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- [00:02]
Father Hugh MacKenzie
Welcome to the LSE Events podcast by.
- [00:05]
Dr. Lewis Ross
The London School of Economics and Political Science.
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Father Hugh MacKenzie
Get ready to hear from some of the most influential international figures in the social sciences.
- [00:15]
Dr. Lewis Ross
Okay, let's make a start. I hope everyone can hear me. Okay, so good evening and welcome to the LSE to this public event. So I'm Dr. Lewis Ross. I'm a member of the philosophy department and the director of the Centre for the Philosophy of Natural and Social Sciences, which is the host for this event. And I'm very happy to chair this event on assisted dying. So assisted dying policy raises extraordinarily difficult questions about life and death. And at the moment, we currently stand at something of a threshold. While there are few states around the world where assisted dying has been permissible for some time, most states do not recognize any right to a state supported death and treat suicide primarily as a public health matter. Yet a growing number of jurisdictions around the world are starting to rethink the law on assisted dying and the U.K. of course, is one of them. So right now a proposed law on assisted dying is making its way through the Parliament and has provoked vigorous debate. So it's a topic that raises and continues to raise very strong feelings. It forces us to ask how deep and difficult questions about ethics, philosophy, law and religion. So what we do at the LSE and what motivated me to host this event when we're confronted with these difficult questions is we try and make progress on them collaboratively. We consider the evidence and we listen to expert opinion. So on that note, we're very lucky to have a truly enviable panel of experts joining us tonight to give us their perspective on this very difficult question. So I'm going to let the panel introduce themselves in order so you can get a flavour of their connection to this topic.
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Father Hugh MacKenzie
Hi, I'm Father Hugh MacKenzie. I'm a Catholic priest based just down the road in Westminster Cathedral, one of the chaplains there. I also go into a hospice in St John's Wood. Quite a bit of my time actually. Over the last 10 or more years, I have been involved in the Catholic Medical association, studied some philosophy of science, even here a little bit as well.
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Kenneth Chamber
Hi everyone. I am Kenneth Chamber, but in English you can say Chamber. That's also a bit better to pronounce it that way. I am a professor at Ghent University in Belgium, Belgium being one of the countries that has assisted dying legislation since 2002 already. And I work at the end of life Care Research Group. So all the research that we do is on end of life matters. So also Palliative care for instance. But most of my research career, or let's say more than half of my research, has been focused on assisted dying. I'm also engaging with a few people in the UK on questions on assisted dying. So yeah, I've been at it since 2006. My PhD was on the topic and I think we built up quite some evidence and I think I can also speak to a little bit the international situation as we have been following that up as well.
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Alex Voorhoeven
Good evening. I'm Alex Voorhoeven, I'm a professor in the philosophy department here. My main area of research is justice in health and I've worked here in the United States National Institutes of Health in their Bioethics division and at Erasmus University Rotterdam where I'm also from the Netherlands. So I have some experience of the Netherlands which also like Belgium in 2002 passed legislation de facto legalizing certain forms of assisted suicide and voluntary euthanasia. Perhaps it's also relevant to mention because in these debates one also sometimes learns sadly from personal experience that together with siblings I had the care for a relative over six years who died of a terminal illness. And you know, we struggled like so many of us do with their path towards the end. And so I'll be speaking both as a philosopher but also partly from personal experience.
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Emily Jackson
Thank you. I'm Emily Jackson. I'm a professor in the law school here at lse. I've been interested in these issues for many, many years and I think like everybody has personal experience that you inevitably bring to bear to them. I was an advisor to both Nuffield Council on Bioethics Citizens Jury on Assisted Dying recently and before that the Jersey Citizens Jury on Assisted Dying. And more than a decade ago now I was on the Department of Health panel to review the Liverpool Care Pathway which was an end of life care pathway.
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Dr. Lewis Ross
Fantastic. Okay, so the plan for the evening is we're going to investigate the views of the panel, what they think the central issues are and where the controversies lie. And then around the halfway mark we're going to turn to give you the chance to interrogate the panel to ask some questions of them both in person, but also the online audience. So I think it's hard to imagine this but apparently there's some hundreds of people watching this online and there'll be thousands of other people who watch the podcast, it's on YouTube and such like. So we'll take some questions both online and in person. One thing I would ask is when we turn to the Q and A, this is A very difficult topic. So, as Alex says, it raises difficult philosophical questions, but also ones that on a personal level, we feel very deeply about, because they're difficult, vexed issues. So one thing I would ask is that when we engage in questions, we try and keep the discussion sort of considerate. But I'm going to start by asking some questions of the panel to get a flavour of their views. And I think maybe we got one eye on this question of the pros and cons of this legislation that's going through Parliament. So maybe it makes good sense to start with Emily. So you're our legal expert and you're someone that's closely studied the proposed legislation. Would you be able to give us briefly a sense of what the shape of the new proposal in England and Wales and a flavour of the debate and the controversy that surrounded it?
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Emily Jackson
Absolutely. So what I'm going to do is say a few things about what the bill actually does and then make a few comments about it. So the Terminal Adults End of Life Bill is currently at committee stage in Parliament.
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Kenneth Chamber
So.
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Emily Jackson
So it was introduced as a private member's bill by Kim Leadbeater in November last year, where it received a majority of 55 at second reading. But there's absolutely no guarantee that it will become law. So though it received a majority there, there are lots more stages for it to go through. So after committee stage, there have been hundreds of amendments tabled as part of committee stage. It's then going to go back to the Commons for what's known as report stage, where more amendments can be can be made. There will then be another vote in the Commons and at that point it then goes off to the House of Lords and of course, I'm sure the House of Lords will have lots of things they want to say about it. So it's by no means a done deal, it's by no means over. There's a lot more stages for it to go through. So what the bill does is it makes it possible in some really quite restricted circumstances, for terminally ill adult patients to ask for assistance in dying. And what that means is that they can ask for the prescription of a lethal medication which they must self administer. There's no option in the bill for physician administration, it has to be self administration. So the bill defines terminal illness as an inevitably progressive condition which can't be reversed and from which the person is reasonably expected to die within six months. So it doesn't have to be a firm guarantee that they would be likely to die within six months, it just has to be reasonably expected that they would. It wouldn't surprise you if they were to die within six months. The bill also spells out that you can't be considered terminally ill by reason of a mental disorder or a disability. There are more criteria. The other criteria is that they have to be an adult, they have to be ordinarily resident in England and Wales. There's a separate and different bill before the Scottish Parliament. They must have mental capacity as defined by the Mental Capacity act, and they must have a clear, settled and informed wish to end their own life. And they must have made that decision voluntarily, and they must not have been coerced or pressured by any other person into making it. And separately, the bill makes exerting coercion and pressure on somebody to do this a criminal offence, a serious criminal offence, punishable by up to 14 years in prison. Two separate doctors must confirm that the eligibility criteria are satisfied, and they must also discuss with the patient other options of palliative hospice and other care, including psychological support. If there's any doubt about mental capacity, or if one of the doctors is not an expert in the terminal illness, an independent specialist must be consulted. In the bill's very latest iteration, as well as these two doctors approval, the person also needs to have approval from a panel made up of a senior lawyer, who could be a retired judge, a psychiatrist and a social worker. In the original bill, there was the requirement for the approval of a High Court judge. Doctors participation in assisted dying is voluntary. Nobody can be under any duty to participate in this. The bill also imposes two separate periods of reflection. There has to be seven days between the two doctors assessments, and then, after the panel decision, there has to be another period of reflection of 14 days that can be shortened to 48 hours if the person's death is imminent. So it's been described by the MP who introduced this, as well as by others, as the toughest regime in the world, with safeguards upon safeguards. Nevertheless, there are people who think that it's still not tough enough. Indeed, there are people who think that no bill, no law could ever be tough enough. And sometimes, of course, that might be because people think that assisted dying is always morally wrong, in which case, however tough a law is, that won't get rid of that objection. I just want to say a few things about it. So one of the most common concerns voiced by opponents of the bill is the worry that it will be difficult for these two doctors and the panel to spot cases of coercion, particularly cases where somebody feels under pressure to end their life because they're worried about being a burden to their family. I'd make two responses to that. The first is that we already allow adult patients with capacity to insist that doctors cease providing treatment that's keeping them alive or treatment that's necessary to save their life. Now, of course, those patients might be vulnerable and they might be worried about being a burden, but in those cases, we think that one doctor, because you only get one doctor, then that one doctor is capable of identifying coercion and pressure in people who wish to refuse a blood transfusion or wish to refuse consent to mechanical ventilation. If we think one doctor can do that satisfactorily in those cases, I find it hard to understand why we think two doctors in a panel would be completely incapable of doing that. Exactly the same thing, making exactly the same judgment about capacity and pressure when somebody wants to have an assisted death. So we're doing these capacity and voluntariness assessments all the time. They are completely routine and there isn't some huge outcry about people refusing treatment in circumstances where they've come under pressure. The second thing I'd say about this concern is that there's quite a lot of evidence from places where this is lawful that the reality in terms of family pressure in case of assisted dying is that families put people under pressure not to do this. The Public Bill Committee heard quite a lot of evidence from people in jurisdictions where it's lawful that people want their loved ones to stay with them for as long as possible. So the pressure commonly comes from people saying, please don't do this. I want you. I want you to stay with me. Another common argument we've heard against this bill, which is, I think, an interesting one, is the idea that you can't legalise assisted dying while palliative care provision is inadequate. And I think it's absolutely clear, I think we can all agree, that palliative care provision in this country needs to be better. It's a scandal that to fund palliative care, you have to sell secondhand cardigans and fund it by charitable donations. So there needs to be better funding. And as the Health and Social Care Committee found last year when it did a report on assisted dying across the world, it's really, really common in jurisdictions where assisted dying is lawful for legalisation to go hand in hand with improved funding for assisted dying and improved access to it. I think this happens certainly in Belgium, and Kenneth can say something about that. But what happens in those cases is when palliative care improves in those Countries, you don't see a dwindling of requests for assisted dying. There's absolutely no evidence that better palliative care results in fewer requests for assisted deaths. So we can talk about some of the provisions in the bill in more detail. And I think there are interesting questions about whether having so many safeguards and so many stages to go through means that actually, in practice, relatively few people are going to be able to access assisted death. There are just three other points I wanted to make before stopping that, I think, matter. First of all, in countries where assisted dying is lawful, there is no evidence of overuse by vulnerable populations. Actually, in practice, the evidence appears to show something slightly different, that people who are interested in assisted dying for themselves are often people who are relatively privileged, who've been able to exercise quite a lot of control over their lives and who want access to assisted dying as a result. And as I've mentioned, people seek access to assisted dying even when they have access to the very best palliative care. Secondly, there's, I think, quite a lot of evidence that in addition to assisting the relatively small number of people who will ever actually access an assisted death, the availability the legality of assisted dying helps a much wider group of patients who may never use it, but for whom it represents what might be called a hypothetical exit plan. So the possible availability of assisted dying serves as a kind of comfort blanket that reassures people who are fearful of what lies ahead. If it did all become unbearable, they would be able to end everything. So this much wider group of patients, and I would include myself in this group, feel that it makes it easier for you to bear whatever life is going to throw at you because you know you have a way out of it, you know you'll be able to stop it if you need to. There's quite a lot of evidence that our capacity to endure pain is higher when we have an officer which enables us to live with the burdens of treatment. Final point for me, in countries where assisted dying is lawful, there are very, very high levels of public support for its continued availability. So Canada is often held up as a country with very much looser provisions than our bill. 90% of adults over the age of 55 in Canada support the medical assistance in dying. That's. So I think it's quite important to note that proximity to assisted dying, familiarity with it makes people less rather than more fearful of it. And I'll stop there.
- [16:32]
Dr. Lewis Ross
Thanks very much, Emily. So now we've got a flavour of the nature of the bill. I want to zoom out A little bit and bring in our resident philosopher. So, Alex, you've worked extensively on the sort of philosophical principles behind all different manner of healthcare policy. Could you say something about how you see this issue? As a philosopher, what are the sort of philosophical principles involved? And as was mentioned in the introduction, you're also from the Netherlands. So I think for many of the audience this is a state you'll associate quite strongly with a more liberal regime on assisted dying than we have in the UK and even more liberal than the proposed legislation as Emily outlined. Do you think that the fact that you've had some experience of living in the Netherlands and your experience there, does that shape how you see these issues?
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Alex Voorhoeven
Yeah, for sure. Thank you very much. So, philosophically speaking, I think there are three issues that are at the heart of any justification for a bill that would legalize assisted physician assisted suicide. And going even further than that. Getting the physician to actually administer, not having to self administer, but getting the physician to administer the lethal dose. And those three things are very straightforward in a way, and they came out in the Nuffield Council bioethics public deliberation that you consulted on. You can find the report online and it's easy to summarize. The first is to reduce suffering, especially unbearable suffering, with no prospect of improvement, when the alternative means of alleviating that suffering are judged by the person and by experts to be not adequate, not as good as death. The second is to give competent people power over their own lives and deaths at one of the most difficult and intimate decisions that we can make in our lives. To have the ability to self determine is, I think, hugely important. And the self determination here has two aspects. One is the absence of interference by the state, the absence of a prohibition on you and your doctor deciding together that you would like to end your life. And moreover, the presence of an opportunity, a genuine opportunity, not merely the absence of a prohibition, but the support, for example, by paying, making it available on the nhs. And even though no doctor is obligated to provide this assistance to you, I think the British bill does say that they have to refer you to another doctor who may be willing to make the assessment. In other words, it's the end of a prohibition and the presence of an enabling set of circumstances that contribute to our self determination in these important matters. And the third is exactly the point that Emily ended on, which is the knowledge that this is available to us is important well beyond the people who will in the end use it. It's important to anyone who has the fear of having to endure a long period of suffering or indignity. And it's really interesting, goes all the way back to some of the earliest philosophers I've studied, Epicurus, for example, the Epicureans, who famously said we ought not to fear death. That one of the key reasons for getting rid of fear about pain in life was the knowledge that you could end it at any point if you so chose. One of his followers says it as follows. We should be able to free to quit when the play, he says, quit the theater of life when the play has ceased to please us or when it causes us pain. So that knowledge, claimed the Epicureans, gives us calm in the face of potential suffering because we know we're capable of ending it on our own terms. However, I do think we need to recognize some reasons against and interestingly, these also came up in the discussion of the Nuffield Council bioethics with individuals. The first is that it's possible that the change in the law might open people up to unwanted pressure, pressure that they themselves would prefer not to face. The philosopher David Velleman says, points out that we may prefer not to face a certain option because the mere fact that we face that option might expose us to pressure that we otherwise might not have. And the second is that of course it could open the door to forms of abuse or to cutting costs, for example, in palliative care. What I would want to point out about these pros and cons is that to a significant extent they depend on empirical claims, especially the two cons that I mentioned. The idea that people might not want to face this option because it would open them up to unwanted pressure and that it would lead to poorer provision of palliative care or other forms of end of life care are empirical claims. And we can look in jurisdictions where the reform has taken place of the kind under consideration in Britain to see whether it has happened or not. The same is true of some of the claims in favor. But I think the core claim about self determination is not really an empirical claim. It's an essentially normative moral claim that each of us who is competent should have this ability to control the end of our life when faced with potentially unbearable suffering. Others, I mean, Emily spoke eloquently already about where the balance of evidence lies. Let me briefly summarize where the Netherlands stands, which as Emily pointed out, is much more liberal regime than is under consideration in Britain Now. So since 2002, voluntary euthanasia and physician assisted suicide have been legalized. If it's obviously voluntary and well Considered the suffering due to a medical cause, which can be physical or mental, is judged to be unbearable with no prospect of improvement. Notice that there is no limitation to terminal illness here, just unbearable suffering with no prospect of improvement. The person in question has been informed of their options. The fourth condition is that in dialogue, the physician and the patient arrive at the judgment at euthanasia, or voluntary assisted suicide is the only reasonable option for them. The fifth is that an independent physician has to be consulted. And the sixth is that due medical care has to be provided throughout. And then finally, the core case, although we can discuss some other cases later, is one of competent adults, let's say older than 18, but it's also permitted for minors in the range from 12 to 18. From 16 to 18, the parents have to be consulted, though it's not necessary that they give their assent. From 12 to 16, the parents have to give their consent alongside, naturally, the assent of the minor. At the end of a process, once it's been completed, a report has to be made to a specialist committee. There are a number of such specialist committees, and they can decide to refer a case where they think these conditions have not been met to the public prosecutor. Now, what is the upshot, so to speak? It's actually that a very substantial part of deaths in The Netherlands, between 4 and 5% in recent years is as a consequence of euthanasia, and that roughly two thirds of all cases involve a terminal or very serious cancer diagnosis. So that's the overwhelming balance of cases involved that now, interestingly, the Netherlands is sometimes also discussed in the context of the widening group of individuals who are gaining access to euthanasia. Leave those non core cases for later discussion because they raise special issues.
- [25:18]
Dr. Lewis Ross
Thanks very much. We'll come back to some of these issues later, especially given the volume of people who make use of this option in the Netherlands, and in light of what you said, that giving someone a certain option can change their attitude to how they view their life, and it might indicate a sort of societal shift in how we view the nature of life and death, because the status quo, as it were, is not that we see it as an option or something we have to justify or something we have to explain. And one concern many people have had is that the provision of this option might change our psychology when it comes to thinking about our lives. So I want to dig into this, but in the meantime I want to turn to Hugh. So, Hugh, you've been the chair of the ethics committee of the Catholic Medical association, and you've served in an advisory role on the new legislation. Could you talk us through your perspective on this topic?
- [26:07]
Father Hugh MacKenzie
Yes, indeed. Thank you very much for inviting me to this illustrious and very friendly panel.
- [26:13]
Dr. Lewis Ross
So far.
- [26:15]
Father Hugh MacKenzie
So far. And indeed setting up the constructive, respectful atmosphere for this discussion. I would just like to make three points, really, three areas, One on religion, one on reason and one on practicalities. So that's mainly my religion, I suppose, not so expert on other people's. And then also on the role of reason and then one or two practical thoughts with regard to the committee stage. We're in that, Emily, so clearly outlined for us. So the first one on religion, I am part of the Roman Catholic tradition. I think it's known for having a sort of, you know, Emily briefly referred to that at the beginning, one of those fairly sort of principled position that all human life, all members of the human species, have a basic dignity. Indeed we're made for relationship with God and for each other and that defines who we are. That's a core value. And also given the, in our tradition, the centrality of the cross as well, on which Jesus suffers, suffering is a bad thing, certainly, but it can never be seen as the main thing to avoid or to fear. Indeed, in that tradition, there's always other and sometimes greater values and hopes to be brought in to the discussion. Just so, from our tradition, we wouldn't assume that the very laudable desire to reduce unbearable suffering is automatically the sort of number one or, you know, well, in one of the basic three principles involved in this debate. So indeed. So given that it is true that as I think Emily sort of touched on maybe at the beginning, that in a sense, however many safeguards we put in place, we're probably not going to be happy with the bill, really. So that's one position that we would obviously have. And so we're not going to be happy with the idea of health care professionals and others actively helping someone to so devalue their own life that they formally enable the patient to end it. In my experience in a Catholic hospice, my experience of that, obviously I've had to sort of reflect about this in the light of being kindly invited here as well. You know, I think it's true to say that at the moment is unthinkable in the way we operate, that really if someone comes in, I'm involved in the multidisciplinary team, we get to talk about patients about to come in and coming in, and if we know that naturally they can be a bit downhearted, sometimes very downhearted. Well, immediately, everybody I'm sure, this is true in most hospices want to change that. That's the assumption. We're all working together to raise the mood and help the person discover that they are important. So to introduce into our minds. They probably wouldn't be in hospices. This takes place. Indeed, they're talking of private companies now. But to sort of introduce the idea to us that maybe, and maybe we don't have to mention it, although that amendment was rejected, as the vast majority have been on the committee. The idea that he doesn't. The doctor shouldn't mention it, that's been rejected. But to even put the idea into our minds, I think is just against the way that we think about human beings. So the second point. Well, that's just if you like a sort of doctrinal thing, the second point rational from the point of the rationale side of it. So in a sense I've just presented a sort of religious position and I've been kindly invited to present a religious angle. But obviously within our ethical tradition as well, we absolutely believe in reason and you know, we're in a fantastic department here, aren't we, of philosophy that I've been lucky enough to experience. And we want to learn from that and engage with that. And indeed we sort of find ourselves in a broad coalition in opposing the bill of people who are not necessarily doing it for religious reasons. For us, I suppose one heart principle that hasn't been mentioned is that self determination for us and freedom is for love. It's a power that's made for relationship, for engagement with others, for friendship. Human freedom or autonomy is not an absolute thing, but from our tradition it's manifestly ordered to fostering friendship. So to act as an island cut off from culture and human connection is for us, it's unnatural, it's inhuman. So pure autonomy. Maybe we can discuss the term self determination, but a sort of radical pure autonomy for us would undermine real freedom. No human action is purely private. We're all part of an ecosystem in which we influence each other. We're cultural beings and we're called to community and that's a fundamental value. Moreover, to be unwanted is the worst form of suffering. Sure, is what torturers use when they're trying to torture someone, saying no one cares for you. That's the worst type of suffering. So being loved can get us through. We believe any physical suffering actually will get us through. We maybe need. That's a debatable phrase, perhaps. But the fostering of love and friendship, of being wanted, is a fundamental value, not really simply Avoiding suffering, though, we want to do everything we can. And I think we're very successful in my hospice and I think most hospices today, this is notwithstanding that. And also we don't need to prolonged life. So we would make quite a big difference actually, between refusal of treatment and formally cooperating with ending someone's life. So if you're dying, we've never, in our tradition, we've never said it's wrong to refuse treatment. People do it all the time and we support that. They don't want to have treatment if it's just going to sort of slow up their death or whatever. So for us, there's a very big psychological and physical and spiritual and emotional difference between refusing treatment and formally enabling someone to end their own life, to give up on their value.
- [33:35]
Emily Jackson
Hi, I'm interrupting this event to tell you about another awesome LSE podcast that we think you'd enjoy. LSE IQ asks social scientists and other experts to answer one intelligent question like why do people believe in conspiracy theories? Or can we afford the super rich?
- [33:54]
Father Hugh MacKenzie
Come check us out.
- [33:56]
Emily Jackson
Just search for lseiq wherever you get your podcasts. Now back to the event.
- [34:02]
Alex Voorhoeven
Indeed.
- [34:03]
Father Hugh MacKenzie
Sadly, not all suffering can be avoided. But despair that life is meaningless and indeed anything which destroys hope, we feel is to be avoided. That's a fundamental thing. To make suffering an ultimate condition, we think undermines that nature of the human person and civilization, the avoidance of suffering. So again, in the hospice where I work and the whole team is in all hospices, does work, as I said, holistically, for the good of the patient. Someone is depressed, we work to affirm them, not to affirm their depression, to raise the possibility of actively supporting their giving up, I think, and we think is anathema to such an ethos. So we are assisting dying, we think we are assisting it, we're enabling it, not trying to meaninglessly prolong it. We want to get rid of all suffering, but that for us is completely different from assisting suicide. And this bill is fundamentally changing. The 1961 act, that's what, that's the main legal chain, you can correct me if I'm wrong, But is the 1961 Suicide Act. That's what is changing. So finally, if I've still got a tiny bit just to say in terms of the committee stage that we're at, which is at this stage, as normally in private members bills, it's about safeguards and slippery slopes, et cetera, and we're happy to engage with that partly to minimize what we see as, you know, something that's sort of wrong for culture anyway. And also to maybe highlight the fact that we think that a key principle has already been bridged and therefore the trouble that they're having now, you know, over the High Court stuff for High Court judges is a sign that it's very difficult to find clear cut safeguards. And indeed we've heard Holland has somewhat different approach to that. If extreme suffering is the ultimate principle, what possible principles we think are there to stop slippery slopes? Moreover, for a being that is by nature social and culture like the human being, it's very difficult to discern the difference between influence and coercion. If we are right and that this bill is going to warp our culture fundamentally, then it's well nigh impossible to make that distinction. And let's be aware that the text of the bill, and correct me again if I'm wrong, is that a doctor, it mentions mechanisms. So a doctor can set up a mechanism to give the poison to the patient, but they cannot press the button. If all the patient can do is press the button, then the doctor can do everything else. Were they to press the button or indeed be convicted of not just influencing but coercing, then there's 14 years, maximum 14 years penalty for going over that line. So the, the, we, we think with the dropping of the High Court judge, you know, which 60 MPs voted in favor of the second reading because of the High Court judge safeguard, with the, the quick dropping of that as soon as the judiciary said that it's going to clog up the courts, you know, it's a sign. The slippery slope has already happened. It hasn't gone anywhere near the King's pen yet, but things are already significantly reducing and they've flipped it in the direction of psychiatrists and the majority of 55% of psychiatrists have said they will not go anywhere near. I mean again, correct me if I'm wrong, but my really 55%, according to When I looked up their website, have said that they will not go, they will not cooperate with any stage of the process of assisted dying. And yet it's sort of been suddenly flipped over in their direction. The slippery slate's begun. This for us is because it has been accepted that the 1961 Suicide act can be amended to accept formal cooperation in suicide.
- [38:33]
Kenneth Chamber
Thank you very much.
- [38:33]
Dr. Lewis Ross
So we'll come back to this point of suicide because the governments at Advisor on Suicide Prevention, one of their. They released a statement where they worried that the passing of this bill would undermine the sort of societal consensus that suicide is Something we always ought to prevent. And as you've indicated, this is a sort of hard won thing. Right. It's been a long time and developing societal attitudes towards suicide to see it primarily as a sort of health crisis that ought to be dealt with compassionately and not something that we countenance of encouraging or facilitating suicide. So we'll get back to that. But one of the first things you mentioned was some of the issues about practicalities I want to bring in, Kenneth, if that's okay. So I think it's fair to say you're one of Europe's leading researchers on end of life care and you also carry out your academic work in Belgium, which has for some decades now had a much more liberal regime than is even proposed by this new legislation in England and Wales. So would you want to sort of take us through how this shapes your views on the subject and how your views have been informed by the research that your team on end of life care has carried out in Belgium?
- [39:42]
Kenneth Chamber
Okay, thank you. I've been scribbling a lot of things while the others have been speaking, so there's a lot of things that we can, I think that we can delve into. But pertaining to your question, what, what has it done to me, I think I came into this topic as a kind of a naive proponent, let's say, of a sister dying. And of course, as the years go by and as we build up the evidence, you know, you see that it's not a black and white thing. So there's different shades of gray, let's say, to assisted dying. And I would say now that, you know, I'm still personally, let's say, in favor of assisted dying, but with a very critical aspect to it. Of course, as a researcher you have to stay critical, especially in view of the evidence that you gather, but also in terms of the conclusions that you tie to that. So as you know, well, maybe not everyone knows, but Belgium actually copied the law from the Netherlands to a large extent. We have a bit of differences, but I think the width of the law in terms of it being beyond terminal illness, beyond just suicide, so also euthanasia and also allowing it for mental or for non physical ailments or illnesses, that also applies in Belgium. And I think we have like a privileged view in that sense in terms of Belgium and the Netherlands being kind of laboratories, let's say, for the world to see how does it play out once you implement that law? And I think we can say a lot of things about practicalities and that's, I think where most of the critical aspects, say the critical aspects of reflection and discussion are poised. I think we in Belgium are largely beyond fundamental argumentation. We've already had the law for 20 plus years and it's more to do now about how do we go about this, what are the problems that we are running into and how do we solve them? I don't know if I have to go into a few of them. I've heard a lot of them already that maybe the Belgian data and the Dutch data can speak to. Well, maybe say something also about the Belgian situation, which is perhaps a little bit different to the Dutch situation and also to the way that UK bill is now poised. So the Belgian legislation leaves decision making largely up to the physician. Right. So we call it the colloqu? Sanglier. That means the physician and the patient have a singular relationship between themselves. And there is the idea that no one else has a say in what those two decide. Right. For the euthanasia law they made, well, they enacted a number of requirements. For instance, you have to consult another physician, you have to discuss this with the team. But in essence the physician, him or herself can decide on their own. And that puts a lot of trust in physicians. That was actually one of the fundamental principles of the Belgian euthanasia law, which is different to the UK bill as I understand it right now. And I think that's a very big safeguard, let's say, that would probably be difficult to implement in Belgium. And obviously, I mean, the sky hasn't fallen after 20 years of doing this way or having the law in this constellation it took does pose a number of problems. For instance, the reluctance of physicians, some physicians to engage. We don't have hard data, but we know that a large number of physicians do not wish to engage in this practice. There is this conscientious objection. You're allowed to do it as a physician, then you have to refer. That's an addition to the law that was made very recently. And also what you said in terms of advanced cancer patients, I think we're at a point where most oncologists, most general practitioners, would be willing to accompany the patient throughout the trajectory onto death. Where we are seeing difficulties in terms of engagement of physicians is more in the realm of non terminal illness. Think of people with psychiatric conditions. Think of people with early stage dementia. Think of people with old age related multimorbidity, not expected to die very soon. And these types of cases are still viewed by a lot of physicians as well, let's say not something that they want to engage in. And this is posing implementation problems. So this is just one, one instance.
- [45:11]
Dr. Lewis Ross
Can I jump in there? So I guess one thing people say in defense of the UK bill, right, is that it's very restrictively drawn. So this is a way that they propose to stop this slippery slope towards a very liberal regime. But I guess if I think about some of the philosophical principles that have been outlined, so one is stopping suffering and the other is self determination. It's hard for me, I suppose, to see the justification for drawing the bill so narrowly. So on the one hand you might have people who have conditions that cause a lot of suffering, so Parkinson's, for example, as far as I understand, it's hard to get a diagnosis that predicts you'll die within six months. Although people often live very difficult lives when they have advanced Parkinson's or even mental conditions, right? People purport to suffer greatly when they have certain mental conditions. So I guess one thing I struggle with is if you've got on the one hand this imperative to reduce suffering, and on the other hand this idea we should be allowing people to self determine or to exit the game when they feel their time on the stage is over, I guess I struggle to see how you can justify drawing the law so tightly. And then the worry I've got is, well, maybe the people who say there's a slippery slope, they're kind of onto something, right? Because if you really interrogate the principles underlying the assisted dying movement, then presumably it will liberalize over time and then we'll end up in a regime where you'd expect to be altering euthanasia to people with mental conditions or people with non terminal illnesses. So I wonder if the.
- [46:50]
Alex Voorhoeven
I'm happy to speak to that briefly first, I think one very important dimension which we haven't fully discussed is social learning. The principles I articulated, so reducing suffering and self determination and the kind of security and the knowledge that you can avoid severe, prolonged, severe suffering and indignity if you so choose, require for them to be properly implemented, a network of knowledge among legal professionals, among doctors and among people in general, and confidence and trust to slowly build up. I think it makes perfect sense from the idea that we need social learning to start with core cases that have a large degree of consensus in which this knowledge, social knowledge, can be built up, in which of course, we can also learn how it works Here, the Netherlands, Belgium have very particular cultures and institutions. They may or may not be replicable with the same reliability in another country. So I think even as someone who's as I pointed out, whose principles I think favor very strongly, a more liberal regime like the Dutch one. It makes perfect sense to start in a more limited way to enable the important amount of social learning that's required.
- [48:14]
Dr. Lewis Ross
I want to take some questions from the room, so I'm going to take questions two at a time, if that's okay. So if you could stick a hand up if you've got, if you've got a question and maybe Talita, we'll take one question from the online audience if that's okay afterwards. Thank you.
- [48:34]
Father Hugh MacKenzie
Two years I accompanied my wife to Dignitas.
- [48:39]
Kenneth Chamber
I'm interested to hear the use of.
- [48:40]
Father Hugh MacKenzie
The phrase slippery slope, which is a very emotive term. It implies that once you take the first step, there's an inevitability about descending into some Dante esque inferno. I would suggest that actually by taking this first step in the current bill, what we're doing is exactly that.
- [49:03]
Kenneth Chamber
We're opening the door.
- [49:05]
Father Hugh MacKenzie
And if at a later stage society decides that this has worked out okay.
- [49:11]
Kenneth Chamber
And we want to move forward to.
- [49:13]
Father Hugh MacKenzie
Expand to a Netherlands, Belgium type system, that's not a slippery slope at all.
- [49:22]
Kenneth Chamber
It's progress based on society's acceptance and.
- [49:25]
Father Hugh MacKenzie
It'S all down to the Parliament to make that change.
- [49:29]
Dr. Lewis Ross
Thanks very much. And Talita, we'll take one question online if that's okay, then we'll turn back to the panel.
- [49:36]
Emily Jackson
So the question is how long did it take for Belgium and the Netherlands to pass the bill on this and how did it happen so early in 2002? Just in relation to your point about, first of all, I'm really sorry for your loss and that you had to do that. And I think the fact that people in the UK currently feel themselves forced to travel to die in another country is one of the problems with the current bill. So I think we have to recognise that people are already doing this in this country, but with no safeguards at all. And they need the resources, resources, the social resources to be able to do that. So it's not, it's tough for people, they need family to help and support them. Not everybody has that. So I think we have to recognize what's going on at the moment in this country rather than thinking that nothing happens. We also know that people in this country stop eating and drinking. That's what Tony Nicholson did before he died. Again, no safeguards there. And that can be a very unpleasant way to die. So I think in relation to the idea of starting small, this idea of we start with this very restrictive Provision. I mean, I think the bottom line is, at the moment, this terminal illness requirement is probably the only thing that could plausibly get through Parliament. We've seen previous bills fail, and I think there are probably is possibly a majority in Parliament for restrictive law based on terminal illness. I don't think there is for anything broader. And in this country, it's for our democratically elected representatives to make the law and what they say is set down the statute. We don't have a situation in the UK like they do in, for example, Canada, where court cases can change the law. That doesn't happen here. So there's no way in which a UK court could make a decision in relation to an assisted dying bill, which would change the law. All they could do is send it back to Parliament and it would then be for Parliament to decide what to do about that. So we don't have that system. It's for Parliament to do it. And I think at the moment, a terminal illness requirement, I think the idea is probably what Parliament might be prepared to agree to and I think what sort? Why people? I think Lewis was right to say, if the criteria are unbearable suffering, clearly unbearable suffering is not confined to people with terminal illness. But I think that the idea that in Parliament there may be a majority for something that can be construed as shortening the dying process. So these are people who are dying and the assisted dying is available for them to cut short their process of dying. Now, it may be that in other jurisdictions, and it may be that at some point in the future in this jurisdiction, the view on that will change. But I think that's probably where Parliament is.
- [52:37]
Kenneth Chamber
Yes. So coming to this point of it being a pragmatic, strategic choice maybe to just focus on terminal illness in this bill, this obviously not how it happened in Belgium and the Netherlands. Well, if you look at what happened in Belgium, you could very, very clearly see that the first years of practice, let's say first five to 10 years, were mostly, I think 85 to 90% were people with terminal cancer, and the other five to 10% were people, other people with terminal illnesses. And it's only since 2010 to 2011 that we've started to see cases of people with psychiatric conditions, people with dementia, accessing the law. So even if we started out very broadly, let's say, or very liberally, the practice was focused very much towards those benchmark cases, let's say the ones that are obvious. So advanced cancer patients imminently dying, mostly. We also have data on that. I'd say that people actually lost only two to three weeks of their life expectancy using assisted dying. That's one point I'd like to make. A second point is also maybe a caveat with that strategic view on this enactment of this bill is that, well, it's going to be more difficult to put the second step in because you have this assisted dying law, you have the assisted dying practice, and making the next step would be actually confirming the view of a lot of critics and opponents that you are experiencing or that we are onto a slippery slope. And coming back to this question of, of you, sir, the slippery slope, this is a very negative term, right? This is the term that is mostly used. It's a cluster argument. A cluster term meaning different things to different people. It has different aspects to it, but voiced by critics and opponents having a more empirical view of things and again being privileged that we have 20, 20 years of evolutionary data puts that into perspective. You could indeed also see positive aspects to the evolutions that we are seeing. And so I've already argued numerous times to lose the term slippery slope because we can't use it in academic, honest, balanced debate.
- [55:26]
Father Hugh MacKenzie
Yes, yeah, yeah, thank you. Yes, with regard to the gentleman's question, I mean, and I do have sympathy, I think you've raised an interesting point. You know, I would use slippery slate, but I do need to be a bit, a bit careful about that. And it can be, as you say, can assume it's negative without arguing that can also be, you know, make us forget that people like your beloved wife, that's who we're talking about here, and indeed even from my side, need to remember that we are trying to talk about the dignity of our loved ones. But the thing is that we do need to remember that as your question, as both the questions have brought out to us, that the current bill in England is just to sort of get through Parliament really and the current limit, there's going to be pressure on them from self autonomy, as Lewis has highlighted and I think the panel have accepted. And at the moment we're just trying to keep it tight because at the moment there's this sort of, at the very least an emotional thing that we really don't want it to happen to two young people or people with non unbearable suffering, whatever that is. But actually what has just been admitted is that's the direction we're going in and we at least need to be quite honest that the degree of suffering that has to be involved and the age that has to be involved is actually in the thinking behind this Bill, Pretty vague. And what's going to. And therefore what it's leading is to saying just suffering itself actually devalues your value as a human person. It actually can take away the importance of your life as part of a community. And it's that point that we, particularly in our tradition, think is wrong rationally.
- [57:30]
Alex Voorhoeven
I do have to disagree quite strongly on this point. So finally, it's heating up a bit. With all respect, you mentioned a few times the idea of the proponents like myself of this position having the idea that suffering devalues life. Nothing of the kind I want to emphasize. Firstly, we both agree that suffering is an evil. I think we can both agree that individuals themselves can find meaning in suffering, and indeed they will be free to find such meaning. They can, for example, to stay around if their loved ones ask them to stay around and bear it for their sake, but they will not be required to endure it if they themselves cannot find meaning in that suffering, if it for them is pointless. And indeed, I would say it. You know, there's a devaluing perspective on people's agency and people's ability to give shape to their lives and to end it with dignity if they so choose. It's that ability, you pointed out. You know, you favor autonomy, but only for certain purposes, purposes that you regard as, you know, fitting for human beings, including the preservation of your life and fellowship with others. Well, some people might, understandably, out of fellowship with others, decide that they do not want to continue suffering in front of their loved ones when they know this imposes great pain on their loved ones. And similarly, some may have ended up through age or circumstance without the close bonds that gave their life meaning and now face a period alone, primarily suffering. I think in those cases, it's in fact respect for the value of human life and our agency which compels us to permit them to seek euthanasia if they so choose.
- [59:33]
Dr. Lewis Ross
I want to say something maybe in support of your views. I'm going to bring in Emily in a second. So one thing you mentioned was issues of fellowship. And you might not want to suffer in front of loved ones. But one of the classic objections that you mentioned in your introduction was this idea that having the option to end your life introduces all of these psychological factors that don't exist in the culture where living until your life ends naturally is a default. And one worry people have had is that people might choose to end their life partly as a sort of gift that they bestow upon others because they don't want to live as a burden. They know that they are taking up resources and time from their loved ones. And there's this worry that although it might not be an explicit pressure that's been leveled on someone, they're not being coerced into choosing this. There's this much more implicit, subtle pressure that exists just by giving them the option. And I think it's the sort of flip side of this thought about fellowship that one might worry about. I want to bring in Emily, then we're going to take a question.
- [60:36]
Emily Jackson
I suppose I think having. Having more options can be a good thing for people. And I guess I think my feeling about assisted dying is that it's completely understandable that one would find this incompatible with one's religious belief. I think that's absolutely, completely to be respected. And I totally respect people who would want nothing to do with this for themselves or for their family or who feel this is wrong. But I don't feel that way. And I do want the option for myself and for people I care about, if that's what they want. And so I guess I feel that the importance about assisted dying, it's not about making it compulsory for everybody. It's about saying for those people who do want this, for whom this really, really matters, even if it is just as a kind of comfort blanket, then that should up to them rather than to other people who don't share. We don't have, we don't share our views about life. We all have very. Come from very different perspectives and have different views. And I just think we. It's like lots of different kind of moral questions. People have their own moral framework that they live by and there's a range of frameworks. We don't all need to follow one. And I would like this option and other people might not want it, but that's, that's fine. And in terms of going back to that slippery slope argument, I think it's really critical that we have a parliament that will be making decisions for us. It's a conscience vote. It's obviously not a party political one. So there isn't an inevitable slippery soap because it's only parliament that can decide to change it. And I completely agree with what Alex said that the Dutch and the Belgian situation is very different from here. And I don't think that a law like that would work here because levels of trust in medical practitioners in both Belgium and the Netherlands are really, really high. And I don't think we have that here. And so I don't think that law would necessarily work here. You can't just transplant one law to another place. So I'm not sure there is some inevitable slide. There might be people who want it to be broadened, but it would be for parliament.
- [62:53]
Alex Voorhoeven
If I may quickly just answer the question online that Talitha articulated. So you may know the history better than I do, but because I'm not a historian of this process. But in fact the 2002 law in the Netherlands codified pre existing practice. That is for a very long period it was legally in the letter of the law prohibited, but de facto no one was prosecuted so long as you followed certain guidelines that had been issued, agreed by the Dutch medical association. And so what the law did was legalize, so to speak, create a formal stamp on a pre existing practice which had grown out of medical ethics medical practice which was then not being enforced. So it's very interesting that this, it was, so to speak, a bottom up process, a reflective process which started, unless I'm wrong, already in this 1970s in the Netherlands.
- [63:56]
Emily Jackson
Yeah, it was the thought that doctors had an irreconcilable conflict of obligations to relieve suffering and not to end life, but where you could only relieve suffering by ending life. It thought that that was okay.
- [64:08]
Dr. Lewis Ross
So I'm going to take a question, but I guess it does require a very large degree of trust in doctors. And doctors have this position of authority and some power over their charges and they often have strong opinions themselves. So one might think that the responsibility placed on doctors to exercise that reasonably is extremely great given the inherent vulnerability of many patients in those situations. Sorry.
- [64:34]
Kenneth Chamber
Well, yes, I just wanted to add to the Dutch, you know, the Dutch formation of the law and how it differed so much from Belgium. So as I said, Belgium essentially copied the Dutch law to a large extent and we didn't have that 30 year development, let's say, as it was the case in the Netherlands. Actually we had a very liberal government in the late 90s who, who put it in their, you know, their government statutes that they would pass a law. And they did it in the space of four years on the back of some evidence saying that this practice was already happening. Clandestine, is that how you say clandestine? So there was raw data to support that and there was also, of course, the public support to do it. The only support that was lacking was the support of the medical field. So the medical associations and the palliative care field after the enactment of the law, that changed quite quickly actually. So in the space of a few years, the palliative care association and the medical association followed with some guidelines for Their physician.
- [65:44]
Dr. Lewis Ross
That's good to know because I think the polling of palliative care doctors in the UK has shown their rather negative on this new, rather restrictive proposal. I want to give some chance to the audience so we will take questions from these two hands here. I'm sure you can see what I was putting up.
- [66:06]
Father Hugh MacKenzie
I'm a regular at this and I have to say this is the first time I've been where the panel was so heavily weighted in one side of an argument moment. You have three people here who are all seriously pro assisted dying. Against this one gentleman, I just wanted to put make that point. What I wanted to ask the real question was about the slippery slope because this one of these gentlemen here just said, said some time ago how almost 4%, I think this is what you said, 4% of the deaths in their country are now linked to, I think you keep calling it euthanasia, suicide, assisted dying being put down. I don't know whether, and I hope to goodness none of you have ever been in a situation where you have considered suicide. Because if you have considered suicide as I have because of a particular circumstance, the possibility of being encouraged to go down that path when you're at your lowest ebb is immense. The idea that of you blithely ignoring coercion I find staggering because there is nothing more grinding than the idea that somebody feels a burden and so somebody can put that pressure on. And I think the way you've glibly dismissed it is quite, quite astonishing really. And finally what I find very interesting is we talk about the slippery slope and I'm sorry sir, but what you have seen across the world is this law comes in and as this one you're trying to bring in now will do, might do, hopefully it won't. And then the slippery slope begins to the point where one of these gentlemen pointed out that 12 year olds can be assisted to die. 12 to 16, I think they have to have parental consent that above their up to 18 they can decide for themselves. We have seen in this country, whatever you think about the trans debate, whatever you think about that, you have seen an explosion of mental torment on one side of the argument to another. And that is not something that's solely evolved. It's happened. And what effect would a, an explosion of sentiment like that happen now when it becomes fashionable? And that's what happened.
- [69:02]
Dr. Lewis Ross
I'm going to pass on to the, the next question. I think we've got the question. Thank you.
- [69:07]
Alex Voorhoeven
Hi.
- [69:08]
Dr. Lewis Ross
First of all, thank you for all of your comments.
- [69:10]
Emily Jackson
I've found it really interesting this evening. I think my question is more maybe for Father MacKenzie, but I'd be interested.
- [69:18]
Father Hugh MacKenzie
To hear him any of your thoughts. And that's to do with religion.
- [69:23]
Dr. Lewis Ross
From a religious point of view, isn't it a better test of your faith.
- [69:28]
Father Hugh MacKenzie
If you actually have the option to.
- [69:32]
Kenneth Chamber
Disobey.
- [69:34]
Father Hugh MacKenzie
Says just right. Is it a better test of your faith? Yeah, I mean, we affirm our freedom, as we say, we believe there's a meaning to freedom, a pattern to its full use, which is relationship with others. But yes, we do have that test and that ability to say no, precisely because faith is about friendship. It's about an invitation to a relationship. And you can't force relationships. That's good. Most of us have worried perhaps about too much coercion. So yeah, that's. Freedom is a good thing.
- [70:16]
Dr. Lewis Ross
So in aid of the gentleman's question, I may want to ask because we have a panel who have some international expertise. Are there lessons from the regimes in Belgium or the Netherlands that you think the UK can learn from? Because I guess there are many aspects that knowing your views, you think are positive. But if you were to say, speak to a UK based audience, are there aspects of these regimes that you think that our country should bear in mind as our law evolves on this issue?
- [70:46]
Alex Voorhoeven
I would like to answer the gentleman's question directly first by saying that naturally I'm distressed, as anyone would be, at the suffering you went through at the low point that you experienced. And I want to emphasize that the, the point of view that I've been putting forward under no circumstances. You sometimes mentioned that someone who is profoundly depressed or contemplating suicide would be encouraged to take that path. There is no regime in which this is intended to be an encouragement or pressure put on individuals by a physician. Rather, it's meant to go the other way around. A request is meant to be put.
- [71:30]
Father Hugh MacKenzie
In a domestic situation. That's where the pressure is.
- [71:34]
Alex Voorhoeven
Okay, let me elaborate my answer and then I'm happy to have a further clarification. So it's definitely not under any circumstances meant to be the physician who initiates the idea that here I suggest a way out for you. Rather it's meant to come from the individual, then it's not merely because the individual wants it. In fact, in preparation for today, I looked up the latest data on individuals with mental illness who have requested either assisted suicide or voluntary euthanasia. And in the study periods 2012 to 2018, more than 1100 such requests came in. They go to an expert panel, so they have to be signed off by two doctors. And in the case of mental illnesses, they have to go to a panel of experts who turn down 87% of the requests. Because the process, it's not a, you know, you make requests and that's the end of it. You start a long process of dialogue with the person, including a dialogue about all the different possibilities of treatment. Now, of that 87% that did not lead to approval, some very substantial number of individuals decided after this long consultation that they did not want to go ahead with it. Secondly, one of the things is the person has to have no prospect of improvement. What does that mean in practice? Because, of course, you might ask, from the person's perspective, if they're deeply depressed or distressed, they may think there's no prospect, when in fact there is. The fact of the overwhelming majority of the cases that was approved, setting aside even those that were not approved, is individuals who have had more than 10 years of treatment, who have often explored rather extreme treatment options such as deep brain stimulation and other things, and who have comorbidities. It's not merely depression, but other forms of mental illness alongside. So, look, this is just to say that you're right that we cannot exclude pressure, but it's definitely not meant to be an invitation. Rather, what it's meant to be is an invitation to a full discussion of all the possible forms of care and has to terminate in an assurance among both the individual in question and the physicians, two independent physicians, often in this case is a panel, actually more than two, who believe that this is the only reasonable option given the suffering that the person is facing. So I did not at all mean for it to be flippant, but rather, and I think the practice, as you may be able to speak to it better, is not one in which this is treated lightly, but rather a process of that experience extends often over a decade.
- [74:33]
Dr. Lewis Ross
So I want to continue to take some questions. I'm going to take two from the room and one from online, so we can take. I don't want to prioritize people at the front, actually. That's not really good. But, yeah, you're almost on the mic, so you can go. And then we'll take one from the gentleman in the. Looks like a black T shirt to me.
- [74:51]
Kenneth Chamber
Sweater.
- [74:52]
Dr. Lewis Ross
Yeah, there we go. And then we'll take a question from online. We'll take them all together so we can have something to chew over before we respond.
- [75:00]
Alex Voorhoeven
Thank you so much for the panel. My background is in suicide prevention. I've helped thousands navigate suicidal Ideations. And I'm curious, when deciding on the age of 12, why 12 and not 10 when it comes to terminal illness? Because oftentimes the reason that children give for suicide are the same for 30, 40, 70, 80. And so while I understand that there may be cognitive development that's not quite there for a 12 year old, parents can still, at the end of the day, say no. And so if a 10 year old versus a 12 year old, you know, what's that difference of choosing that age in particular?
- [75:43]
Kenneth Chamber
Thank you.
- [75:44]
Father Hugh MacKenzie
Hi, thank you for all of your talks. It's been very insightful.
- [75:48]
Dr. Lewis Ross
I want to raise a point of the state. The nhs, which there seems to be a consensus, is deeply struggling. So adding this service.
- [75:55]
Father Hugh MacKenzie
I know you spoke about palliative care.
- [75:57]
Dr. Lewis Ross
Not being impacted, but surely there'll be.
- [75:58]
Father Hugh MacKenzie
A strain on either all services in.
- [76:00]
Dr. Lewis Ross
Favor of this one or this one.
- [76:01]
Father Hugh MacKenzie
Will be in the same sense all the others. There will be people falling through the cracks, there will be scandals and how that will be dealt with when that happens.
- [76:10]
Dr. Lewis Ross
And also in the same way, the alternative of that being going to private healthcare and therefore dying being something that.
- [76:17]
Father Hugh MacKenzie
People can profit off of, which I.
- [76:18]
Dr. Lewis Ross
Think we all agree shouldn't be the case.
- [76:20]
Kenneth Chamber
Thank you.
- [76:21]
Dr. Lewis Ross
Thank you, Talita. We'll take a question from online.
- [76:25]
Emily Jackson
So the question is reacting to Professor Alex. Does the UK bill formalize a practice that already occurs within the nhs? And if you think that this bill usually includes provisions for consciousness conscious objections by physicians alongside guarantees for patients.
- [76:53]
Dr. Lewis Ross
So the question was whether there's a provision for conscientious objection on the behalf of physicians and also guarantees for patients.
- [77:01]
Emily Jackson
To be able to assess their consultations.
- [77:05]
Dr. Lewis Ross
Do you want to go?
- [77:06]
Kenneth Chamber
Maybe I can start with first question on the age limit. I don't know, we haven't said that yet. But Belgium doesn't have an age limit anymore. So in 2014 there was a law amendment saying that age was ousted as a criterion. And so the full focus was then on the suffering of the person, suffering of the patient. So in theory, it could be an 8 year old requesting assistance, dying, of course, thinking to the developmental side of things, and also the proneness of younger people to mental illness. Also there were extra provisions for people under the age of 18. So, yeah, you have to have physical illness, so that has to be physical ailment, it has to be terminal. You have to have a psychological evaluation, psychiatric evaluation, to ascertain that you are actually, you know, you know, fully competent to request this. Very. Yeah. So this determination and the last one is Also that parental consent is necessary. So this for the Belgian legislator was symbolic issue, because we have only seen since 2014 about five or six cases in Belgium of under the age of 18, because they wanted to do away with the age criterion, because it was discriminating to some extent and fully focus, as I said, on the suffering of the person, of course, with no prospect of improvement, terminal illness and so forth. So that is also the reasoning behind the Dutch legislation. They also, they've made it kind of wedged between 12 and 16 and 16 and 18, but for Belgium, it's all the same. So does that answer your question?
- [79:04]
Dr. Lewis Ross
Does someone want to speak to the resourcing question? I think the gentleman's question was he's talking about, well, there's only a finite amount of money delegated to the health service. And my understanding is, in the proposed UK legislation, this would be taken out of the health budget. So the natural concern is then it's a competitor with palliative care. And I wonder if anyone has any comments on.
- [79:27]
Emily Jackson
Well, I think it would be an absolute mistake to see this as an alternative or a competitor to palliative care. Palliative care needs to be better funded and there needs to be better availability. Palliative care in this country can be absolutely superb, but it's not. Everybody can get access to it when they need it, and that is absolutely disgraceful. And we need better funding for this and I think we should pay more tax to put more money into the NHS personally. But I think this would have to be. I think you're absolutely right. The NHS is crumbling. We all know about that. If this law were to be passed, it's not going to come in the next day, there's going to have to be at least a two year implementation period and I think it could possibly even be longer. And there will have to be proper resources made available to do this properly. And I think we as a country need to put more money into our health service across the board, not just in relation to end of life care.
- [80:24]
Dr. Lewis Ross
So our time is dwindling, but I think we can squeeze in two more questions if there's some. Oh, there we go. Good stuff. The man in the Looks green to me, but my eyes are bad. And keep your hands up. The woman. And what looks also to me like a black thing. Yeah, there we go. Yeah, yeah, yeah, yeah.
- [80:47]
Alex Voorhoeven
Hello.
- [80:47]
Dr. Lewis Ross
And I learn I'll get glasses for the next public event. Take it away.
- [80:52]
Father Hugh MacKenzie
Thank you for a very interesting discussion. I wanted to touch upon the point made by.
- [80:59]
Alex Voorhoeven
By Father Hugh regarding the difference between.
- [81:02]
Father Hugh MacKenzie
Assisted dying and assisted suicide, because the semantics are important. Is it the case, and we were talking about slippery slope. Sorry for bringing it up again, but isn't it the case that this starting as an assisted dying bill or end.
- [81:18]
Kenneth Chamber
Of life bill, but really at a.
- [81:20]
Father Hugh MacKenzie
Point where you assist in a person.
- [81:22]
Alex Voorhoeven
Who is already terminally ill, but eventually it leads to assisted suicide?
- [81:28]
Kenneth Chamber
Because you are looking at cases where a person is not terminally ill, and.
- [81:33]
Father Hugh MacKenzie
Therefore you semantically framing it as assisted dying initially, but eventually it becomes assisted suicide.
- [81:42]
Dr. Lewis Ross
Thanks.
- [81:45]
Emily Jackson
Apologies for this question not being perfectly elucidated.
- [81:48]
Alex Voorhoeven
I'm still trying to wrap my head around.
- [81:49]
Dr. Lewis Ross
That's okay.
- [81:50]
Emily Jackson
But, Father Mackenzie, you mentioned that you.
- [81:53]
Alex Voorhoeven
Draw a very sharp distinction between the withdrawal of treatment and assisted dying.
- [81:59]
Emily Jackson
Because in your opinion, and correct me if I'm wrong, you said someone that.
- [82:04]
Alex Voorhoeven
If we withdraw treatment from someone that.
- [82:06]
Emily Jackson
Is actively dying, they are in the process of dying. But I'm kind of struggling to kind of draw a very principled distinction. Where do we define that someone is actively dying? Because in the assisted dying bill, we have someone that is inevitably progressive and there's this reasonable expectation that they will die within six months. So how do we define dying? Is it temporarily contained to a positive.
- [82:38]
Alex Voorhoeven
Action of withdrawing treatment?
- [82:40]
Emily Jackson
I'm just also struggling to define dying in that sense.
- [82:44]
Dr. Lewis Ross
Thanks. You've been popular in this race.
- [82:48]
Father Hugh MacKenzie
Thank you. I think the two questions are related to each other because, yeah, I think we see withdrawing the key issue is that which causes the death. So if someone is dying because of a disease, then we're not to treat is to use sort of extraordinary means to stop that disease from happening. But if you can't totally cure them, for instance, if they're dying anyway, the basic cause of their death is the disease, not the actions that you take. And that's why at the moment, to be the core, you know, to formally cooperate with someone causing their own death at the moment is illegal by the suicide act of 1961. And the proposal is to change that so that you can be, as it were, a party to the action, which in our tradition has normally been, you know, participating in the cause. You're actually becoming part of the cause of the death so that I don't know if that answers the questions that have been posed there. I do want to come back to the discipline with Alex Forget at some point, I mean, can I answer the child question or do you want to get those questions answered?
- [84:12]
Dr. Lewis Ross
We have about two minutes, Hugh. So you can. You can pick which battle you most want to fight.
- [84:17]
Father Hugh MacKenzie
Before we wrap up, let's just dive in where we did actually have a bit of disagreement, which is great, wasn't it? Because it moves things forward I think. And, and I want, you know, in answer to the gentleman's question over here, I wasn't sort of saying that people can't find that. You're saying for instance that people can't find meaning in suffering. And you've made a good point there. What I suppose our position is that, and I think in our tradition is that human beings intrinsically have meaning and that self autonomy in the way Emily was a describing it, to sort of create your own meaning or to deny that there's value to your life in a self determining way is for us a contradiction of what it means to be a human being. And the key point here is that what this law is doing, and I think we're in agreement on this and we just need to be aware of it, but correct me if I'm what this law is definitely enshrining is the fact that there is no intrinsic value to your life and your life and your life. If you decide that there isn't. So it's introducing the concept that there is no intrinsic value and meaning to human life. That is a new idea and that's going to have significant effects. That's all. Just be, you know, let's reflect about that because if I've understood the answers to my point here and the disagreement we had, that is the point that particularly Alex was making.
- [85:51]
Dr. Lewis Ross
So I think we're out of time. So I'd just like to take this chance. Firstly to thank the audience in person for coming along. Thank you to the disembodied online people in the void and especially thanks to the panelists for contributing. And I'd encourage you to get involved in the political process. If you have strong views on this, write to your MP and to reflect on how we should address this difficult issue. So thanks very much everyone.
- [86:24]
Kenneth Chamber
Thank you for listening.
- [86:25]
Emily Jackson
You can subscribe to the LSE Events.
- [86:28]
Father Hugh MacKenzie
Podcast on your favourite podcast app and.
- [86:30]
Emily Jackson
Help other listeners discover us by leaving a review. Visit lse.ac.ukevents to find out what's on next. We hope you join us at another LSE event soon.