Jonathan Renouf

Yesterday the States Assembly voted 32-14 to set up an Assisted Dying Service accessible to people who have a terminal illness. The proposal to extend the service to those who do not have a terminal illness but have “unbearable suffering” was rejected 27-19. It was a very difficult decision for me, but in the end I voted “pour” in the case of terminal illness and “contre” in the case of “unbearable suffering”. Many, many people have written and spoken to me about these proposals, and so I thought I’d put a version of my speech in the Assembly on this website, for those who would like to know more about the reasons why I voted as I did.

Assisted dying speech

I want to start by thanking all those who have got in touch – both with me personally, and with all States members – to share their thoughts. It has been incredibly informative and helpful to hear a wide range of views and be provoked to consider the questions raised by the Proposition from many different angles.

I also want to thank the officers who have developed and guided these proposals with exceptional patience and calmness.

I’d like to thank to the Health minister and previous ministers who have developed these proposals, and lastly my thanks to all those who have spoken in the debate so far.

Public opinion

My first point is that I am satisfied that it is clear from public consultation that there is strong support in the island for assisted dying – in principle. Put another way, not a single survey or poll has shown majority opposition to assisted dying – not even close to that. That is my starting point, and I make that point notwithstanding the volume of correspondence we have had from opponents. I am struck by the number of people who I ask in casual conversation who voice an opinion that “of course” they are in favour. 

However, even if it is right the public at large does support assisted dying, that does not get us that far. We have before us detailed proposals, and whilst they need to be assessed in the light of public support for the principle, that does not guarantee that these particular proposals should be voted through. We still have choices to make. So let me say where I stand.

My speech is on the theme of balancing risks. There are no absolutes here, there are balances of rights and risks.

Route 1 – Terminal Illness

I believe that on the balance of risks, we should support Route 1.

My reasons are that it can be tightly drawn, restrictive in scope and clear in implementation. I take note of the moral objections, passionately made, but I am of the view that they are outweighed by the case for allowing those who face an agonising end to their lives to have a way out of their own choosing. No one who is morally opposed to assisted dying need participate – either by choosing an assisted death for themselves or by assisting someone else’s death. 

Neither do I think the so-called “slippery slope” arguments carry much plausibility in the case of Route 1. The metaphor of a slippery slope is clear; it implies a loss of control, an accidental or unintended extension of the right to die. But Route 2 cannot happen by accident. It cannot happen- as the Solicitor General has made clear – by judicial command. It cannot happen out of sight. If we are to go to route 2 in the future, it will only be possible after a debate in the Assembly. And if this debate is anything to go by, it will be preceded by the fullest and most careful consideration.

There are arguments against Route 1 but this is where I think the question of balance comes into the equation. 

One argument is that health professionals are opposed and there are divisions in the medical community. But society is divided on this, so it is not surprising to me that medical staff have different views as well. Those differences of opinion within the medical community should not be a veto on these proposals.

The main argument used against route 1 is that safeguards might fail. To take one example; it is argued that it is possible a terminal diagnosis could be in error. Indeed, in theory, it could. But the argument that a terminal diagnosis could be in error does not mean that it is a realistic possibility in cases where assisted dying is being requested. 

Two different diagnoses must be given, with the 2nd one being given by a doctor independent of the first one, and without seeing the assessment of the first one. These diagnoses will be being made within 6 months of expected death (or 12 months in the case of some neuro-degenerative conditions): if there is uncertainty about whether death is more than 6 months away, then assisted dying will not be possible. 

There are exceptionally rare circumstances in which people have been told that they have a limited life expectancy, who end up outliving the projections. However, these are not likely to be relevant in the case of requests for assisted dying. Once you get within 6 months or less of death, the range of possible outcomes shrinks dramatically, and the certainty of death and the accuracy of predictions about its timing becomes greater. Deputy Howell gave examples of people who have been wrongly diagnosed. But those cases were not diagnosed in the context of assisted dying. They weren’t subjected to the kind of intensive analysis that will be required under this proposal. 

What is more, it is clear that people do not choose assisted dying simply because of a diagnosis. As one doctor writing in Jersey put it, the urge to live is very strong. People do not take up the option of assisted dying unless they are in great pain. And that happens close to the end. When the diagnosis is all too certain.

Given all these circumstances, I do not think that in reality there is likely to be any case where someone goes through with assisted dying who was not actually terminally ill and close to the end. So there may be a vanishingly small possibility of a mistake. But that has to be balanced against the other side of the equation – namely the pain that will be caused by denying assisted dying to those in desperate need. 

For some opponents of assisted dying, there is no “other side of the equation”, because there is no circumstances in which choosing an assisted death is morally justifiable. I respectfully disagree. We do have to balance these two sides, and when you do, the balance seems to me to lie with allowing people in desperate pain the chance to choose the time and manner of their death. 

Route 2: Unbearable suffering

However, I do have reservations about Route 2. I return to my point about the balance of risks. 

Route 2 is more complex and the balance is much harder to weigh. 

There is a potential for slippage. The exercise of one person’s freedom of choice could have wider implications for society in terms of valuing lives, for example people living with severe disabilities. As Deputy Bailhache said, the ethical review (which came down against Route 2) is relevant and important in this context. 

But the other issue that weighs on the scales is the issue of safeguards. Route 2 opens up exceptionally complex cases. The design of an assisted dying service that offers Route 2 is therefore going to be complex, requiring considerable effort and resource and many difficult judgements. 

I have to say that there is an interaction here with the issues of clinical governance and clinical standards and resources that are currently affecting the department and the minister’s response to them. I could go into that in more detail, but members will I think understand the issues to which I am alluding.

It will take a lot of effort to develop the processes for Route 2. Exceptionally complex moral and practical issues are brought into play. I worry that including route 2 may stretch the process of designing the service at a time when the health service is already under pressure.

In summary, I would rather all the effort went into getting route 1 right. I also have in mind that we will retain the right to amend the law in the future if it becomes clear that the need is strong.

Given that there are significant and well argued risks around route 2, I ask myself, what is the greatest risk if we do NOT pass Route 2. That risk is clear: it is that some people who are not yet dying but are suffering pain they regard as unacceptable may find themselves unable to access AD. We’ve all heard from at least one person in this category in the run up to this debate, and it is an agonising choice. I try and put myself in that position and I strongly suspect I would want a way out.

But again, we must weigh the risks, however hard it seems. Because this is not a decision that can be taken on its own. We have to consider what impacts one person’s freedom will have an impact on society as a whole – even though the outcome of those deliberations may be to deny assisted dying to some who desperately want it. It is an agonising dilemma.

On one side is the view expressed most powerfully by Deputy Doublet, that we have a duty to ensure those in pain do not suffer. However, I note the view expressed by a practitioner of assisted dying in Australia who addressed a meeting for States members some while ago, who said that the hardest thing she had to do was say no to someone who wanted to die because they didn’t meet the criteria. In other words, we have to accept that we cannot satisfy all the demands for assisted dying. 

Even if we pass route 2, there are categories excluded who would like the choice. Indeed, even under route 1, some people will be turned down who may feel they should access assisted dying. We cannot end all suffering. 

What kind of society do I want to live in, the Dean asked? One where terminally ill people in great pain can choose their own exit. As I’ve said, in the case of Route 1, I think the balance is clearly in favour. Unbearable pain is much less clear. I note that the jurisdictions with the rules and regulations I most respect, such as different states in Australia, have assisted dying that aligns most clearly with route 1 and do not allow route 2.

Conclusion

The tightly drawn criteria in route 1 seem to me very hard to abuse. However, route 2 is complex. Therefore, the cautious, risk averse option is to set up the assisted dying service and make it work with the simplest, clearest cases first.

When I was younger I did a bit of climbing – badly. But one thing I realised was that in climbing when you make a move it is a good idea to make sure of your footing before taking the next step. Let’s take the first step to Route 1, and then get our feet on firm ground. Find a secure footing. We can always move forward again. The balance of risks suggests that route 1 is clear, route 2 has too much uncertainty.