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Intelligence Squared
Do We Have The Right To Die? With Lady Hale and Rowan Williams (Part Two)
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Lady Hale
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Rowan Williams
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Mia Sorrenti (Producer/Host)
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Rowan Williams
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Lady Hale
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Rowan Williams
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Mia Sorrenti (Producer/Host)
That's why you Rack welcome to Intelligence Squared, where great minds meet. I'm producer Mia Sorrenti. Should assisted dying be enshrined as a fundamental right, or does it place our most vulnerable citizens in profound danger? In this episode, we return for Part two of our recent live debate with former Supreme Court President Lady Hale and former Archbishop of Canterbury Rowan Williams. Hale and Williams joined us at King's Place to discuss the urgent and divisive question of a sister dying. Chaired by doctor and broadcaster Dr. Xan Van Tulleken, this event marked the launch of do we have the Right to Die? The second book in our Partner To Think Again book series published by the Bodley Head. If you haven't heard part one, we recommend jumping back an episode to catch up. But now let's return to the discussion live at King's Place in London.
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Dr. Xan Van Tulleken (Chair/Moderator)
You talked about criteria and circumstances and the resources question raises issues which they found in Canada where people say my life is unbearable because I'm homeless, because I live in terrible poverty and these solutions could be found to these things. These are not unsolvable problems. To what extent could a law allow for those things and to what extent should we consider that differently to someone with a severe illness?
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Lady Hale
Well, as I understand Canadian law, it doesn't allow for those to be criteria, you've got to have a permanent incurable medical condition doesn't necessarily have to be terminal immediately, but you do have to have that, as I understand it. And I would stick with that sort of criterion and not, I mean, there is a moral case, but I'm not saying that I share it, to say that this is a matter of free choice and for whatever reason I find my life unbearable, I should be able. Well, of course you can already
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Audience Member / Personal Storyteller
bring
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Lady Hale
about your own death. So we're really talking about the circumstances in which somebody else is free to help you. And I think we're completely justified in restricting that to the sorts of medical situation that we've been talking about.
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Rowan Williams
If I can just come in on the Canadian situation, my understanding is that there are some quite troubling statistics about the disproportionate uptake of maid in disadvantaged areas in Canadian cities. I spoke to friends in Quebec about this who said that the percentage of medically assisted deaths in one of the more impoverished areas of Quebec was greater by a factor of about four or five than it was in more prosperous ones. That again, ought to give us some pause about how, even if you're not directly saying I want to die because I'm poor, pressures of different kinds, levels of attention, levels of investment by physicians are going to vary in socially diverse contexts. And that's also a factor which has been noted in Oregon, for example, where again, a significant percentage of people approaching assisted dying or having asked for assisted dying will register economic pressure or social, I don't know, social disadvantage as a factor in their request. So we're back in a way to the tiresome slippery slope argument. I say it's tiresome because it feels like a not quite special pleading, but it feels like a get out of jail free card here. But it is a factor here. And the arguments, as I tried to say in what I wrote, the arguments for the legal provision of physician assisted dying that rest upon intolerable discomfort, pain or whatever are the same arguments that can be used by people in mental distress, in extreme poverty, and so on. There's no obvious break in the argumentation leading from one to the other, which is why in context like Canada, Oregon and the Netherlands, there has been that slippage, if I can use a rather loaded term there. That's, I think, why the whole social, economic, political context somehow has to be factored in, in the long view here, and I don't quite know what you do about it.
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Dr. Xan Van Tulleken (Chair/Moderator)
Can you speak to that, Brenda? Because I think I'M not. My understanding is that in Canada there are people arguing that they should be able to access the service because their lives are intolerable without a diagnosis. But even meeting the criteria, there are enough people who meet the criteria where the tipping point is your child is caring for you, they're spending all the. This is consuming all their resources. You can see that your grandchildren are not getting enough resources and you think, well, if I wasn't around, this would all be easier for them. And in circumstances of precarity or extreme poverty, that just becomes a much larger consideration. Is it ever possible to have a law that equal that, that acknowledges and cares for that unfairness in some way?
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Lady Hale
I doubt very much whether it's possible to have a law of permitting assistance to die that was able to cope with that. One can, of course, have a welfare system that is capable of making people's lives a great deal happier than they otherwise would be. But I don't want to be patronizing to people whose situation they find intolerable so that they may have circumstances. There may be a wide range of circumstances which they regard as a disadvantage, which adds to their desire not to carry on with this unbearable medical condition that they've got. It's going to be a complicated decision for anybody to take. But I think we have got to believe that most people are free agents and grown up and able to make those sorts of decisions. We let them make all sorts of other really difficult decisions. I know this is perhaps the most important decision of all. I know that. And of course we take more care the more important the decision. But I think we've got to be very careful about being too maternalistic about it.
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Dr. Xan Van Tulleken (Chair/Moderator)
The manny state.
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Rowan Williams
Manny state.
- [08:34]
Dr. Xan Van Tulleken (Chair/Moderator)
Can I ask you both to speak? The word unbearable has come up a number of times. Brenda, can you start by talking about what you mean by unbearable, what that criteria is?
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Lady Hale
I should say, of course, that that criterion was nowhere in the Ledbetter bill. I'm afraid unbearable has got to be. I said it was a subjective thing because some people can bear quite extraordinary levels of, of disability, quite extraordinary levels of pain, quite extraordinary levels of general discomfort and inconvenience, and other people can't. But I don't think it's a matter for us to say, oh, you're a wuss or whatever, you know, you just can't cope with. I don't think it's for us to say that once we've checked that the person has had all possible help to cope with the situation and that they're of Free mental capacity. Once we've checked that, I don't think it's for us to say we don't agree with you. We don't think it's unbearable. I wouldn't find it unbearable, so why should you find it unbearable? I don't like that.
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Dr. Xan Van Tulleken (Chair/Moderator)
Robin, can you talk about unbearability?
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Rowan Williams
I sympathize very much with what Brenda said there. I don't know how one can judge this from the outside, but that's also why I find it so maddeningly elusive to try to imagine what a just legal approach to this would entail. I think there's always been in medical practice a tacit recognition that there will come a point where a patient might plead with a doctor to accelerate death. And plenty of doctors will do that, have done that, always have done that. I recently. This is something I shared with you. Brenda recently had an account from a friend of mine of a case many, many years ago in rural Wales, where my friend's late husband, a priest, was called in by the doctor in a situation where somebody was undergoing what appeared to be unmanageable pain, where the prognosis was extremely grim, where very little at all could be done beyond an extra strong shot of morphine. The doctor called in the priest who sat with the sick man and said, here are your choices, and I'm not going to tell you what to do, but this is what the doctor tells me to tell you. Here are your choices, and I will sit with you as you make those choices. And the sick man said, well, if you think this is the best thing for me. And the priest said, it's the thing that will spare you pain. And the man said, then give me the injection. It was something which I think haunted the priest for years and years and years afterwards, not quite knowing whether he'd handle it rightly, but it's that kind of area which seems to me in a rather different territory from the legislative process, very much to do with who trusted whom in a very private setting. Now, I can look at that and say, I don't see that that was an evil act. I don't see coercion. I don't see except three people thinking very hard together about an act which they all knew was, let's say, irregular. And that reminds me of what Jonathan Sumption at one point said about this, that there ought to be a law against assisted dying and it ought sometimes to be broken. And a great deal of me resonates with that, I have to say, because I can't dismiss exactly that. Subjective reality that's been talked about. But it's exactly the nebulous quality of that which I mean in terms of what others see and what others can cope with, that makes me worry a bit. What if the 18 year old comes to say I'm suffering unbearable depression? That's already something which is a criterion in some jurisdictions that will secure your. This. Most of us I think would say can I hope without being patronizing or matronizing. Most of us would say I'm not sure that you yet quite know what you're capable of.
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Lady Hale
No, I agree with that.
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Rowan Williams
And that's where drawing the lines is so hard.
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Lady Hale
I do find it very hard though on this particular point to agree with my brother's umption,
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Rowan Williams
I dare say.
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Lady Hale
Yes, we agree on an awful lot of things, but on this one I think that the acceptance that there is a law which from time to time will be broken is a bit difficult basically for a lawyer, well, for a judge, that's it. But also it's so random. You will sometimes have a very compassionate doctor together with a very compassionate priest, but there will be other people who don't have those. And in particular in today's world where you don't have the close relationship with your doctor that you used to have. Now you could argue, point that in both directions, but as a way of relying on let's break the law from time to time, I'm afraid I don't find that acceptable.
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Rowan Williams
No, I'm not myself backing it, just noting that I feel some sympathy with
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Dr. Xan Van Tulleken (Chair/Moderator)
that and it's worth saying medically it does require quite a lot of expertise. You think they don't teach you how to kill people at medical school and it's not actually very easy to do. Your opinion may vary depending on sort of which ward you've stayed in, but it's not. If you were going to have this as a humane process, you would want someone who's expert, thoughtful, considered, understands, you know, big doses of morphine can cause terrible nausea, itching, hallucinations, distress. So it's leaving it to a doctor's discretion, however well meaning they might be, is also fraught.
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Rowan Williams
Legally or not, there's an accountability question which I think has to come in where any medical process is concerned. And the risk clearly is if you just go on the assumption principle that accountability is absent and it's not only the deceased but the deceased family who will want to know about that.
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Dr. Xan Van Tulleken (Chair/Moderator)
Can you both talk about the moral distinction? This sort of. I know we've talked about slippery slopes but this sort of very blurred line where the quality of the assistance can be anything from someone arranging a pill and handing it to you, to someone giving you an injection and doing the act. And those things can really, from handing you the pill to putting it in your mouth, helping you swallow it, giving you an injection, setting up an injection and allowing you to push the button. How do those things grow? And can I start with you? Theologically, morally, is there a hard line in there somewhere for you or for anyone?
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Rowan Williams
Interesting. Just by the way that I think the Netherlands and Belgium legislation does make a distinction between assisted dying and assisted suicide, depending who actually performs the final and decisive act. But the way I've sometimes characterized it is this, that I would regard assisted dying in the sense that we're discussing, to be a process where you initiate a medical procedure whose primary and explicit purpose is to accelerate death. So not that you continue an existing procedure whose results might are very likely to result in death, nor continuing a procedure which in certain circumstances will. But something which is begun with the explicit purpose of bringing about death. That's the line, I think, which to me makes the distinction more or less workable. More or less. And a line which potentially at least allows one to say that at one end of a spectrum there is a set of medical options which will in fact accelerate a process that's already begun, as opposed to something which specifically begins at the other end with that primary aim. That's the theoretical distinction I'd want to draw.
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Dr. Xan Van Tulleken (Chair/Moderator)
Can you morally and legally, can you parse out those distinctions for us?
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Lady Hale
Oh, well, legally, there is a distinction between helping someone to bring about their own death, to use as neutral a phrase as possible, but I would call it suicide and killing someone. They're two different criminal offences, and the latter is a more serious offence than the former. So it's clearly a distinction that one can draw in law and does draw. And the bill looked as if it was only permitting assisting suicide, in fact, but it didn't like to say that it was assisting suicide for reasons that I don't quite understand.
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Rowan Williams
The word suicide is a very neuralgic one.
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Lady Hale
Yes, indeed. But, sorry, this is a subject which has got difficult concepts and difficult distinctions to draw, but we don't do any good to anybody by fudging them. And that's what I thought was going on. And we can say, yes, there is a moral distinction, because the final act, the decisive act, is done by the person who is going to die, and that is a distinction from the final decisive act being done by somebody else. So I can see benefit in that distinction, although lots of people won't.
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Dr. Xan Van Tulleken (Chair/Moderator)
In a moment, we're going to have microphones go out and so do please think about your questions. We'd love it if the questions were. Clearly, everyone will have opinions, but if the questions not, speeches would be fantastic. Sorry to phrase it that way, but everyone knows what I mean and so do organize your thoughts. We'll have microphones going out. I have a final question for each of you. This feels like it would offer a dramatic change to our society, that it is an option for people to treat their problems in a way that currently does not exist and has never really existed in the uk. And that could be very good or very bad, but it will expose problems in our society. And I suppose that's the thing that I'm wondering about, is how you see that core thing, that it will reveal inequalities, vulnerabilities, deficiencies, most of which we are unlikely to fix. This will not bring about a huge revolution in social care. Perhaps it will, but is it valuable that this, apart from giving people access to a better route to death and a better form of dying, is it possible that it will have the benefit of catalyzing change in other areas, or will that be a negative thing?
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Lady Hale
Well, it would be wonderful if it did have the.
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Dr. Xan Van Tulleken (Chair/Moderator)
But do you think it. Do you think it will?
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Lady Hale
It's difficult to know one way or the other, because we have both agreed that we need to have much more consistent palliative care available for people so that there are genuine choices to be made, while accepting that there are some conditions that no amount of palliative care can alleviate. There just. Are the people that I was talking about, no amount they were getting the best possible care they could possibly get, but that was not going to make their situation any more bearable. I don't know. It's difficult to know. In principle, it is a dramatic change, but in practice, given what we are already saying about some people behaving in the merciful and compassionate way in the case that you talked about, but also given that people are already being treated with a view, with the primary purpose of alleviating their unbearable pain, that's already happening and people are being given large quantities of drugs in order to do that. So quite how much difference in practice as opposed to in principle, it would make difficult to know
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Rowan Williams
not only practice and principle, but what I'd call climate. I think this is what a number of people have been anxious about. The sort of anxiety is expressed by some disability groups not All I know, but some quite vocally, the association for the Prevention of Suicide had a very strong statement about this. The Royal College of Psychologists likewise, a feeling that one effect of this would be to consolidate or reinforce a sense that certain, certain conditions would be regarded as, if you like, automatically grounds for someone suggesting a sister dying to them. And people feel vulnerable about this, they really do. And it's not only campaigners and associations, it's also a number of individuals. I was taken aback to hear one or two people I know who have experienced extreme coercive relationships and violence and relationships saying I would feel very, very unsafe. I put that on the table, not again as a sort of argument clincher, but as a factor which we have to bear in mind in terms of what sort of society we will be moving into. And there are all kinds of laws of unintended consequences around that. But just to round that off with a, I hope a slightly more positive note, it does seem to me that a lot of the, the positive feeling that many, many people express, obviously a lot of people in this hall would express on this subject, has a bit to do with the fact that we're all afraid of dying badly. We want to die well, we want to die with those we love around us. We are aware that an over pressurized medical environment is quite likely not to give us that possibility of dying well. And if one thing that this debate does, and this debate generally does, is to bring a little bit closer to the surface, our thinking together about what a good death is, it will perhaps serve a positive purpose in that respect. And I'd like to see a little bit more of that coming into, into this as well. The assumption, of course, is often made explicitly or implicitly that death with dignity, and the word dignity has been slightly kidnapped by one side of us. Death with dignity must mean death autonomously chosen. But I think many people would have a slightly different idea of dignity and what a good death might entail. It would have a lot to do with dying accompanied, supported and respected. And when people feel that's not something you can take for granted in our society, in our system, there's an issue which we all need to address. Whichever side of this discussion we come
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Dr. Xan Van Tulleken (Chair/Moderator)
down on, there is a dignity in being able to rely on a healthcare system to deliver a good death, well,
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Lady Hale
see, I would agree that what we are all afraid of is a horrible death. And we all would like the sort of good death that you've been talking about. I think that's what we all want. And I would have wanted such a good death for Paul Nicklinson, who is left with the choice of refusing food and drink and antibiotics. So basically was on the way to starving himself to death until pneumonia killed him. So yes, I would want a good death for people like him and a good death. People like people I have known whom they were not going to be able to have their pain alleviated, but would have wanted to die at home surrounded by their loved ones in peace.
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Dr. Xan Van Tulleken (Chair/Moderator)
You've both, I think, captured everyone's attention and laid out many of the issues very clearly and meaningfully. We would love to get questions from you and I believe there are roving microphones, so if we can get some hands up, there is a lady down here right at the front in an orange cardigan. Thank you so much.
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Audience Member / Personal Storyteller
Yes, hello. Four years ago my late husband who had motor neuron disease decided that his suffering became far too much and he decided that he wanted to go to Switzerland to end his life, which I helped to facilitate. And I drove him there and
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Lady Hale
he
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Audience Member / Personal Storyteller
was very close to death anyway. But getting the control back at the end of his life and finally knowing that his suffering was going to end was very, very powerful for him. It just made him feel so much better. Even though I think he probably only had a matter of weeks to live, if that. It was still a very positive thing. I broke the law. I personally didn't care that I broke the law because I helped him to kill himself. I was never questioned by the police, even though it was very well known what I'd done, because it was, was quite widely publicized by a very strange quirk of fate, which I'm sure you'll agree is very unusual. Last November I was diagnosed with motor neurone disease, which is exceptionally rare obviously for a random sporadic disease like that to happen to two spouses. Now I know I have my own line in the sand. MND is a brutal, hideous, ugly disease. The extreme end of the sort of things that you've been talking about. And I am nowhere near that yet. But when I do reach that line, I don't really want to. I mean I would if I had to. I don't really want to have to go to Switzerland in secret, possibly not being able to tell anybody about it in a strange place to have the death that I might desire. So where is the morality in not allowing me to do that at home. You know another interesting thing, my brother in law in Canada had a maids last year he had very advanced cancer and then he was diagnosed with a brain tumor and his line in the sand was he wanted the maids because he didn't want to get to the stage where he didn't even know my sister's name. And he had a lovely death. It was done at home. His children were there, his grandchildren were there, and it was what he wanted. And it was a peaceful, loving thing. How can you deny me that? Why should. I mean, I would do it. And the other thing as well, it's expensive. I could go to Switzerland because I know I can afford it, but many people can't. I've had people say to me, oh, well, you can jump out of the window or you can take an overdose. But I don't want to take that chance because there are horror stories around that. So, as I say, I'm not there yet. But if I do reach that stage, I want it to be peaceful. So where's the morality in not allowing me that? How can the law say you can't do it? How can I have been, you know, I broke the law when I did that to help my husband die. I could have been given 14 years in prison as the law stood. It's an absurdity.
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Dr. Xan Van Tulleken (Chair/Moderator)
I think you framed. I mean. Thank you, first of all. Thank you so much. And you have framed the key issue here and the thing that anyone who opposes this has to face up. Sir Rowan, can we hear from you?
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Rowan Williams
To repeat the thanks for your candor with this, What a moral response would look like is something I find very, very hard to frame up against the realities of the kind of situation you've outlined. My not being convinced about the legislation proposed has to do with another moral question, which is how one balances out who is most vulnerable in a society in the long run. How you maximize or minimize the fear or the vulnerability felt by certain categories of people, how that's balanced against the unimaginable immediate need and pressure that you've described. That is a moral question as well, and it's not one that admits of easy resolution. I think I'm simply trying to say that the moral pressure or the moral seriousness is there, and not only on one side of this question. There are issues which persuade me to be hesitant about legalizing because of the wider situation of those others for whom fear and vulnerability around these issues is a reality. That's a very inadequate answer, I fear.
- [32:49]
Dr. Xan Van Tulleken (Chair/Moderator)
Brenda.
- [32:52]
Lady Hale
Well, I don't really have anything other to say than that. Of course, it must be apparent that I agree with you, I'm afraid. And I think that you have demonstrated all the criteria that I would want demonstrated to allow you to have the help that you would like. One of the reasons that led to change in the law in Canada was that the prohibition of assistance led to people taking their own lives earlier than they otherwise would have done because they didn't want to get past the point where they were unable to do it for themselves. And that too is a moral consideration that comes into this. So thank you.
- [33:43]
Dr. Xan Van Tulleken (Chair/Moderator)
Thank you so much. The QR Code has gone up again. I have cleverly written down the results of the first one so that I can remember them. While you are voting, I will remind you that there is an extraordinary book out on this subject. Genuinely, how wonderful to have this resource from two people who've collaborated with overlapping opinions, a huge amount of shared common ground, deeply moral convictions from both people and different conclusions. And to have that resource as a way to think through the next two years of public discussion, public debate and legislation will be invaluable. So I know, you know, I'm trying to fill the air while you vote and encourage you to buy the book, but I would genuinely say this will be a book that you will look back on and think what an extraordinary thing to be at this conversation at this moment in history, in a few years time, whatever happens. Has everyone voted? Well, oh, here we. No. Really? Okay, so hang on, I'll give you this. So the first vote, so 69% has not changed. The number of people opposed has actually gone down 3%, but it has only added to the undecided, which is exactly the outcome we wanted. Thank you so much to Lady Hale, thank you so much to Rowan Williams and thank you all so much for sharing your very difficult stories, for your attention, for your courtesy, for your generosity and and for your time. Thank you so much.
- [35:35]
Mia Sorrenti (Producer/Host)
Thanks for listening to Intelligence Squared. This episode was produced by Connor Boyle and it was edited by Mark Roberts. For ad free episodes and full length recordings, you can become a member@intelligencesquared.com membership and if you'd like to join us at future live events, you can find our full program and buy tickets over@intelligencesquared.com attend. You've been listening to Intelligence Square Squared. Thanks for joining us.