Sir Graeme Catto on allowing terminally ill patients to die with dignity
Over the years Sir Graeme Catto has cared for patients who have opted not to have lifeprolonging treatment and in doing so have taken some control over the end of their lives.
While dialysis could help sustain the lives of the kidney disease patients he cared for some ultimately decided that their suffering had become “intolerable”. On the few occasions this happened, there was a lot of “soul searching” among the doctors and nurses working in the unit, Catto recalls. But they respected the patient’s right to choose to discontinue treatment – effectively ending their life.
In 2010, Catto – whose career biography includes respected roles such as Emeritus Professor of Medicine at the University of Aberdeen, President of the College of Medicine, former Chief Scientist to the Scottish Executive Health Department and a former President of the General Medical Council – accepted an invitation to serve on the Falconer Commission on Assisted Dying.
The commission was set up to consider the current legal and policy approach in England and Wales and spent around 12 months hearing evidence, consulting experts and studying practices in other countries before concluding, in a report published in January this year, that the current legal status of assisted suicide is “inadequate and incoherent”.
Both of these experiences ultimately convinced Catto that there is “no good reason why society should frown on assisted deaths for those who were already terminally ill,” he says. He now supports and actively campaigns for a change in the law as the newly appointed chair of Dignity in Dying, an organisation that believes everyone has a right to a dignified death and states that “high quality end of life care should be complemented by the choice of an assisted death for terminally ill, mentally competent adults who meet strict safeguards and feel their suffering has become unbearable.” Over the years the case for assisted dying has been weaving between moving personal accounts of those who have argued that they would, if they could, take their own lives but because of the nature of their illness require assistance to carry out their wishes. Some have sought to challenge or clarify the current legal status of assisted dying through the courts and earlier this month it was announced that the case of locked-in syndrome sufferer Tony Nicklinson, who wants a doctor to be able to lawfully end his life, will be heard. Each case is unique and Nicklinson’s case raises its own ethical and legal issues.
While Dignity in Dying supports allowing terminally-ill adults the choice of an assisted death, its proposals would not apply to individuals such as Nicklinson who while severely disabled is not terminally ill. However, it does believe that as a society we are “better off facing up to these issues and hearing the arguments in full” and so the organisation welcomes the decision to give the case “a fair hearing” in court.
The “unresolved” legal and ethical status of assisted dying was one of the reasons given by the commission for evaluating the strengths and weaknesses of the legal status quo. It concluded that there is a “strong case for providing the choice of assisted dying for terminally ill people”. However, it also acknowledged that this issue can’t be viewed in isolation and stressed that if a framework for assisted dying that provides people with greater choice and control regarding how and when they die is to be implemented in the future then it must also protect vulnerable people from the risk of abuse or indirect social pressure to end their lives.
The commission’s members visited Belgium, the Netherlands, Oregon and Switzerland as part of their research, which Catto explains helped them to see for themselves the impact of established assisted dying legislation.
“There was a huge amount of evidence from other countries where this kind of legislation has been in place for about 15 years in Oregon and for more than a decade in Holland and Belgium. So there is a lot of evidence about who goes for this and whether there is a ‘slippery slope’ and there is no evidence for any of these scaremongering stories. There is simply no evidence at all for it and indeed what evidence there is, is against it.” On the contrary, those who opt for assisted death tend to be “feisty, independent-minded individuals,” Catto says.
“They may be vulnerable in a physical sense because they are terminally ill, but they are not in any way mentally vulnerable. They are quite strong minded.” Furthermore, he says the number of people seeking an assisted death in these countries has not dramatically increased and actually only represents a very small proportion of deaths, which he says is in the region of a fifth of one per cent of all deaths. And yet having the legislation in place actually provides the population with “a huge amount of reassurance that this exit is available to them if life becomes absolutely intolerable,” he says, adding, “so they get the reassurance without necessarily taking up the offer.” In such countries assisted dying is just one of the options openly discussed when a diagnosis is given and patients are told that they have a limited amount of time left, he explains.
“If this were to be considered in the UK, it needs to be as part of a policy on end of life care. It is not instead of, it is part of. That has been true in the other countries as well and palliative care has improved inordinately in those countries that have assisted dying.” Each of the countries that have opted for some form of assisted dying have “absolutely no plans whatsoever” to change the legislation, he says, adding that there is “huge public support for it however controversial it was at the time.” There is also strong support amongst the British public for assisted dying, Catto points out. A 2010 British Social Attitudes survey found that 82 per cent of the general public believe that a doctor should probably or definitely be allowed to end the life of a patient with a painful incurable disease at the patient’s request, while analysis of the results showed that 71 per cent of religious people and 92 per cent of non-religious people agreed with the statement. However, Catto says he is also aware that the minority who are not in favour remain “vociferously” opposed, and so he acknowledges that this is a sensitive issue that must be handled with care.
He also accepts that the political will to change the law on assisted dying is still some way behind public opinion. While he personally believes the law should be changed north and south of the border, he admits he is “not overly optimistic that that is going to happen in the short term.” He continues: “I don’t expect there to be a sudden change in legislation in this country but I think with the continual dripping effect of these cases keeping coming up, an educated population will increasingly realise that this is available in other countries and as people see what happens at the end of life they will want something different.” Catto says he is “really pleased” that Independent MSP Margo MacDonald has decided to try again to progress end of life assistance legislation in Scotland as it will give the Parliament another opportunity to debate and consider the issue objectively.
“I hope that they will look at the evidence that does exists.
Opinions are free but there are some facts around this.” While he remains hopeful rather than optimistic that the Bill will succeed, he says it would be “enormously influential” for the rest of the UK if the new intake of MSPs chose in a free vote to support the legislation.
“I think it would be enormously influential for the rest of the UK. I personally can’t see any particular downsides. I do understand that there are a group of people who will not want to participate in this who will feel very strongly against it, but of course there are others who are precluded from going for an assisted death because of the way the law stands at the present time. So I personally think there would be huge advantages for individuals in Scotland were this legislation to go through. I hope that is what happens.” Catto says it is “beyond me why we can’t just allow people to make up their own minds.” However, while his is a respected and influential voice that adds weight to the case for assisted dying, he argues that ultimately this is a choice for society.
“I think one of the reasons I have become involved, and perhaps why people think my views are of some relevance to this, is that very often doctors are said to be against it.
“I want to try and change that balance to show that actually, many doctors are evenminded about this; but it needs to be a decision for society and not for medicine.”