It’s rare to get a politician who openly admits they are torn on an issue, but in recent days there have been two striking examples. First, Wes Streeting, Labour’s shadow health secretary, admitted that though he voted to legalise assisted dying a few years ago, he feels conflicted. Then Nicola Sturgeon, former Scottish first minister, wrote a piece saying that, with new Scottish legislation on the table, the reservations she expected to subside are becoming stronger.
I wrote last year about my own trajectory in relation to proposals to legalise doctor-assisted suicide for the terminally ill. A decade ago, I would have supported assisted dying out of a respect for personal autonomy and a desire to alleviate suffering. Today, I understand these objectives are not standalone but need to be weighed against the impact on those for whom an abstract liberal notion like autonomy is highly simplistic, and the state-sanctioned wrongful deaths that seem to me impossible to avoid.
The first prompt for my reappraisal has been my evolving understanding of the complexity of relationships. We are not all autonomous islands floating in a sea of humanity; we are highly influenced by each other and by cultural norms. Writing about domestic abuse has opened my eyes to the extent that coercively controlling relationships drive people to do things because others want them to. Of course there will be women who get a terminal diagnosis, whose partners have been emotionally abusive to them for years – telling them their life isn’t worth living – who will come under intolerable pressure to opt for assisted dying. How can we ignore that around a third of female suicides are thought to be related to intimate partner abuse? Or that some men who violently kill their sick wives rely on defences such as “mercy killing” and “suicide pacts”, sometimes very effectively? Even the fact that men are much more likely than women to leave their partners after a terminal diagnosis feels salient to understanding the gendered implications.
The risk of coercion goes beyond intimate partners in a society riven with ageism and anti-disability prejudice; what happened to older people in care homes during Covid is just one example. More than a fifth of people over 65 have experienced physical, emotional, financial or sexual abuse. There are relatives who will find ways – perhaps quite subtly, even unintentionally – of hinting to people with a terminal diagnosis who need round-the-clock care that they should opt for assisted dying. How would that make you feel? Almost half of people who chose assisted death in Oregon in 2022 cited concern about being a burden.
Then there is the internal pressure that arises from some feeling that they ought to do it to save relatives difficulty and financial consequences: where the right to die becomes the duty to die. That message will be reinforced at a societal level; Times columnist Matthew Parris recently argued in a widely condemned column that assisted dying could help address the cost of an ageing population; that there are those willing to be honest about this should give serious pause for thought. Moreover, palliative care doctors talk about how the wish to die is not stable, and often abates in terminally ill patients in the wake of an initial diagnosis, and can be affected by depression, which is hard to diagnose.
The second factor that’s changed my mind is the international evidence that, once you cautiously nudge the door on assisted suicide, it is very difficult to stop it swinging wide open.
The most cited example is Canada, where a limited form of medical assistance in dying (MAiD) was legalised in 2016 for people with “grievous and irremediable medical conditions” with assurances about its narrow scope. Today, that definition has been interpreted to include a person with severe sensitivities to chemicals unable to access appropriate housing from the state, and there have been reports of officials promoting assisted dying to people with disabilities applying for government assistance and medical professionals trying to coerce people into it. A parliamentary committee has recommended MAiD should be extended to some sick children and it is set to be expanded to people with chronic mental illness. In the Netherlands, euthanasia is an option for people who are autistic and lonely and is about to be extended to children of all ages. In Oregon, where the law has remained more stable, terminal conditions today include arthritis and anorexia.
Proponents argue adequate safeguards are possible; the latest House of Lords bill proposed certification by two doctors that someone has the capacity to decide to end their own life and has done so without coercion or duress, signed off by a high court family judge. But this dissolves on scrutiny. Medical professionals are not trained in or necessarily any good at detecting coercive control; judges will have limited evidence to make their own call. In the family courts, judges can fail to detect coercive control even when confronted with detailed evidence about intra-familial relationships. Narcissistic abusers can be highly adept at fooling professionals. What level of outside influence is considered too much, how is it measured, and how sure must a judge be, given life and death is at stake, surely rendering the balance of probability evidentiary threshold usually applied in the family courts inappropriate?
In the House of Lords debate, there was a marked failure to engage with these detailed concerns. Some claimed there is no evidence of problems abroad, as if coercively influenced wrongful deaths would magically reveal themselves after the fact. One only need look at the fight to reveal the true number of hidden homicides of women by their abusers to understand the naivety in that and, in somewhere like Oregon, the system is simply not set up to catch wrongful deaths. With brutal utilitarian honesty, former supreme court president Lord Neuberger acknowledged there would be abuses, but argued the benefits for those acting autonomously would outweigh them.
We live in a social media-driven world characterised by excessive moral certainty, in which powerful individual stories that invoke strong emotions can dominate the discourse to the detriment of the voiceless. There is a real risk that a law gets passed without any of these devastating concerns being addressed. Assisted dying is not a right-left issue, but it garners more support from MPs on the left, including Keir Starmer, and a Labour government might feel under pressure to introduce big reforms that don’t cost money given its self-imposed fiscal constraints. That is why voices like Streeting’s and Sturgeon’s are so important; we desperately need politicians willing to acknowledge that assisted dying is one of the most complex and fraught ethical questions they will ever be asked to confront.
• Sonia Sodha is an Observer columnist
