The Lancet is one of the world’s leading medical journals. But some of its most influential publications are reports by its “Commissions” for policy makers. These are white papers by experts which identify the most pressing issues in science, medicine, and global health.
With the Covid pandemic and a global push for the legalisation of “assisted dying”, its latest report, the “Lancet Commission on the Value of Death”, could not be more timely.
Its scope is vast – from a survey of philosophical and theological views of death to the sociology of “death systems” to economic and technological pressures to medicalise death.
But its overarching theme is that health and social systems around the world are failing to give appropriate, compassionate care to people who are dying and their families. Today’s overemphasis on aggressive treatments to prolong life, vast global inequities in palliative care access, and high end-of-life medical costs have led millions of people to suffer unnecessarily at the end of life.
The Commission calls for public attitudes to death and dying to be “rebalanced”, away from a narrow, medicalised approach towards a compassionate community model, where communities and families work with health and social care services to care for people dying.
“The COVID-19 pandemic has seen many people die the ultimate medicalised death, often alone but for masked staff in hospitals and intensive care units, unable to communicate with their families, except digitally”, says Dr Libby Sallnow, palliative medicine consultant and honorary senior clinical lecturer at St Christopher’s Hospice and UCL (UK) and co-Chair of the Commission.
“How people die has changed dramatically over the past 60 years, from a family event with occasional medical support, to a medical event with limited family support. A fundamental rethink is needed in how we care for the dying, our expectations around death, and the changes required in society to rebalance our relationship with death.”
On the whole, the report is a thoughtful, wise and compassionate document. Again and again, it returns to a central theme, that “Death and dying must be recognised as not only normal, but valuable.”
What about ‘assisted dying’?
However, to its great discredit, its authors have refused to exclude “assisted dying” — its preferred term for assisted suicide and euthanasia — from end-of-life care. Most of the commission members were either neutral on the topic or supported it. The sections dealing with “assisted dying” and advance directives were written not by a doctor but by a sociologist, Professor Celia Kitzinger, of the University of Cardiff. Her specialties are feminism, homosexuality, and conversation analysis. Back in 2006 she made a splash in the British media when she contracted a same-sex marriage in Canada and attempted unsuccessfully to have it recognised in the United Kingdom. She is an unusual choice for writing what is possibly the most controversial section.
In fact, most of the report undermines arguments for assisted suicide and euthanasia. It emphasises that pain is seldom the reason for requests for “assisted dying”: “a sense of burden and a loss of meaning drive the pursuit of an assisted death, rather than unbearable physical symptoms. A ‘sense of aching loneliness,’ the ‘pain of not mattering,’ and a sense that their ‘life story has ended’ influenced the wish for death to come sooner.”
But it points out, “new relationships can counteract loneliness and suicidal thinking”. It envisages a “realistic utopia” for death in the 21st century in which death is more relational, in which each dying person is surrounded by a “network of care”, in which though “not always welcome, death has inescapable purpose and value”.
This is the philosophy of palliative care, but the report talks more about “assisted dying”, advance care planning, and advance directives than about the future of palliative care.
Looking into a crystal ball
It is hard to escape the impression that this report, so impressive in many ways, is preparing its readers for a future in which assisted suicide and euthanasia are the default choice for death, rather than palliative care.
A concluding section of the report is devoted to futurecasting. Five scenarios are described. The fifth is that “Assisted dying becomes a component of universal health care” in nearly all high-income countries and in many medium and low-income countries. It will be “available not only to those judged to be near the end of life but also to all people with unbearable suffering, those developing dementia, and those who are ‘tired of life’,” the report says. “It is tightly regulated but provided by many health-care professionals, including those working in palliative care, and in some countries up to a quarter of people die in this way” [emphasis added].
Those concluding words ought to terrify us. Let that sink in: one in every four deaths will be through euthanasia. What does that say about relationships and about doctors? It would be a complete transformation of medicine.
In such a future, palliative care is bound to disappear. The report emphasises how low funding for palliative care is on most governments’ priorities. If one in four deaths are “assisted”, will there be any funding at all?
Three years ago, the editor of The Lancet, Richard Horton, asked in an editorial: “How did it happen that palliative care lost the dignity debate?” His answer was, “Those in favour of assisted dying have portrayed palliative care as somehow antithetical to patient autonomy. According to this view, palliative care is conservative and paternalistic.”
This still holds. But there is another reason – that leading physicians and medical journals like The Lancet are too timid to say No to euthanasia and assisted suicide. They are willing to accept a future where the default way of dying will be euthanasia.