The Rabbi Who Changed His Mind
I have changed my mind. For many years I was against the idea of assisted dying on the grounds of the sanctity of life, as well as the ‘slippery slope’ argument. However, after many years as a congregational minister of seeing people die in pain, I see no merit in individuals being forced to live out their last days in misery if they want to avoid it. I am also confident that the safeguards being proposed around assisted dying are sufficiently strong and will ensure that it is not abused. I know palliative care can be wonderful, but it has limits and there are those it cannot help, and assisted dying should be available as an option for those who so wish.
What is vital to this debate is clarity of terms. Assisted Dying is neither euthanasia nor suicide nor the Liverpool Care Pathway. Euthanasia refers to situations in which someone else takes a person’s life because the state has decreed it, irrespective of the person’s own wishes. Voluntary euthanasia is when the individual concerned wishes to die and applies for an authorised person to administer life-ending medication. Suicide is when a person takes their own life for a variety of different reasons, varying from those in a state of extreme distress to those who do so as a pre-planned political statement. Moreover, in most cases, the person would have lived for many years had they not committed suicide.
In contrast, Assisted Dying is where an already dying patient takes their own life, doing so of their own accord, whilst in sound mind, so as to hasten their death, usually in order to avoid either pain or incapacity. This also differs from the procedure known as Liverpool Care Pathway (LCP), where medical staff makes decisions on behalf of patients in the last days of their life and who no longer have capacity. Death is hastened not by administering anything, but by withdrawing medical treatment or food and water, although keeping the patient comfortable.
At present, assisted dying is not legal in Britain, although it is permitted in the USA in Oregon, Vermont and Washington. Voluntary euthanasia can take place in Belgium, Luxembourg and the Netherlands. However, in all those places it is only for citizens, and the one country that allows those from abroad to come to be helped to die is Switzerland, and hence the trail of people going to the Dignitas clinic there.
The reason why assisted dying has become increasingly discussed as a possible option in this country is largely because of two consequences resulting from the changes in our lifestyle in recent decades. First, thanks to modern improvement in housing, central heating, sanitation and medicine, people live longer. However, this also means that more people reach a bodily condition in which pain or indignity are constant, at which point some would prefer to die rather than carry on living. Thus the bonus of living longer carries the penalty that we have more time in periods of terminal illness. Between 1991 and 2001, life expectancy rose by 2.2 years but the period of healthy life only increased by 0.6 years, whereas that of unhealthy life increased by 1.6 years.
The second factor is the growth in the belief in personal autonomy and the right to make decisions affecting oneself. It includes choosing one’s marriage partner and selecting one’s career path, both of which were pre-determined until recently, and still are so in some circles. Those who expect to control all aspects of their life now wish to extend that to determining when their departure from life occurs, especially if they are facing terminal illness.
A key factor for them is the desire to avoid pain. However, it is not just physical suffering that appals them, but a range of other situations: the humiliation (in their eyes) of failing powers; the limitation of their ability to enjoy life; their dependency on others; the lack of control over their bodily functions; the sense that they have nothing to look forward to save ever-worsening decline; the unwelcome image of being sedated into a state of narcotic stupor in their final days or with their bodies sprouting a forest of tubes.
Of course, there are many who regard terminal illness as a regrettable part of the natural cycle of life, to be mitigated through medical care if possible and to be endured if not. That is entirely their prerogative and must be respected. The question is whether those who wish to avoid that pain and indignity should have the right to do so. And whether other people have the right to prevent them making that choice about their own life?
A biblical passage that – deliberately or accidentally – is relevant to the changing perceptions today (and perhaps long ago too) is the famous line in the Book of Ecclesiastes 3.2: ‘There is a time to be born and a time to die’. It is noticeable that it does not say who chooses that time. In previous eras it was assumed that both were pre-ordained by God, and that any human interference was sinful, but now it can be read very differently. The time to die could just as well be our decision. The God-barrier has long been pushed aside both in the beginning and end of life, with humans acting in lieu of God, whether by doctors’ efforts to create life via test tubes or postpone death through heart transplants. Why should a terminally ill person not have the same decision-making rights?
The objection raised by some, that assisted dying is ‘playing God’, ignores the fact that we frequently ‘play God’ – doing so every time we give a blood transfusion or provide a road accident victim with artificial limbs. Should we stop doing that? If the religious ideal is imitatio dei, then it is our duty to use our God-given abilities to imitate God as much as possible. Assisted dying is part of the constant act of playing God in the sense that God wants us to help those in distress: to heal where possible, to comfort when needed, and to help let go of life when desired.
This theological position is reinforced by the practical concern for those dying in pain, along with the anguish of relatives watching on helplessly. Other rabbis – past and present – do recognise the problem and are not unsympathetic to the predicament it poses. However, they hold that that matter is in God’s hands and not for humans to fathom the reasons or change the outcome. The most daringly pro-active response is that one is permitted to pray for the person’s death. While this may be a way of nudging God in the right direction, it still rules out any human intervention. Hospices and palliative care can be the answer for many individuals, but those whom they cannot help need different answers, and assisted dying might be one of them.
One concern, though, is that the right to opt for assisted dying might have a deleterious effect on others, especially those in a similar condition but who do not wish to end their life. Might they feel pressurised to do so? The Bill currently being proposed by Lord Falconer to permit assisted dying legislation proposes a wide range of safeguards that should allay such fears. They include the stipulations that:
- the person is terminally ill;
- the person is mentally competent;
- the person makes the request of their own free will.
The process for ensuring the above is rigorous:
- it can only be initiated if requested by the person him/herself;
- the person must be assessed by two independent doctors to ensure that he/she is terminally ill and of sound mind;
- the patient must have been fully informed of palliative, hospice and other care options;
- the person has to make two oral and one written request; the latter must be witnessed by an independent witness not connected with the family or hospital;
- there has to be a fourteen day waiting period for reflection;
- the person can change their mind at any time and including right up to the last minute;
- it is an assisted death only, and while doctors can prescribe medication, only the patient can administer it.
According to the provisions of the Bill, assisted dying will not be allowed for those who are unable to take the life-ending medication themselves. This may rule out some deserving cases, but is to ensure that the person is taking the medication of their own free will. It will also not apply to those suffering from chronic pain but who are not terminally ill. This may disappoint some, but is so as to limit permission to those shortly about to die anyway and to avoid any slippage into shortening life more generally.
We are in the fortunate position of knowing in advance what will be the likely effects of permitting assisted dying, as a result of the experiences elsewhere, especially in Oregon, which has the closest system to the legislation being proposed for Britain. Since it was introduced in 1997, several thousand dying patients per year enquire about assistance to die, but only around 0.2% (in 2012 this meant 75 people) opt for it. Moreover, it is a static average figure that is not shooting up but stable. It indicates that many people wish to know it’s there and have the emotional safety-net of knowing they can resort to it if their situation makes life intolerable, but never find they reach that stage.
Furthermore, those who would be considered to be in the category of ‘the vulnerable’ have been less likely to take up assisted dying than those who are in positions of greater independence and responsibility. It suggests that it is particularly favoured by those used to controlling the course of their life. This may not be everyone’s choice, but why should they be denied it because others do not wish it?
There are those who are worried about the effect on doctor-patient relationships if doctors are involved in the process of assisted dying. But if the doctor is providing a lethal potion only in response to the patient’s request, their role will continue to be seen as beneficial and patient-oriented. It is significant that the declaration taken by most doctors upon qualifying is no longer the Hippocratic Oath (which spoke of not causing harm to a patient), but has generally been replaced by the Geneva Declaration (which changed the emphasis to considering the health of patients).
Assisted dying would only be permitted to alleviate the pain or indignity that a patient wished to avoid. It would also be the case that, as stated in the proposed legislation, doctors would not be obliged to participate in assisted dying if it was against their conscience.
Concern over the impact on family relationships is another legitimate question, but it need not make assisted dying any more problematic than the current options. Caring relatives will remain caring relatives, and will seek to support loved ones who are dying, whatever the manner of their death. It is virtuous to tend to the dying, but no less virtuous to allow them to choose assisted death if that is their clear preference. Meanwhile, uncaring relatives will remain uncaring, and be guilty of the same neglect as happens currently; but they will be prevented by the strict provisions of the proposed legislation from taking any steps to hasten the patient’s death.
Those thinking of assisted dying, should an intolerable situation arise, would be advised to discuss it with their families well in advance, both to prepare relatives for that option and to be aware of their reactions. It might result in lengthy discussions, or delaying any decision until the immediate circle had come to terms with it, or the person changing their mind. Whatever the scenario, the key object would be to help all sides feel emotionally prepared for the final outcome and mutually supportive of each other.
The challenges posed by those dying in pain have led to significant developments within the religious world. Whilst many Christian and Jewish clergy – especially those in the hierarchy – still hold to the traditional opposition to assisted dying, there are a growing numbers of ministers who now favour it. They come from a wide range of denominations within both faiths: Anglican, Methodist, Baptist, Congregationalist, Unitarian, along with Reform and Liberal rabbis. They have linked together to form IFDiD – Inter-Faith leaders for Dignity in Dying – to offer an alternative view and to show that there can be religious reasons for it. IFDiD also seeks to provide guidelines for the pastoral care of individuals and their families before and after death, as well as to develop rituals for those undergoing the process of assisted dying.
At the same time, attitudes are changing within the laity too. A YouGov poll that was conducted in April 2013 asked whether people would support a change in the law to permit assisted dying under carefully regulated circumstances. A breakdown was done of whether those responding came from a religious background or not. This was not defined as nominal believers, but people who take their faith seriously enough to attend services at least once a month, if not weekly. The result was that 62% of those from religious backgrounds said they did support the law being changed. It means that religious spokesmen who oppose assisted dying certainly have a right to their opinions, but do not speak for all believers. It also demonstrates that there is a not a monolithic religious view – the ‘No camp’ – but a diversity of views, with a considerable number sympathetic to it.
There is no doubt that this is difficult territory, but it is religiously appropriate to try to navigate it. The right to live one’s life to the very end does not imply the religious obligation to do so, especially if that end is a travesty of that person’s life and everything that has gone before. If there is a right to die well – or at least to die as well as possible – it means having the option of assisted dying, whether or not it is taken up.
Rabbi Dr Jonathan Romain MBE is a writer and broadcaster and director of the Maidenhead Synagogue in Berkshire.
This is a shortened version of the talk given by the author to the 2021 SOF Annual Conference on Zoom.