already taking place in the Netherlands where friends and relatives come to be with the subject and say goodbye before the doctor arrives to give the injection. This type of send-off occasion is something new and evolving and will be quite different for different types of people.  These could be celebration, reflection and coming together events.  Film makers and writers could be employed composing videos and power-point presentations of people’s lives to be played at the event where the atmosphere could be more of a reception and even a party, a pre-departure wake.  Imagine being able to  say goodbye to family and friends before retiring with those closest for the final sleep.

CELEBRATING DEPARTURE

When such events become more mainstream they could take many different forms, depending on the situation, personality, beliefs and values of those concerned. Some would continue to keep the whole thing private; others prefer a jolly, quite rowdy affair as some are in Holland. Some however might seek a religious ceremony and while churches, mosques and synagogues might at first ban such events, their adoption over  time does not seem to me that far-fetched, particularly when clergy discover that some of their most faithful parishioners were choosing the time for their “Final Departure.” Biblical texts could be selected and seen in a new light and Anglicans might devise a new Liturgy for the Departing. Others might also see organising these events creates new opportunities for providing help, support and comfort to individuals and families facing a farewell to a loved one. Other churches and religions might then take this up.

PALLIATIVE CARE
Whatever the development may be as regards assisted dying, the provision of good palliative care in hospital or where possible as most would prefer it in their own home, is likely to be the usually unspoken choice of most people. Done well with sensitivity as I have seen it the results can be good for both the patient and family and here the hospice movement and the training of specialist palliative care nurses has been wonderful, if underfunded.  It has also been found with Dignitas and Oregon that about 70% of those who have prepared for or signed up for assisted dying, in the end choose palliative care while remaining glad to have assisted dying there as an option.

CONCLUSIONS?
So, to conclude I would argue that the right to die at a time of our own choosing should be incorporated into law and become part of Human Rights Legislation. I hope that this might help and encourage a deep cultural change in our attitudes towards death, a change which would recognise that while modern medicine gives us the opportunity to live longer, the inevitable downside is that many of us may end up facing mental and physical changes which diminish us as persons and which we see no reason we or those who mean most to us should have to endure. When we reach this point, subject to safeguards to prevent us being pressured for monetary gain, a fear the countries which have legalised assisted dying have found has been greatly over-estimated, we should be able to choose if we wish to continue to live or to die, or in some cases, such as dementia when we fear that the power to make a responsible choice may be lost, be able in advance to pass that choice to a doctor or family member to carry out what we have clearly stipulated should be agreed is the right time.

It is beyond my competence here to spell out exactly how assisted dying should be done. Should it be the Oregon model of giving patients the lethal medication to take as and when they choose or should it be administered by a doctor as in Holland or should assisted dying be carried out by an agency quite separate from either the NHS or the hospices like an English version of Dignitas, or should it be an extension of hospice services? Then there is the latest idea being mentioned in the Netherlands.  The health and justice ministers issued a joint proposal for a “completed life” pill that would give anyone over 70 years of age the right to receive a lethal poison, cutting the doctor out of the equation completely.

The experience of other countries needs to be monitored by UK professionals and different models could possibly be introduced gradually to see how they work and to see what unforeseen consequences arise. Doing nothing and leaving the situation as it is strikes me as increasingly likely to result in more people dying after suffering from chronic conditions for far longer than if these changes are adopted. Finally, I would say that a society that recognises we have a right to die safely and painlessly at a time of our choosing seems to me to show greater respect for our unique value as responsible, aware persons able to choose what we think is best for ourselves and our families than a society that denies us that choice.

WHAT ABOUT COVID 19
This has been written in the midst of the pandemic and completed on the day the schools have re-opened in England. It has tested everyone and the NHS as never before with 125,000 plus deaths and the hospitals still near breaking point.  We have seen seen the empathy and dedication of nurses, doctors and carers whose lives have been at risk as they have worked unbelievably long hours We have learnt we grossly undervalue and underpay health staff, especially those who are paid least as we have woken up to the value of all staff from porter and ward cleaner to nurse and consultant and admiration, gratitude and pride in the NHS and its staff  has never been more widespread as millions have stood in their doorways and clapped.

In endless media coverage we have been shown the dedication of care workers in care homes and seen their dedication to their residents. However, faced with the need for unprecedented borrowing, the Government has only offered NHS staff 1% in extra pay and care workers, teachers, police and other public servants face a wage freeze and the financing of social care has yet to be faced.  This means with huge staff shortages in both social care and the NHS, the NHS remains in a perilous state, particularly if a vaccine resistant virus or new pandemic appears.

By treating the most vulnerable first with our brilliantly developed viruses the decision was taken that saving lives and keeping the NHS working came first, before keeping the economy moving.  Faced with another virus outbreak such a policy may become increasingly difficult to maintain and there are already those who see it as a mistake. Fundamentally we are not out of the woods yet.

So far the pandemic has not to my knowledge led to an increase in calls for assisted dying.  Possibly this is because the outcome of being placed in an ICU is so uncertain.  You might come out fine, severely weakened or die under an anaesthetic.  However that might change as time passes and cases of “long Covid” multiply.  This could leave very substantial numbers of people permanently struggling with a range of highly debilitating unpleasant conditions. We simply do not know to what extent this will happen or how many may call for an assisted dying option.  We live in tough times.

John Baxter
9/3/2021   johnbaxter119@nullgmail.com   see www.johnbaxter.org for ANVIL
6,291 words.