Month: August 2015

An unacceptable choice? The case of Gill Pharaoh

Gill Pharaoh-as-a-nurse

The assisted suicide of Gill Pharaoh, a retired palliative care nurse who feared the onset of frailty, causes me great confusion as a proponent of assisted dying. The moral arguments for and against such a death are inevitably confused with those related to physician assisted dying (PAD), although the circumstances are entirely different. The PAD ‘purist’, who supports the right of terminally ill people to choose the time of their death, will be tempted to dissociate themselves from Gill Pharaoh’s case. Her choice has nothing to do with PAD.  She was not terminally ill. Society’s horrified reaction to it might spoil the recent, early progress made in the Houses of Parliament towards the legalisation of assisted dying. She would not have been served by the proposed legislation. Let us disown her eccentric story – (indeed, her partner reported that she began to plan her death at the age of 30) – it does not belong in the saga that is society’s ongoing tussle with the idea of assisted dying.

I don’t think this separation is intellectually honest. There is an overlap. The fears that drove her to seek a planned death before she was changed by frailty are similar to those that might drive a terminally ill patient to PAD. They are reduced quality of life, pain, dependence on others and perhaps (although this is morally questionable) concern about being a burden to others. Cancer or other terminal illnesses bring such fears and complications, and because the condition is inexorable it appears to society that it may be morally justifiable to open the door to unnatural death in order to escape those consequences. Ageing however, although quite capable of bringing similar burdens, is not reason enough to choose death. To choose death to avoid older age appears… what? Cheating? Weak? Weird? We know that old age can be dignified, pleasant and full of value. Opponents of unnatural death describe instances of lives re-evaluated after periods of suffering and despondency; or how enhanced support has allowed pleasure and satisfaction to be accessed despite ill health and deteriorating function. They are offended by the idea that people can choose death because (as in the case of Gill Pharaoh) a dose of shingles resulted in neuralgic pain, tinnitus plagued social interaction and fatigue led to hours spent sleeping or resting in the afternoons. It appears to offend the human condition. Life is suffering, choosing death to avoid suffering is an abnegation.

Is it wise to even consider the relevance of Gill Pharaoh’s choice to the case for assisted dying? It may not be, and the purist can easily ignore it, but it would be dishonest of me not to tackle it. For there is a common essence, and it is autonomy. For me, it is respect for autonomy (where it has no detrimental effect on others) that justifies PAD. Should terminal disease augment the power that society lends to a person’s autonomy, such that death can be chosen before death would naturally occur, while non-terminal disease – perhaps associated with similar suffering – should not? What’s so special about terminal disease? These are questions for society and law-makers. Terminal disease presents legislators who are considering the legalisation of PAD with the opportunity to alleviate suffering and respect autonomy without actually creating death, only moving it forward in time. It feels acceptable. To legalise the kind of choice Gill Pharaoh made feels unacceptable, because doing so would bring death into a situation where it would normally have no place. It feels like suicide, plain and simple.

Supporters of PAD need to consider how to discuss cases like that of Gill Pharaoh. Do they disown or embrace? If the latter, do they risk accusations of passively condoning the slippery slope, or the Dutch trend to assist those who are literally ‘tired of life’? We are at a critical juncture in the UK. An Assisted Dying Bill is making its way through the Lords, after an abortive attempt last year (1st reading was on June 4th 2015). Supporters do not want to see the arguments around Gill Pharaoh’s choice feeding into general criticism of the Bill. Thus, her choice will remain an example of eccentricity, and not one to be emulated or encouraged. This approach may not be intellectually honest, but it is probably necessary.


[‘My final night with partner before she ended her life’ – audio, Radio 5 Live shorts]

Other posts on Assisted Dying


The show goes on

Moving on


Moving on is a feature of the trainee doctor’s life, and next week sees another transition point for thousands. I found it both stressful and innervating, and I’m sure the adaptability that being forced to change institution every twelve months is a good thing. Yet the need to leave a familiar environment, trusted colleagues and patients whom one has been caring for, exposes some human challenges unique to medicine.

Ward doctors get to know their patients for relatively short periods of time, sometimes only a day or two, sometimes a month (if they are very ill, or if there are delays in discharge). But there is barely time to warn them that you will not be there come change over day. This can feel like a form of minor deception. On the last day you know that whatever undertakings you make, whatever promises to come back with tests results or other information, it won’t be you who fulfils them. We know that of all the things patients value, continuity is high on the list. Yet the faces they come to know best, those of the F1, F2 and core trainees, disappear at a stroke. Others remain, the registrars and consultants, and they try to ease the transition by saying things like, ‘Change over day today, you’ll be seeing lots of new faces!’ I wonder how patients react, privately, to this shift. Employees everywhere move on, but I can’t think of any other arena where those providing such an emotionally complex service, in a time of great stress (illness), appear to float off with barely a by-your-leave.

If you happen to be on-call the day or night before change over, your own questions about patients may remain unanswered. If you are unlucky with timing you will finish a night shift, clean your teeth and drive off to the next hospital in one seamless marathon. I remember calling in from the atrium of my new hospital during a break in the induction program, to find out what a brain scan had shown in a young man with strange paralysis. I could not get through to anyone. Then I remembered – most of the doctors at the old place were new too. My old registrar might know the answer, but she was undoubtedly running around trying to see all the patients on her own. None of the doctors who had replaced me would know who the hell I was. I was gone.

There may also be a sense of frustrated responsibility. I had a vitally important message to hand over to another team about one of their ward patients. A blood result had come through  – or been noticed – late on the final night indicating that a patient’s kidney failure was due to a rare condition, vasculitis. She had to be referred to a specialist kidney hospital for a biopsy and immunosupression first thing in the morning. But I had to go; in fact I had to leave an hour early to drive to a new county. So I wrote in the notes (underlining the result five times), asked the nurse in charge to grab the medical team as soon as they arrived, and sped to the new hospital. Between induction lectures I tried to contact the team. When I got through the new doctors didn’t even recognise the name of the patient! At last the registrar came to the phone – the one constant at this time of potential chaos. (Barring the consultant of course, but I wasn’t going to call him was I?) The registrar knew what was going on. He had already made the referral.

‘Thank God,’ I sighed. He laughed, and said,

“Hey, don’t worry. We’ll manage. The show goes on!”


After that, I worried less about moving on.


three covers