Right to die? the doctors who believe in it

If life has become intolerable, should Dignitas be an option? Carol Midgley meets the medics who say it should

I find Dr Colin Brewer in his kitchen at home enjoying a civilised glass of afternoon wine with Dr Michael Irwin, former medical director of the United Nations, who in some newspapers goes by the somewhat hyperbolic title Dr Death. It is all quite jolly and old-school considering we are here to discuss a decidedly unjolly subject: suicide. Or specifically medically assisted rational suicide (MARS).

The doctors have co-authored a new book advocating MARS with the wry title I’ll See Myself Out, Thank You. It features a series of articles written by supporters of the campaign for law change from the Reverend Dr Paul Badham to Baroness Warnock to The Times’ columnist Melanie Reid. What has already made waves is that in one section Brewer, a psychiatrist, lists seven people for whom he has provided psychiatric evaluations supporting their applications to Dignitas by establishing they had the mental capacity to make that decision.

Only one of them was suffering from a terminal illness. Their complaints range from crippling arthritis coupled with heart disease to early Alzheimer’s to an elderly woman with a history of depression who had developed a progressive illness and an intractable pain. One, named Eddie, whom Brewer describes as a “truly charismatic person, witty, well-informed and very articulate” is going blind. He lost much of his sight in an accident, is now losing the rest and dreads living in a world of blackness.

Brewer writes with candour that “from a purely selfish point of view” he wishes Eddie, who is in his sixties, would delay or even abandon his planned journey to Switzerland but Eddie is resolved. “Like me, his family would prefer him to stay around but they accept that this impressive and strong-willed man is entitled to his own definition of intolerable suffering.”

Critics see these cases as a challenge to the director of public prosecutions and an exploitation of the guidelines. The doctors say it is no such thing. “I don’t see how doing a medical report can be construed as aiding and abetting”, says Brewer, 71, who is research director of the Stapleford Centre, a private addiction clinic in London. “I’m not helping people to die. Sometimes in fact it’s quite the reverse: I have to hinder them if they don’t have the mental capacity. Sometimes I say: ‘I don’t think you’ve exhausted all the reasonable treatments; there might be something you’d be interested in and could consider.’ ”

Irwin, 83, has accompanied four people to Dignitas, two of whom had a terminal illness. In 2005 he was struck off by the GMC after he admitted trying to help a terminally ill friend Patrick Kneen to die. He travelled to the Isle of Man in 2003 with about 60 temazepam. Kneen, a right-to-die campaigner, was in the event too ill to take them and slipped into a coma, dying a few days later without Irwin’s help.

“They [the GMC] asked, ‘Would you do it again?’ and I said, ‘I won’t promise not to’, so I was struck off,” Irwin says. Brewer too has been struck off but for a reason unrelated to assisted dying. It was after he was accused of inappropriate drug prescribing to his addiction patients. The singer Shaun Ryder and music entrepreneur Alan McGee, however, have told of how his methods helped them overcome their drug problems.

The doctors hope the book, “a reasoned libertarian argument”, will be read by the public and by the medical profession (polls suggest that up to 75 per cent of the population is in favour of changing the law on assisted suicide but the British Medical Association is not), but equally they hope it will flag up a looming spectre: dementia. In 2009 Irwin established the Society for Old Age Rational Suicide, which promotes law change so that very elderly, mentally competent individuals who are suffering from various medical problems are allowed to receive a doctor’s assistance to die if this is their persistent request. He and Brewer believe that dementia is now people’s main ageing concern.

“I find when talking to people, certainly over the age of 50, that the biggest reason they have for a living will is the fear of dementia,” Irwin says. “It’s not cancer or things like that, it’s dementia now.” The problem for any dementia sufferer who might want to end their life, however, is that in most cases to qualify you have to have mental capacity at the time. In Dutch law people can make an “advance decision” so that when they lose mental capacity they can still have euthanasia, but such “anticipatory deliverance” is rarely acted upon.

Who would make the decision? Might a confused person be terrified at being reminded of their previous request? “If people are serious about it they have to go early when they still have a few weeks or months of potentially enjoyable life ahead of them,” Brewer says, “but they’d rather go too soon than too late. [Advance decision] can be done and I think in the future it will be done more often, but it’s a step further than people want to discuss at the moment.”

Dementia, they say, is one of the major causes of chronic and expensive nursing-home care but they know that any mention of money inflames their opponents since it reinforces the idea of “bedblockers” being pressured into ending their lives. However, they pose the question: is not wanting to be a burden financially or otherwise such a a bad thing anyway? “People are actually very altruistic,” Brewer says. “They say, ‘I don’t want my money to be wasted on looking after me; I’d rather it went to the family or some charity I approve of.’ Other people say, ‘I don’t want the state to have to spend money on me. I’d rather it went to younger, fit people who have a chance of recovery.’ ” And there’s no problem with that? “Not at all. It’s very praiseworthy”.

In the book Baroness Warnock argues that with dementia increasing there is a “strong argument for enabling such patients to make an advance decision that would be fully and properly respected”. She believes that since making general sacrifices for one’s family is seen as a virtue, why should one not be allowed to “exercise that virtue at the end of one’s life”?

Many, though, will be alarmed by the idea of the non-terminally ill being helped to commit suicide. Alastair Thompson, a spokesman for Care Not Killing, said he found this a “deeply depressing” debate around dementia. “We need to be having a proper debate in this country about how we care for people with dementia, how we fund research into new drugs and treatment,” he says. “Depressingly, we seem to be stuck [with] half a dozen people who are pushing an agenda that will actually see the execution of people, the killing of people with dementia. It’s completely the wrong end of the telescope.”

Thompson says that the law in Belgium now means it is possible to euthanise disabled babies. Asked about the claim that people would rather leave their money to their children than spend it on nursing fees he says: “It’s a bizarre situation where they’re saying everybody’s life has some finite worth to it and as a consequence let the accountants decide at what point it’s worth treating someone or not.”

This week it emerged that a Belgian man is going to the European Court of Human Rights after his depressed mother Godelieve De Troyer, 64, was killed by lethal injection there at her own request even though she was physically healthy. Two elderly Scottish cousins committed suicide together in Switzerland in November because they feared being put in separate nursing homes. Neither Stuart Henderson, in the early stages of dementia and partially blind, nor Phyllis McConachie, who had injured her hip in a fall, was terminally ill.

When I visited Dignitas in 2003 I was told of a French brother and sister aged 31 and 29 who were suffering from schizophrenia and entered a suicide pact there. Had Dignitas refused, they planned to kill themselves on a railway line. With psychiatric and non-terminal illness, though, does there not exist the hope of possible improvement? Perhaps a new drug or future treatment?

Brewer and Irwin say that if someone was suffering from a treatable psychiatric illness they would not meet the criteria. Dignitas’s bureaucracy has become more stringent in recent years: when I went you could arrive and die on the same day. Now you must see two separate doctors and the average suicide visit involves a four-day stay. However, not all mental illnesses respond to medication.

Brewer says: “If someone says, ‘I’ve been unhappy for as long as I can remember, I don’t like the sort of person I am. Nothing that anyone has done has made me like myself any better or made me think the prospects are good. I wake up every day wishing I were dead’, I mean unless you are going to argue that psychological pain is somehow less important than physical pain — and I don’t think many people would buy that — then I think you have to say there must be a place in the scheme for people with chronic unrelievable emotional and psychological illness.”

Yet might that new drug not be just around the corner? “Well, you could say that about someone with cancer,” Brewer says. Given the rates at which new cancer drugs are being developed, it’s the equivalent, he says, of saying “don’t do it” to someone with six months to live but who wants to die now because next May they might have found a cure.

Irwin says it is a mistake to focus this debate purely on the terminally ill: the Voluntary Euthanasia Society certainly never did. Neither do countries such as Holland, Belgium, Luxembourg and Switzerland. The criteria, he says, is simply “any adult who is competent and is suffering unbearably from an irreversible condition has the right to end their life”. Irwin believes the Belgian model of embedding voluntary euthanasia within palliative care is the right one. Brewer cites the non-terminal case of Tony Nicklinson who suffered from locked-in syndrome and resorted to starving himself to death after losing a legal battle to allow doctors to help him end his life.

Alastair Thompson cites the Royal College of Psychiatrists, which stated in evidence to the DPP that “if someone is suicidal they need help and support not the keys to the drugs cabinet”. He says: “There isn’t a single major doctors’ organisation in this country that supports changing the law on assisted dying or euthanasia.”

What many, including me, find confusing is that in the UK people are effectively allowed to slowly starve to death on the Liverpool Care Pathway, which usually involves the withdrawal of medication, food and fluids, yet we balk at the kinder alternative of ending their suffering quickly. My father-in-law, who had Alzheimer’s, died in this way and although we didn’t disagree with it, it was a long, long process that he could have been spared.

Brewer says it is blatant hypocrisy and self-deception and merely about ensuring there’s a “decent interval” between starting sedation and the death. “It’s a medically assisted fudge,” he says. “Willing to wound but afraid to strike.” Irwin says that it’s because people can end their lives at Dignitas that we allow for doctor-assisted suicide in the UK — it just takes place off-shore. He claims that many doctors are still quietly helping to end patients’ lives anyway. He cites a 2004 study by Professor Clive Seale of London University that estimated that there were about 1,000 deaths owing to voluntary euthanasia and another 2,000 deaths owing to non-voluntary euthanasia, illegally occurring annually in the UK.

In the book Irwin cites the case of Nan, one of his close friends, a former occupational therapist, mother of three and right-to-die activist whom he accompanied to Switzerland to end her life. Nan, 85, was suffering from severe osteoarthritis that restricted her life and said that her life consisted of far more pain than pleasure. She had asked Irwin to have a piece of Lindt chocolate ready for when she drank the lethal dose of barbiturate but found she didn’t need it. Her last words were: “No thanks — it is not too bad.”

After my interview Brewer emails me to say that he hopes I found them “the jolly old gents that I think we are, relaxing by a fireside, rather than as a couple of sinister and homicidal conspirators”. I assure him that I did not find them remotely sinister or homicidal. “My feeling is that as people get used to it they’ll say, ‘This is actually not a bad way to die,’ ” he says. “Why have a messy death? Is there any fundamental duty to hang on until the bitter end?”

I’ll See Myself Out, Thank You, Skyscraper Publications, £10.99

Michael Irwin is our speaker on Friday 17 April, 7.30 pm at the Moseley Exchange. Free entry. All welcome.


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