In 1978, after I had written several articles for medical journals in favour of what was then called voluntary euthanasia, I was invited to join the committee of the Voluntary Euthanasia Society (VES). Its founders in 1935 included the royal surgeon. The next year, during the first Westminster debate on the topic, the royal physician, Lord Dawson of Penn, said that there was no need for legislation because ‘all good doctors do it anyway’. 50 years later, his diaries revealed that he had euthanised the dying King George V with a syringeful of morphine (mixed, weirdly, with cocaine) straight into the imperial jugular. The injection was timed for late evening so that the announcement of his death would get into the next day’s Times but be too late for the lumpen press.
I remember saying at my first committee meeting that I would be pleasantly surprised if we managed to get the law changed in my lifetime. In the 1990s, the VES renamed itself Dignity in Dying (DiD) and sharply reduced its ambitions. For a year or so from last October, the DiD-sponsored Leadbeater Terminally Ill Adults (End of Life) Bill—the world’s most restrictive such bill, but better than nothing—allowed me to hope that I might have been wrong in my prediction. But the filibustering that doomed it in the House of Lords seemed to mean that unless the government stepped in or unless I became a centenarian, it looked as if my earlier prediction was to be proven right—until mere days ago when Lauren Edwards MP, a dea ex machina, won second place in the ballot for private members’ bills. She will reintroduce the Leadbeater bill, and parliamentary rules mean that the Lords will not be able to block it on its second journey. It is not yet a done deal because some MPs might change their votes, but things are looking promising, and even wavering MPs may want to stick their fingers up to their unelected colleagues.
We live in an age of euphemisms, so voluntary euthanasia, a perfectly good description, has been largely replaced with assisted dying or medical aid in dying (MAID). Personally, I prefer ‘medically assisted rational suicide’ or, better still, ‘deliverance’, but here I will stick with MAID. In the steadily growing number of countries where MAID is legal, palliative care physicians often eventually accept that it is a rational and appropriate option for some patients. Some foreign palliativists even provide it themselves, but in Britain, atypically religious doctors are over-represented in palliative care compared with other specialities and other countries. The large majority of British palliative care physicians have set their faces against any kind of MAID legislation. In 2019, the prestigious British Medical Journal published a letter from five senior palliative care physicians who supported legalisation. Almost unprecedentedly for British doctors of consultant grade, every one of them requested anonymity because they feared for their careers. In the 1960s, the abortion debate was just as heated and contentious, but no letter-writing consultant ever requested anonymity. Yet in Belgium, palliative care physicians were among the main campaigners for Belgium’s MAID legislation, introduced in 2002.
Among the people who were responsible for filibustering the Leadbeater bill to death in the House of Lords, the worst offender was probably Baroness Ilora Finlay, a professor of palliative care, who proposed 194 amendments. That is not a typo; one hundred and ninety-four. In the run-up to the debate on the Leadbeater bill, I corresponded with several palliativist opponents, including Finlay, partly to try to understand the reasons for their opposition but also to question the claims that some of them were repeatedly making in public, in medical journals, and in Parliament.
It was at a conference around 2017 that I first heard Baroness Finlay claim that death from barbiturates, the class of sedative drugs most commonly used for MAID, was not peaceful and could, in fact, be horrible because barbiturates caused the lungs to become full of fluid—a condition called pulmonary oedema—and thus patients experienced great distress while drowning in their own secretions. It turned out that this claim had first been made by three American doctors, the most prominent of whom was Dr Joel Zivot. He subsequently repeated the claim in a 2021 article for the Spectator. And Danny Kruger MP, a proudly evangelical Christian and a recent recruit to Reform UK (these things seem to go together), said the same thing, citing Zivot, in a letter to The Times around the same time. His mother, ironically, is Prue Leith, a prominent supporter of MAID.
Zivot based his claims on post-mortem examinations of five US citizens who were executed by a lethal injection of drugs that included a barbiturate named pentobarbital, one of the several barbiturate sleeping tablets prescribed for many decades to millions of patients before they were replaced by drugs that were much less lethal if used in overdoses for suicide attempts. Zivot is—commendably in my view—strongly opposed to capital punishment, but this may have clouded his judgement on MAID, which he seems to be opposed to.
He and his co-authors, in a 2022 paper making the ‘barbiturates cause pulmonary oedema’ argument, claimed that the post-mortem lungs of the executed offenders were full of fluid. But the enormous doses of pentobarbital that are used in such procedures cause profound unconsciousness in seconds when injected into a vein. Therefore, even if their claim about the fluid were true, which it isn’t, the executed men would be completely unaware of discomfort from pulmonary oedema—or, indeed, anything else. Unawareness is the purpose and effect of general anaesthesia, yet the three authors claimed that the offenders would experience severe distress as their lungs became waterlogged.
The fluid claim itself seems to me to be impossible for a number of reasons, even though one of the co-authors is a pathologist—i.e. the sort of specialist who does post-mortem examinations.
First of all, short-acting intravenous barbiturates were used for initiating anaesthesia and for short surgical procedures in millions of patients after they were introduced around the end of the Second World War until about 1980, when they were superseded by even shorter-acting intravenous anaesthetics. I worked in anaesthesia for a while, and as a psychiatrist who administered electroconvulsive treatment when it was widely used, I also administered the short-acting barbiturate anaesthetic that always preceded the application of electricity. I have personally given several hundred barbiturate anaesthetics and if they even occasionally caused the lungs to fill up with fluid, I would surely have been warned about it, but it simply does not happen.
Pentobarbital also remains the standard drug for veterinary euthanasia, with no indications that when we take our ailing pets for their final outing, they will suffer anything more than a needle prick. Furthermore, unlike Dr Zivot, I am old enough to have interviewed several hundred patients who had unsuccessfully attempted suicide with barbiturate sleeping tablets before they were phased out in the 1980s, and not one of them claimed to have experienced breathing difficulties before becoming unconscious. The usual sleeping dose of pentobarbital was 100-200 milligrams (1/10 to 1/5 of a gram). Pentobarbital has been the standard drug used for MAID in Switzerland for several decades. In suicidal overdoses, as little as 2 grams can be lethal, and 5 grams seems to be invariably lethal. Yet the standard oral dose for MAID in Switzerland is 15 grams—15,000 milligrams. After that dose is swallowed, patients fall asleep in no more than three minutes, and no patient at Dignitas, where oral barbiturates are the norm, has failed to die. When it is given intravenously, as it often is, the onset of unconsciousness is almost instantaneous.
Finlay and others who have spread Zivot’s claims gave the impression that they were quoting from a paper that had been published in a medical journal, whether peer-reviewed or not, but when I looked into it, I soon discovered that this was wrong. Like most papers that get as far as being submitted to a medical journal, many of them now appear automatically on a website, medRxiv, which makes it very clear that the paper ‘is a preprint and has not been peer-reviewed… It reports new medical research that has yet to be evaluated and so should not be used to guide clinical practice.’ (Emphasis in original.) The paper, in other words, seems to have been rejected before peer review or has failed the review process. It has never been published in any medical journal known to the vast PubMed library.
When I started emailing the authors and Baroness Finlay about these findings, the replies that I got, or in most cases failed to get, were very revealing. I first emailed Zivot with the points I’ve just made. He did at least reply, but all he said was ‘I have no comment’. His two co-authors did not reply at all. For the pathologist author, that was particularly surprising—and damning— because of an MRI scan study published in a medicolegal journal in 2011, well before the Zivot paper was written, which showed that pulmonary oedema is a very common post-mortem finding regardless of the cause of death, a finding separately confirmed to me by a former British coroner.
A simple question to an AI received the following answer: ‘Varying degrees of pulmonary oedema are an extremely common finding in autopsies, occurring in 50% to 80% of all post-mortem lung examinations. It is one of the most frequently recorded abnormalities in both forensic and clinical pathology.’ Even more damaging to Zivot’s claim is that pulmonary oedema does not appear until several hours after death unless the death was due to pre-existing lung or heart disease. In patients whose MRI scans of the lung within an hour of death were negative, pulmonary oedema was found when the MRIs were repeated five hours later. That is because in the hours after death, body fluids are redistributed for various reasons, including gravity. Blood, for example, pools in the lowest parts, causing a bluish-red colour that contrasts with the waxy whiteness of the rest of the corpse.
I therefore emailed Zivot and his pathologist co-author to find out exactly how long after execution their post-mortems had been done, because that was obviously crucial for their claim. Neither of them replied but their paper makes it clear that they were done no earlier than the day after execution. Yet in his 2021 Spectator article, Zivot wrote that ‘In 2017, I obtained a series of [five] autopsies of inmates executed by lethal injection, which confirmed my worst fears. [X’s] autopsy revealed that his lungs were profoundly congested with fluid, meaning they were around twice the normal weight of healthy lungs. He had suffered what is known as pulmonary oedema, which could only have occurred as he lay dying. [X] had drowned in his secretions. Yet even my medical eye detected no sign of distress at his execution.’ (My emphasis.) In reality, it was very clear by 2017 that the pulmonary oedema in this case, and the other four, could have occurred and almost certainly did occur several hours later. Zivot’s ‘medical eye’ did not detect any signs of distress because there was no conscious distress to detect.
Having failed to get any response from Zivot or his co-authors, I emailed Baroness Finlay, an experienced practitioner and professor of palliative medicine, with the documented medical evidence that I have just described and additional medical information, inviting her to answer whether she still supported Zivot’s claims. Her eventual and only response to that specific question was: ‘I cannot answer for Dr Zivot’. I replied: ‘I am not asking you to “answer for Dr Zivot”. I am asking you, as an experienced physician, either to accept that his claims cannot possibly be correct and to agree not to repeat them or to explain why you still support them, if you do. That was my main reason for writing to you and I regard your response as a refusal—like Dr Zivot and his co-authors—to answer my question’. As of 16 June , she still has not answered it.
Our legislators get rather touchy if they are accused of telling lies in Parliament. As well as his other achievements, Winston Churchill famously coined the euphemistic alternative ‘a terminological inexactitude’, which is apparently acceptable. I shall therefore accuse Baroness Finlay of no more than that if she repeats the claim in or out of Parliament, while leaving my readers to draw their own conclusions from her refusal to answer my simple question, even though I told her that I would report her refusal in this article. I sent the same information and request to Danny Kruger MP, but an automated reply informed me that he is a busy man, might take some time to reply, and is only obliged to answer people who live in his constituency, which I don’t. I pointed out that I was asking for a reply on a matter about which he had commented in The Times, rather than in Parliament. I am sure the Freethinker will publish his response if I receive it after this goes to press. No doubt it will also offer him, Baroness Finlay, and others whom I have criticised the right of reply.
I also had some correspondence with Dr Claud Regnard, another palliativist, who interested me because unlike many senior palliative care doctors, he claimed to be non-religious. He is a co-author of several papers in respectable journals whose main message is that the drugs most commonly used in MAID have not been specifically tested for the purpose. That is true but it is the equivalent of demanding new controlled trials every time a standard sedative or anaesthetic is used for a new procedure. I asked him, among other things, if he agreed that doses of sedative and anaesthetic drugs vastly in excess of normal could be relied on to cause rapid and profound unconsciousness. He refused to say, as did Baroness Finlay. He also refused to answer when I asked him if he supported Baroness Finlay’s claims about pulmonary oedema. Significantly, although I was clearly asking them for a public statement on a matter of some importance, both he and Finlay also said that I must not quote their emailed replies. Since they failed to reply to specific questions, that is not a problem.
I now want to examine what I strongly suspect is a powerful factor in the opposition to MAID, even when it comes from intelligent and thoughtful atheists like Douglas Murray and Kathleen Stock, namely, an atavistic horror of suicide that began historically as a mainly Christian phenomenon. During the debate that led to the decriminalisation of suicide in 1961, Lord Justice Denning said that ‘for nearly a thousand years suicide has been regarded as the most heinous of felonies … [because our religion] decreed that … to commit suicide was invading the prerogative of the Almighty, by rushing into His presence uncalled for…’ Until 1824, he added, ‘suicides were buried at a crossroads with a stake through their body and until 1882, a suicide had to be buried by night; and ever since 1882 up to this day, according to the law of the Church of England, a suicide is not entitled to Christian burial.’
This still is Catholic law but until very recently, both churches got round it by pretending that all suicides are not just mentally ill (which could mean anxiety or obsessive-compulsive syndromes) but so seriously mentally ill that they could not be held responsible for their actions. In a criminal trial, you have to be very mentally ill indeed to get away with that and be found ‘not guilty by reason of insanity’. Only in 2016 did the Church of England Synod vote—though not unanimously—for a change in Canon Law to permit an ordinary funeral service and burial even in cases of terminal illness and rational suicide.
It was not always thus. Although most of the opposition to MAID in Britain and the USA comes from Christian organisations and individuals, early Christianity, arising as it did in a Graeco-Roman world where suicide was widely regarded as an honourable choice in certain situations, had no strong views about suicide. Early commentators noted that all the several suicides mentioned in the Bible were discussed in neutral or even positive terms, and some of the early Church Fathers even regarded the death of Jesus as involving elements of suicide. The poet and novelist A. Alvarez also emphasises, in his classic personal and historical 1972 study of suicide The Savage God, that early Christianity did not generally or automatically condemn suicide.
More recently, The Rev. Prof. Paul Badham, an Anglican theologian, has argued persuasively that deliverance is not incompatible with Christian faith and principles (see his contribution to the 2015 book I co-edited with Michael Irwin, I’ll See Myself Out, Thank You: Thirty Personal Views in Support of Assisted Dying), and he has been joined by several other senior Anglican clerics, including the late Archbishop of Cape Town Desmond Tutu and Lord Carey, a former Archbishop of Canterbury from the Evangelical wing of the Church (to the obvious annoyance of his episcopal colleagues who insist on maintaining their medieval and completely undemocratic right to occupy 26 seats in the House of Lords). Furthermore, Lord Carey believes that the right to choose deliverance should include those, such as the late Tony Nicklinson, with locked-in syndrome and slowly progressive conditions such as Alzheimer’s.1
That tolerant attitude of early Christians changed when Christianity ceased to be a persecuted cult and became Rome’s state religion. Within a few decades, it set out on the path that eventually made it proportionally the largest and most enduring persecutor and slaughterer of religious and philosophical dissenters in recorded history. St. Augustine was the most prominent of the church leaders who decided that suicide was a worse sin than murder, because suicide not only meant leaving life before God allowed you to do so and without formal confession and absolution, but was also, in effect, an act of criticism of God—suicides did not accept the world that He had made. A suicide would thus be guilty of the sin of despair. In 562 AD, the Council of Braga denied funeral rites to all suicides. Before long, it was ordained that even attempted suicides would be automatically excommunicated.
This, I believe, was very much the view of the late Dame Cicely Saunders. She was rightly praised and honoured for her promotion of hospices and palliative care, and nobody who met her, as I did (we got on surprisingly well), can doubt her compassion, but she held the fundamentalist, or at any rate, post-Augustinian Christian view that even though suicide is not now a crime, it is still a sin. I heard her say so at a conference in the late 1980s. She wasn’t very keen on living wills either at that time, and her influence on British palliative care from beyond the grave remains very powerful. Given her background—an agnostic who experienced a sudden conversion to Evangelical Protestantism early in life—such views are not surprising. 64% of White ‘mainline’ US Protestants believe that ‘a person has a moral right to suicide when [he has an] incurable disease’ (as do 62% of White US Catholics), but that falls to 36% for White Evangelical Protestants and 34% for Black ‘mainline’ Protestants.
When Islam swept over the Judaeo-Christian world, it absorbed these Augustinian attitudes to suicide (and other things): ‘The Prophet said, “He who commits suicide by throttling shall keep on throttling himself in the Hell Fire (forever), and he who commits suicide by stabbing himself shall keep on stabbing himself in the Hell Fire.”’ (Sahih al-Bukhari 1365.) British surveys show that for most religions, even among those members who identify themselves as active participants, most or many support a change in the law, but there are significant differences along what should now be predictable lines. In a 2013 survey, support for the principle of MAID was 59% for Anglicans and 44% for Roman Catholics, but only 23% for Muslims and 6% for the Pentecostal Christian sects that flourish particularly in Afro–Caribbean communities.
It is tempting to think and hope that many ancient beliefs and prejudices have disappeared, but they are still there, lurking under a thin post-Enlightenment veneer. Superstitions remain very widespread and I find it difficult to believe that a millennium and a half of monotheistic demonising of suicide has left no mark. I do not share the Church of Freud’s privileging of the subconscious (or its belief that it uniquely holds the key to it) but that doesn’t mean that the subconscious doesn’t exist or isn’t important. Experiments in psychology involving something called Terror Management Theory show that even subliminal reminders of death can profoundly alter everyday responses, as well as more specialised ones like the sentences that judges impose.
In contrast, other major religions—Buddhism, Confucianism, Hinduism, Shinto—either encouraged suicide in some situations (e.g. the legend of the 47 Ronin) or at least did not routinely vilify the deceased, refuse conventional funeral rites for the grieving family, or ritually desecrate the corpse. Eastern Orthodox Christianity’s position was also very different from Rome’s and Canterbury’s. The Byzantine 6th-century Code of Justinian took a sympathetic view of suicides, provided that they were not trying to escape punishment for a crime. However, even in Japan, MAID is not yet legal.
Despite Christianity’s historical horror of suicide, until relatively recently it had much less of a problem with homicide. And here I am not only referring to Catholic Christianity and its Inquisition. In 1553, the celebrated Spanish physician and theologian Miguel Servetus, discoverer of the pulmonary circulation of the blood, was burned alive in Geneva along with his books on the orders of Jean Calvin because of a disagreement about the nature of the Trinity. A little over 300 years ago, a young Edinburgh student, Thomas Aikenhead, was hanged with the full approval and encouragement of the city’s Calvinist religious leaders for his blasphemous opinions. That was the last such execution in Britain, but similar manifestations of Christian morality continued in France until the 1770s and in Spain until 1826, the Inquisition’s last victim being a mere post-Enlightenment deist. In many Islamic countries, atheism is still a capital offence.
It both amuses and irritates me to be regularly lectured on the sanctity of human life by the spiritual descendants of Calvin and Torquemada2, not to mention Mohammed. Another ironic feature of religious opposition to deliverance is the way in which religious leaders who officially reject each other’s central doctrines and once fought murderous wars for supremacy now band together to obstruct MAID legislation.3 ‘Kill them all,’ said the commander of the first Inquisition’s forces when besieging a town that contained both Catholics and heretical Cathars. ‘God will recognise his own.’
- ‘Dear Colin. Thank you for your thoughtful email. Unhesitatingly I am fully with the argument you advance. [That legislation should include patients with early dementia who retain Mental Capacity.] Whilst I am a supporter of DiD I regard it as a step towards MDMD.…My change of heart was greatly influenced by Tony Nicklinson. With warm regards. George Carey.’ Personal communication, 20 August 2018. ↩︎
- ‘…the first official executions of heretics were recorded in 385 [AD]. They were followed by literally millions of other victims, and during its long reign as an established faith, Christianity claimed more violent deaths than any other religion. Indeed, no system of any kind has equalled the terrible record of persecution inflicted on infidels, pagans, heretics, witches and Jews through inquisitions, …through propaganda, harassment, imprisonment, torture and death by the Christians over a millennium and a half.’ From Nicolas Walter’s Blasphemy Ancient and Modern (1990). ↩︎
- For example, Islam rejects Christianity’s central claim that Jesus is the son of God and died on the cross. ↩︎
Related reading
The Right to Die: The Freethinker and the Assisted Dying Debate Over the Years, by Daniel James Sharp
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