Fundamental

Galatea of the spheres (1952) by Salvador Dali

The ongoing debate about assisted dying offers many pauses of reflection. Having engaged in mini-debates on social media, in the safety of the written word, and only occasionally face to face, I find it hard to understand how doctors who are similar to each other in so many ways can end up so far from each other on this question.

Accepted, doctors are not all the same. Any patient, any doctor, any manager, can tell you that. Although it would seem that they all entered training with the same essential sense of vocation, their characters and personalities continue to develop in different directions, perhaps sharpened or hardened over time by the rigours of the job. You will run into ‘non-simpatico’ colleagues during your career. This happens in all walks of life, and part of being professional is accepting such differences and getting on with things. In our job, there is a strong and overriding reason to find a way through – good, safe patient care.

The people I debate AD with are probably like-minded on almost every other topic. Character-wise, we are similar. Anyone engaged in the AD debate is concerned for the welfare of the dying. So how can we end up on different sides of the line? It must be something fundamental? But what? Could it be a different appreciation of the value, or sanctity, of life?

The first and most obvious ‘fundamental’ relevant to this debate is religion. We rarely advertise our faith, or lack of it, when expressing our views. Some say we should. I am inclined to agree, if only to allow readers or audience members to understand where, spiritually, the writer or speaker is coming from. But religion is not a classic ‘conflict of interest’. There is no personal gain to be had by the debater who hides his or her religious affiliation. Their religion is part of their cultural upbringing and psychological profile. So, on balance, although I have previously argued that law makers should be transparent, not everyone who states their case in the AD debate should be required to reveal their religious background.

Anyway, I don’t believe that religion separates pro- and anti-AD groups. I know atheists who are anti, and believers who are pro. It is must be something even more fundamental.

What could be more fundamental than faith? Maybe our attitude to life itself. Human life. The lives we see and feel every day, and the lives of those we don’t see. The strongest argument against AD is centred on a fear for vulnerable groups in society (the disabled, the elderly, perhaps those with mental illness). It is quite straightforward to deal with this fear: the AD legislation being considered in this country would apply only to those who are dying. This is in marked contrast to Dutch law, which applies to people with unbearable suffering without hope of cure. They do not have to be dying. Nevertheless, this fear divides pro and anti. Do those who oppose have a heightened sense of social responsibility? A broader view? An ability to elevate the protection of those who might be drawn into AD through external or internal pressure (guilt), above the needs of the few who will benefit now?

The next most common objection I have seen is based on personal revulsion at the very idea of prescribing poison. The thought of a man or woman taking a lethal cocktail that you gave them. A legacy of death. It is easy to empathise with this. AD requires an action on the part of the involved physician; not at the final moment, not even at the patient’s bedside, but earlier, in the consulting room, at the desk, opening up the path to death by writing a letter, signing it off, furthering the process, prescribing the drugs… distasteful. Perhaps this is the difference between us. A willingness to breakthrough that comfort barrier to help the small number of patients who need a different kind of care. One way of thinking about this is to compare the act of that prescription to the act of removing a feeding tube, turning off a vasopressor infusion or switching off a ventilator. Withdrawal acts that are legal, ethical, and hasten death by removing artificial barriers to its natural approach. No different?

I cannot pretend to understand others at the deepest level. In this debate, and especially during these three weeks of heightened awareness while the Royal College of Physicians undertakes its AD poll, each doctor invited to respond must examine their own nature. We are all different. But after we have voted, and while we carry on treating patients and doing our best for them, I hope that the fundamental differences that have been revealed between us do not translate into mistrust. We are the same in many and the all the right ways.

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