Commentary: Palliative care and assisted dying are not mutually exclusive

Two decades ago, I argued that it was logically consistent to be a good palliative care doctor and to think that for some patients the best option would be a managed death.¹

In working with practitioners, policy makers, and fellow academics committed to improving the care of dying patients, my observation was that orthodox top-down pronouncements on the idea of assisted dying were the norm, often with no dissent, challenge, or even examination.

I made no claims about whether it was time for change. Instead I wanted to challenge the silence around a question that health professionals were to a large degree avoiding.

This article led me to the eye of a storm I couldn’t have anticipated, with influential people calling for my exclusion from bodies related to palliative care. It was bruising but I survived, and when I was adviser to the House of Lords committee considering Lord Joffe’s Assisted Dying Bill I was told unofficially that mine was one of the few names that was acceptable to “both sides”—indicative of the polarised nature of this debate within parliament.

I have never campaigned for or against legal assisted dying; nor have I formally researched practitioners’ views. I still work alongside professionals who care for terminally ill patients and people with life limiting illness. And I still challenge the belief that a wish to die at a particular time and in a particular way can be “cared away,” however great the skill of the professionals and resources committed to end-of-life care.

In terms of challenging empirical claims about assisted dying, I present evidence from other countries where assistance in dying is available and invite colleagues to draw their own conclusions, unfettered by a desire to persuade them one way or another.

Meanwhile an important debate is happening in wider society. Patients are more aware than ever of what is, and is not, possible for them as they approach the end of their lives, and practitioners need to be prepared and able to respond compassionately, especially when they cannot give patients what they most desire because the law precludes it.

It feels as if we are experiencing a rare example of public morality shifting ahead of legislative change, with polarisation of past parliamentary debates no longer reflected in society, given recent opinion polls.² Given this is so, the law may well change soon, and as a medical educator I feel a duty to engage medical students and experienced practitioners with the practical ethical issues that this could prompt, in terms of offering assisted dying as a therapeutic option or conscientiously objecting to doing so.

In 2018, my diary is less likely to contain invitations to speak on the rights and wrongs of assisted dying—people are doing that work for themselves. It is much more likely that I will be asked to help practitioners, policy makers, hospice managers, and trustees to think through the decisions they will need to make if the law changes.

And so I ask today as I asked in 1998: if UK law changes will palliative care continue to exclude assisted dying? Surely we have come to understand that there need be no contradiction between being a good palliative care doctor and respecting a patient’s wish to die and their request for assistance.

Rather than fighting against a possible future in which dying people could request medical help to die, I would urge this important group of professionals to think about how they would negotiate such a future in the best interests of their patients.