In 1963, Rush Rhees spoke of never having been able to make up his mind about euthanasia and his ‘folly’ in agreeing to speak in a students' debate on the subject.Footnote ¹ He felt he might as well have spoken on one side or the other, that he was not ‘qualified’ to speak about the topic; that no-one is qualified to speak on the subject unless he has had to make this decision ‘as doctors so commonly do’.

The depth of his remarks in this letter demonstrate, for me at least, that Rhees was as ‘qualified’ as anyone else to speak here. (I'll come back to why I leave qualified in scare quotes.) Even so, I think his initial judgement about doctors is wrong.

That he might not have insisted on it, as I think later remarks suggest, is not the point; today, so many others do. Supposed leaders, thinkers, politicians, lobbyists, even some doctors themselves believe they are the (only) proper, qualified arbiters, the rightful decision-makers, the ‘professionals’Footnote ² who must at least be in the vanguard of facilitating someone's apparently ‘settled wish’ to die, or actively deciding when to end the lives of others, whether of those in PVS /‘persistent vegetative states’, those who cannot request it, as well as those who do, whether terminally ill or not.

This a grave mistake in my judgement.

In fact, Rhees qualified his remark straightaway in the letter: ‘on the other hand’, he said ‘I do not think that being a doctor is enough by itself, for I think that some doctors may overlook sides of the question which run into considerations of morality and of religion’.Footnote ³

That doctors may overlook such considerations is fundamental in the current climate of an aggressive, often misleading press from a wealthy lobby and successive attempts to legalise assisted suicide/euthanasia.Footnote ⁴

For example, one mistake is to think that questions about how we treat people who are dying, or have expressed a wish to die, are always questions of medicine; they are, as Rhees says and works through them, questions of morality and of religion. The latter are not particularly my concern here (except where the link between religious considerations and moral ones in inextricable) but since one or other version of the clinical setting is where most people die nowadays, which attitude the attending doctor(s) and other healthcare practitioners adopt is critical to their decision-making and to the lives or deaths of their patients.

Witnessing death might bring us to a sense of ‘the majesty of death’ but typically, there is a wide range of reactions; anger, despair, helplessness, bargaining are common, and well rehearsed.Footnote ⁵ Witnessing death often may also induce a sense of ‘ordinariness’, perhaps even a hardening of heart, ‘steeling oneself’, (natural human) defences against a constant round of trauma, loss, sadness.

Regardless of frequency however, I would argue that a complex combination of these and other feelings, will always be present, even in someone who purports to feel nothing at all. ‘Always’ will be objected to: but if we remove psychiatric illness (about which I have many other suspicions) or abnormality which interferes with the usual gamut of human emotion, then I will stick by ‘There is always a more or less complex mix of reactions and feelings’, especially to the death of one cherished by another.

This is important because of the way the lobby speak of compassion, as virtually undiluted by other human emotion or motivation, in ‘loved ones’ helping others to die. In my view, compassion is not usually pure, nor can it be free from the mix with other emotions, not least the pain of the one watching a truly loved one suffering. Framing a law therefore, based even partly on the idea that everyone assisting another's death will be ‘completely motivated by pure compassion and only that’, is impossible, and not only because it is an erroneous starting point.

It is important to note how difficult and even practically impossible it might be to fully excavate human feelings and motivations at all times during end-of-life scenarios, even when one tries to do it for oneself. In this debate that is rarely, if ever, attempted. On the contrary, pure compassion is taken as given and used as a weapon to disparage any objection; with heavy emphasis on the ‘loving, compassionate’ family member, but no questions about for example, resentful ones; and on the engaged, familiar (caring) family GP, with no questions about the stressed, inexperienced, exhausted, target-driven, resource-constrained hospital doctor or even the malign (Shipman, Allitt).Footnote ⁶

I do not take it as controversial, even amongst practitioners, that the sheer number of deaths taking place in a hospital, or other ‘sterile’ environment, can contribute to a slide into an impoverished, sterile view of death, and not just on the part of practitioners. In the discussions that have been rising in number and temperature on this vexed subject recently, not one of them to my knowledge has employed the phrase ‘the majesty of death’ let alone attempted to apply it to the discussion, nor to try to understand what it means, or what light it might bring.

The full complexity of reactions is concerning, including in particular, ‘routineness’. Again, the complexity cannot always be resolved to its constituent parts, even if one tries – and the point is that many do not even try – but the very fact that doctors are ‘commonly’ expected to make decisions about life and death may actually render them the worst possible judges, if they come to view death as mundane, to treat it irreverently, or, as Rhees puts it, in a ‘vulgar’ way. His use of ‘vulgar’ further highlights some of what is most important, and yet goes unnoticed in the debate.

I am aware that my thoughts may be judged unnecessarily harsh of the medical profession so let me be clear: I do not speak about all, nor even the majority of practitioners (doctors, nurses, related healthcare workers, carers). In fact, many doctors welcome such reflections,Footnote ⁷ as they mirror their own anxieties; for example, not wanting to be forced into the position of being regarded as ‘experts’ in this particular decision-making or indeed, to feel pressured into performing an act which is anathema to many of them, for various reasons. What, from one-side looks like harsh criticism, is from another point of view a defence against being pushed into an unenviable place. It is bad enough to be more and more faced with making such heart-rending decisions; worse for some to be cast or castigated as the ‘expert’ responsible.

The debate here then, is with those, practitioner or not, who do believe it is their rightful preserve to end life, for whatever justification they seek to use (‘mercy killing’ ‘allowing someone to die with dignity’ are common amongst them).Footnote ⁸ They can feel reinforced, justified, by a disastrously ill-informed public opinion, led by superficial debate in the public square and ‘validation’ from, for example, a supposedly official, impartial, but in reality, unofficial and heavily biased ‘commission’ (Falconer's). These and other recent changes in the ‘backdrop’ to the discussion of assisted/euthanasia, conspire to ‘permit’ those doctors who already are led this way, to embed certain practices in clinical settings,Footnote ⁹ some of which are not medicine at all.

What complicates matters further is how some doctors interpret their rôle, even in the light of Hippocrates' injunction to first do no harm, and how they can even be outraged when anyone feels them to be doing something outside their domain. If nothing else, this changes the nature of the patient-doctor relationship fundamentally. Good clinical governance has patient safety at its core; when that safety is removed, it is no longer possible to speak of the highest quality of patient care.

Rushed into A&E with severe pneumonia Jane Campbell, a severely disabled woman, was life-threateningly ill. The consultant treating her said: ‘If you go into respiratory failure I presume that you won't want to be resuscitated with a ventilator.’ Taken aback, she protested. The consultant explained to her that the chances of ‘weaning her off’ a ventilator would be very remote – ‘And you wouldn't want to live on a ventilator.’ When she said that meant she would die, and of course she wanted to be ventilated, he looked a little puzzled but let it drop. The next day, in intensive care, another more senior consultant said the same thing. Now very scared, her husband intervened with a photograph of her in her PhD gown demanding treatment as for anyone else with lots to live for:

Simon Fitzmaurice'sFootnote ¹¹ respiratory failure, caused by his Motor Neurone Diseases (MND), resulted in his being ventilated in hospital. A doctor he had never met, came to his Cork hospital bedside and in front of his wife and mother, told him ‘It's time to make the hard choice’ i.e. to die. He was told he could not go home on a ventilator essentially because medical policy in Ireland was not to ventilate patients with MND. Simon fought, won and went home to his wife and three children, with the aid of a ventilator.

Then 12 years old, David Glass,Footnote ¹² with complex physical, sensory and learning disabilities, was admitted to a Portsmouth hospital (in July 1998) with a respiratory tract infection. His mother Carol discovered that her son was subject to a DNR (Do Not Resuscitate) notice without the family's consent. It was claimed that due to a judgement on the potential quality of David's life, no further intensive therapy unit treatment would be provided. This was not a discussion that David could have, but his doctors went ahead and decided to administer diamorphine to ‘allow’ David to ‘die with dignity’. (N.b. the terminology used in the 1993 Bland caseFootnote ¹³ and which is now in common use – as though its meaning were obvious). Carol and her family made a dramatic intervention. They took the diamorphine drip out of his arm and administered resuscitation themselves. His doctors were reportedly ‘outraged’ that David had not been allowed to die with dignity. The family took him home and in 2005 David (then 19) and his family were delivered support in a judgment from the European Court of Human Rights, that in imposing the treatment, the hospital had violated David's human right to life.

A doctor who has treated David and who preferred not to be named said of the fateful decision to put him on diamorphine that David was recovering and getting back to normal. He was astonished that diamorphine was used in a case like this, with a child. ‘I sometimes think that there is almost a different set of rules for the very disabled. Among some members of my profession there is almost a presumption that the right to live doesn't apply to that group of patients.’

None of the three cases was a fight about a clinical decision: they were moral struggles to preserve a life. In each of the three (very different) cases, severely disabled people are judged by doctors who decided their lives were, or would not be worth living. In all three cases, they, their spouses and families begged to differ; their valuation of their loved ones was about them continuing to live. This is the polarisation which so affects the current debate: the doctors (and others) view ‘of a life not worth living’ (exacerbated by the huge variation and lack of accuracy of medical predictions of the end-of-life – medicine as a ‘probabilistic art’) as opposed to the families, the other loved ones whose thought is not to aid someone to die, but to help them to live. (Note too, that even the fact it is claimed often in the media that the ‘loving compassionate response’ is to help someone to die, described so glibly as ‘mercy killing’, can put pressure on loved ones to agree to help. The law as it stands provides protection from that pressure from those who need it.)

These examples are not isolated, and can be part of a systemic failure ‘to tackle challenges to the building up of a positive culture, in nursing in particular but also within the medical profession’ as shown in the recent Francis reportsFootnote ¹⁴ and controversy, for example, over inappropriate application of the Liverpool Care Pathway.Footnote ¹⁵ The body of evidence, extant and growing almost daily, challenges the idea that doctors are generally the right, and only people ‘qualified’ to make these end-of–life decisions.

Rhees speaks elsewhere of another crucial difficulty:

The cynicism Rhees speaks of, including the ‘evil of thinking oneself to be God's agent’, is a deep corruption: of course again, many practitioners do not want to be involved in making end-of-life decisions for a variety of other reasons, religious and moral amongst them, or from the ‘primitive horror of taking another person's life’.Footnote ¹⁷

So it is not what they commonly do that qualifies doctors in any special way to make moral judgements about end-of-life situations. What they commonly do may, in fact, disqualify them, may make them the worst of people to act as judges.

And most importantly here, to facilitate a request from an individual to die, or their family, to switch off the life-sustaining machinery, or provide overdoses of barbituarates, to ‘end this misery’, is a decision made when medicine has reached its limits. Injecting someone with a lethal dose of poison is not an act of medicine, whether it is carried out by a doctor or not. The decision is therefore fundamentally not a medical one at all. It is a moral decision. Being qualified as a doctor can do nothing of itself to turn someone into a moral expert. (What could count as making anyone a moral ‘expert’?) Doctors are not just prone to cynicism, but to all human frailties: distraction, financial pressures, family matters, sheer exhaustion, failing to guard against that ‘routineness’, or the kind of arrogance in Rhees' example, as well as maybe demonstrating brilliance, care, dedication above and beyond the call, and many other positive or extraordinary qualities. But they have no primacy in this moral decision-making no matter what their practice.

Euthanasia is a moral decision. It may be with consent (voluntary), the so-called ‘settled wish’ expressed by the individual. (This phrase too, is used by protagonists as though there was never anything problematic here.) Often, it happens, consent cannot be given (non-voluntary), as in the ground-breaking case that was the end of Tony Bland's life.Footnote ¹⁸ Involuntary euthanasia is where consent may be given but is not sought (which is, after all, murder and yet is not even counted as euthanasia in Holland following a change in regulations there in 2010).

Assisted suicide falls into the category of ‘voluntary’, where the means are provided by someone else but the person themselves, at least in the changes imagined in GB law, has to ‘do the act’ themselves.Footnote ¹⁹ Now, the problem I am trying to elucidate is not about individual decisions to die per se but about the impact of the various individuals' campaigns, the support from a lobby calling for a general law, and the potential dangers of that law.

The problem is that a law brings generality, applying equally, as in Holland since that country legalised euthanasia, to the 12 year-old, the over 70 year-old who is ‘tired of living’, even now to psychiatric patients, as well as to people terminally ill with a dreadful cancer. Holland has now also formalised (the Groningen Protocol) and legalised infanticide of disabled babies.

But we are not entitled to simple move from this case, to every case like it. That ‘generality’ is the false move: because one severely disabled person decides they do not want to carry on living, we cannot deduce that all others in the same situation will feel the same way. The threat to those who want to live lies in accepting this move to generality, and introducing a law which, by its nature, covers everyone. Part of the threat is that an imagined ‘right’ to die becomes a ‘duty to die’.Footnote ²⁰ Rhees saw that, and did not want to argue for any sort of legislation for he thought there was something to be said for keeping it illegal, which provides a kind of ‘pause, that:

There is a suite of questions about influences on such decisions which might make them ‘lighter’, such as the very fact of the discussion, copycatting, increased rates of suicide, decisions not to prosecute cases for consideration of ‘public interest’, whether sanctioned assisted suicide/euthanasia in some (extreme) cases changes matters, because of an erosion of moral will or because the possibilities of abuse are too great, and so on.

Rhees' judgement was accurate, that this is really not a ‘good subject for public debate’, but that it is, the debate needs balance, more measured thinking, and an elevation from out of principally emotional responses. It demands reflection on whose voice to listen to, if no-one can be otherwise ‘qualified to speak’ on matters of moral judgement.

Rai Gaita offers the following:

If anything can qualify someone to speak, it is surely has to do with such authority as stems from the way they have lived their lives. This is not without difficulty itself, for it demands a moral valuation of that way, but at least this can be noticed: that the one-sidedness of the diet in the public square is deeply destructive.

As Gaita points out, philosophers have been in the vanguard of wondering who might be judged as candidates for being killed or helped to die, depending on whether they are ‘fully-paid-up persons' or according to whether their ‘quality of life’ is up to scratch. Thus a radical change of mind-set is introduced, where one part of the population, usually non-disabled, non-vulnerable deems it proper to assess another part of the population usually disabled, vulnerable, as candidates for euthanasia/assisted suicide. (This is integrally linked to a specious measure of the ‘quality’ of anyone's life.) This does not so much cause a shift in our culture, according to Gaita, as it reflects a shift that has already come before and is being expressed in this way.

Those philosophers have often been praised for ‘having the courage to follow their arguments wherever those arguments take them’, and they have taken them beyond what only twenty years ago were considered to be reductio ad absurdum. But:

It is hard to believe the public debate might ever return to considering this when so many argue that in some cases suicide is ‘not serious’ and is, in fact, the right of each one, the right course of action and indeed, the only, moral, compassionate response.

That philosophers have argued for the relaxation of the limits on killing other human beings constitutes a significant part of a shift in the culture, that radical change of mind-set. It has permitted others, as Gaita points out, to find at least arguable, what was previously judged unthinkable. Some people now find it acceptable to judge that certain lives are not worth living, ‘and they are much more ready to appeal to compassion and a certain conception of human dignity to urge the killing of those who are afflicted with terrible suffering.’Footnote ²⁴ There is even an argument that this is a necessary connection: I believe however that there is no necessary connection, and indeed it is worse for the doctor to lose their sense of the ‘human-ness’ of the patient in front of them.

Gaita is scathing, and I believe with justification, of the apparent ease of conscience with which those philosophers have set about influencing the discussion, developing a new ‘practical ethics’ in which is proposed a relaxation of the restraints against killing people. They have, he says, extended the arrogance and insularity of the worst kind of academic professionalism beyond the academy.

Little wonder the lobby for a law to permit assisted suicide/euthanasia have added their arguments to others (e.g. restricted views of autonomy and rights to their particular conception of compassion and dignity) to argue that what was previously morally unthinkable, must be thinkable if we are to be moral. It is a strange reversal, too often implemented as the only compassionate response possible, or as good sense, good (even best) practice, in the ‘best interests’ of the patient, even when that patient is a child. There is not even often any clear thinking about possibly conflicting ‘best interests’. For some, and not just those practising medicine, there is no longer a question: is it ok for one human being (usually non-disabled) to think of another (usually a disabled person) ‘this person's life is not worth living’?

The next steps are from ‘this life is not worth living’ to ‘it would be a mercy to allow this no-longer-fully-paid-up person’ (Gaita's phrase) to die, to ‘we should do something to let this person die with dignity’ and ‘it's the only compassionate thing to do’, to the final act of one human being injecting another with a lethal dose of a poison to kill them. And again, this is argued as not just reasonable but the only compassionate response possible. Philosophers with no suspicion that anything is beyond their professional competence, or may be too deep for their individual talent, ‘mistake [their] vices for the virtue of thinking radically, courageously…’, have contributed to drive that feeds an aggressive and now much less self-reflective lobby, who make the same mistake of vice for virtue.

This is what accepting the false move to generality brings. The step legalising the practice is the dangerous step for it endorses the notion that, for these ‘hard cases’, suicide is not serious and is in fact a morally good course of action. That is the position of the lobby and one that needs to be countered. People who attempt suicide should be treated with mercy and compassion, but there is no move here to arguing that committing suicide, taking one's own life, is a moral good and thereby a right. That involves false reasoning about the notion of ‘rights’ (there is no, and can never be, a ‘right to die’ since death is inevitable for us all) and ignores the serious practical and moral questions raised by any suicide. There are, as Rhees points out, are deeper moral questions raised by any suicide that cannot and should not be ignored. I will come back to some of those.

For the moment, it is critical that the situation in Holland has passed from ‘hard cases’, and all too swiftly:

The result is an incremental extension,Footnote ²⁷ when the ‘pause’ is removed, when the questions are no longer even thought of as legitimate questions, when the only ‘voices of authority’ are those already inured to death, or predisposed to a sterile view and not even to speak of ‘the majesty’ or the ‘mystery’ involved in deep considerations of death.

For Rhees, to recognise the majesty of death is to recognise the difficulties of life, that the rites associated with death are not a misguided attempt to ward it off, in fear of such a terrible disaster, but are rather recognition of the finality, as well as the fittingness of death, its importance. And there is a difference between the sense of longing for death and being sick of life, which lies in that ‘vulgarity’ of seeing death as simply an escape from suffering. The fact that we can bring people to death does not remove the shallowness – does not remove the distinction between a good death and a bad one – and we treat death in a profane manner or an irreverent one when we say ‘we need the bed’ or ‘it's too expensive to put you on ventilator’ etc.

Where a law is passed to allow assisted suicide/euthanasia the evidence shows that:

Although the initial intent is expressly to limit euthanasia and assisted suicide to a last-resort option for a very small number of terminally ill people, some jurisdictions now extend the practice to newborns, children, and people with dementia. A terminal illness is no longer a prerequisite. In Belgium 47% of deaths by euthanasia are not reported as such, and nurses, despite its being illegal, are involved in carrying out acts of euthanasia and many are of vulnerable people who do not give consent.Footnote ²⁹ Legalizing euthanasia and assisted suicide therefore places many people at risk, affects the values of society over time, and does not provide greater security, as is sometimes perversely argued, for vulnerable people.

Since 2010 after a change in regulations, Holland no longer even counts involuntary or non-voluntary deaths as euthanasia and only counts those who have apparently made an explicit request in their official statistics. Holland has also taken the further step in the last two years, also previously unthinkable and apparently still so in the UK:

Those are the ones we know about, the cases officially reported. To be less than ‘of sound mind’ or competent to make such judgements is, it seems, no longer a defence against euthanasia in Holland; neither to be a child between 12–16 years of age, nor just to be old/er (i.e. neither particularly ill nor dying). The discussion of the moral question in Holland is however beginning to resurface but still does not include discussion of these deep moral questions, still less Rhees' remark that:

I have left in the word ‘unholy’ for Rhees was unpacking a religious notion of the sanctity of life which he thought too often led quickly to nonsense,Footnote ³¹ but chooses his word carefully to demonstrate the depth of the wrong in speaking this way. Yet that is exactly the reflection so often heard in the public square when anyone says, and they do all too often, ‘You wouldn't do it to a dog’. That's to say, we euthanase dogs and animals – as though too that were easy and unproblematic – so we should not leave humans being in misery. But as Rhees says this is just stupid: the death of a human being is not just an irreparable misfortune. It is terrible and majestic, horrifying and sometimes, more often than not, peaceful; the death of a human being is not ever comparable to the death of an animal for the role each plays in human life and living are categorically different, so causing someone else's death is more terrible than that of an animal.

‘Getting off the bus’ is not simply a matter of compassion in the face of suffering. ‘For us to judge who should go on living means taking a false view of life.’ There is nothing here on which to base a general law to validate such judgements.

Again, the great danger here is to remove from all cases any pause that might still exist in individual cases.

His use of ‘obviously’ is not a statement of opinion; it is a matter of the logic of the phrase. He goes on:

Rhees speaks here of matters rarely (if at all) opened up in current debate fifty years later. Any suicide, assisted or not, has consequences. We cannot say generally that anyone may be justified in having, for example, a casual disregard of the impact on family of their suicide, nor indeed that coming to view their life as pointless can be justification for either them or me to help.

The idea that it is clearly wrong to judge a life of unmitigated suffering as pointless, is harder to explain to an aggressive lobby for a law to allow assisted suicide/euthanasia, which uses words like ‘cruelty’ to refer to this view. There is a question here about the importance of life (not to be confused with the sanctity of life, especially from a religious viewpoint, even if the two are closely connected). There are questions about when condemnation is appropriate and, importantly, when it is not; about prolonging life, and futility, even in the face of great medical advances; about suicide, murder and about what constitutes justification; even about saying a life of unmitigated suffering should always be pointless.

Rhees' view – that one should be even less justified in helping someone else to die who says ‘I no longer want to live’ – can startle. But even in the case of an individual asking a lover or a parent or a child in whose love they can have the deepest of trust and faith, in choosing to help, is the loved one always completely free from their own pain and consideration of relief from watching their loved one suffer? If all cases were just at that level of difficulty there would still be questions: but what about those who have nursed a child or a husband for many years and are exhausted, perhaps wanting some kind of life for themselves after all they have given of themselves? What about the ones who want to get their hands on the money, the family ‘jewels’? If someone kills another person at their request, it seems different, but is there not still a possibility of being horrified at being asked, at what I have done if I accede to the request?

We cannot prove that it is a terrible thing to kill someone. Rhees is right to say there is something here about the importance of life; having a reverence for life (and not only in a religious sense). And there is no justification of the condemnation of killing in circumstances which are less clearly murder. But that remark does not undermine the fact of the condemnation, nor its appropriateness in some cases.

Of course, not every circumstance in which one chooses death is evil: the captain goes down with the ship attempting that everyone else is saved – women and children first – the father who stays behind certain of his fate - death as a form of sacrifice. For those choosing death: a lot depends on their attitude towards death and life but also in the equation here – the shallowness or irreverence of the one taking that life (the evil of thinking of themselves as God's special agent), or then again the love and depth of attention. The intention of the one taking the life is central: but so too still is the problem of whether we can separate pure intentions out, like pure compassion; I do not believe it is always, mostly right or anything but rarely possible.

It is right and proper in circumstances of severe impairment, to bring every resource available to make someone's life as comfortable as possible – accessible environments, wonderful attitudes, impeccable palliative care, a deep respect for life in the decision to help someone die – where it would be terrible not to. This is not the same as a speedy exit from suffering. It is respect for the person, for their life, their existence (like closing the eyes of the body of someone who has died). For Rhees, and for me, the question of whether someone's life is pointless or worthless does not either depend on whether s/he thinks it is pointless, and still less on whether society thinks it pointless. For the pro-euthanasia lobby, that is anathema.

The crucial pause in each and every case, to try to decide the question ‘Is this really the right thing to be doing in this case?’ It is too easy to fall into the belief that there is no question at all, that this is so obviously the right thing, where anyone, doctors included, may not even think about it all, or at least not as they did at first.

In the end condemnation, as with compassion, can only rest within the individual circumstances. The differences in court judgements, between the acts of Fiona Pilkington, Frances Inglis and Robert LatimerFootnote ³⁴ in killing their disabled children, should at least bear out the complexity of every individual situation.

A general law could never cover all cases of assisted suicide/ euthanasia and it is just naive to think legalising assisted suicide/euthanasia will not be followed by the deaths of vulnerable people; if even one innocent dies as a result of such a law it would be too many. That after all is the mirror argument of those who claim it is inhuman to leave even the tiny number of people who live in intolerable suffering to their fate, as though that was what objectors to a law would wish.