12 hours ago
Palliative care doctors on assisted dying: he's for, his boss is against
Here at the end of the train line on the west coast, nestled a few hundred metres from the beach, is where the sun sets on Britain and on life. The hospice in Weston-super-Mare could hardly be a better place to go: the bedrooms have doors onto a lush garden and there is even a specially adapted hot tub I would like to book.
But every week two of the palliative care doctors who work here, Fiona Chiplen and Adam Baker, are asked, 'Doctor, can you help me die?' Every week they are asked to do what is at present against the law, though maybe not for much longer. 'We got asked twice this morning,' Baker says.
We are sitting in a quiet room with multiple boxes of tissues: this building is a mix of sunniness and abundant tissue provision. This room has hosted many a difficult conversation but today it's a new one. Chiplen, a consultant in palliative medicine and Baker's boss, stands on the other side of the assisted dying debate to him. She is against, he is for.
For years these colleagues have agreed in private to disagree. Chiplen in particular is concerned that if she went public her views would have a detrimental effect on her relationships with her patients. Yet now MPs have backed the assisted dying bill, which is undergoing House of Lords scrutiny, they are willing to argue with each other, in public, in the most open, kindest possible way. This is to find a path through the 'polarisation', which Chiplen says doesn't help at deathbeds. 'We understand there's a huge amount of hurt on both sides of the law,' Baker says.
I ask how many dying patients they have each cared for. Chiplen has nearly two decades in the field, Baker three years, and both estimate 'in the thousands'. Chiplen says that when she began, 'I used to keep a list of all the patients I had cared for' in memoriam, but that became impossible. If they, with their jobs, and their respect for each other's decency and care, can't wrangle across the divide to make things better for everyone in a new British landscape with assisted dying then, Chiplen says, 'Who can?'
Chiplen, aged 48 and with a soft Scottish accent, was drawn naturally into palliative care. Her first complex ethical quicksand came as a junior doctor. 'We had to resuscitate somebody and it was successful but the person was paralysed from the neck down,' she says. 'Of course you try to help someone but it was really quite traumatic. It had a big influence on my view of resuscitation.'
Baker's entry into palliative care was more dramatic. At 35 he had spent seven years as an emergency medicine doctor, and says, 'It was all I wanted to do.' But he burnt out and says that 'a big part of that was a number of really horrible deaths'. Patients could die in corridors, they could die in the back of ambulances waiting outside. 'It's awful and no fault of the staff, who are some of the best people I've ever worked with,' he says. 'The system just has so much pressure.'
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One death he will never forget was soul-crushing. A woman's main blood vessel in her chest ruptured. Baker rushed to the sound of her emergency buzzer but a fellow doctor was already on the way out of her cubicle, telling Baker, 'I haven't got time for this.'
'It wasn't the fault of that individual,' he says. That doctor was being asked to prioritise in the most ghastly way. But for the moment of that woman's death to be low down on a list felt like a dehumanisation too far. He took a break from medicine and ended up rowing the Atlantic with his wife.
Out at sea he looked to the horizon, and to the depths, and his humanity was allowed to surface. He heard about a farmer who, dying in a hospice, had a visit from his favourite cow (at Weston-super-Mare they have had visits from every kind of pet, including a donkey). He cried at 'how beautiful' that was. He realised that, unexpectedly, hospices are the places where doctors have the time and focus to value human life at its richest. He explains that it is no contradiction that over time he has become more sceptical of the opposition arguments to assisted dying.
I ask them first to see if they can summarise each other's viewpoints. 'Interesting,' Baker says, and they both smile. 'I think Adam feels things are not equitable the way they are,' Chiplen says.
'We looked after somebody with motor neurone disease who was on a ventilator,' she adds. 'They were deteriorating, losing the ability to communicate, to look after themselves. They reached a point where they decided they wanted to have their treatment withdrawn. They were able to come into the hospice, where we withdrew the ventilator, made them comfortable, and they had a really peaceful death with their family around them.
'But another patient with pulmonary fibrosis, who was very poorly, didn't have that choice. We're able to help some people at a time they feel their life is no longer worth living, and we're not able to do it for other people.'
Baker nods. 'Those two cases that Fiona highlighted really summarised it for me,' he says. 'Two patients, both wanted to end their life, but I'm currently legally only allowed to support one. Both came into the hospice and their very opening lines were that they wanted me to help them die. One was by stopping their ventilation, which is entirely legal. And the other, their request would have required me to administer medication, which is illegal, and I would have gone to prison and lost my licence. And I do acknowledge that those are different in law. But the more I look at it, I struggle to see on a personal level the difference.'
Would the motor neurone disease patient have considered themselves lucky from this point of view? 'Quite possibly, yes,' Baker says.
'If we don't support assisted dying, we don't remove it from the equation,' he continues. 'It is available for British citizens but requires them to go abroad at a cost of over £10,000. So by not supporting our patients who might want to explore that, we just make it available to a small few who can afford it. That doesn't sit comfortably with me.'
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The 'slippery slope' argument also doesn't seem substantial to Baker. 'Some big characters in the public domain use that but this idea that you can't have a stopping point for consistency has been shown to be a fallacy in law,' he says. For instance, in the case of abortion our country has reached agreed time limits without too much angst.
What is Chiplen's main argument, I ask Baker. 'I think Fiona's concerns would be that people are exploring an assisted death because the money that should be going into palliative care isn't being made available,' he says.
She nods. She is not so extreme as to say that this would take away all those wishing for help to die. 'I know one view put forward is that if only everyone had access to good palliative care, no one would ever request an assisted death,' she says. 'I don't think that's necessarily the case. I would a hundred per cent acknowledge that there are people who are distressed no matter how much we do. But I do think that people's unmet needs contribute to their wish to die.'
She remembers another patient with motor neurone disease who, earlier on in her illness, talked to Chiplen about various milestones ahead that she felt would be completely unbearable, such as becoming incontinent or being unable to feed herself. 'And what was very humbling to see was that she reached those milestones where she had said, 'Life will be intolerable to me,' and yet it wasn't and she continued to find joy,' she says.
This, for Chiplen, is a broader point: that some patients underestimate how much meaning they can find even when they are touching distance from death, 'whether that's somebody who's very poorly and bedbound or not. All people have value.'
In the assisted dying bill patients must be judged to 'have capacity' to make the decision. She is concerned that patients would end their lives prematurely, worried to leave it too late and thereby be deemed too sleepy or confused. She also worries about those with depression, whose mental capacity may be muddled.
Neither Chiplen nor Baker pretend that the other's points are simple to fix. They are now writing a book together on how thousands of dying patients can lead them to differing, and caring, viewpoints. I ask Baker whether this is partly a cost thing: is assisted dying cheaper than remedying our failure to offer everyone good end-of-life support? They both agree that palliative care — and their own hospice — struggles for funds.
'There are powerful financial arguments that are used to argue both sides but I might separate that from the patient experience,' Baker says. 'I've had so many conversations with people that want to talk of wanting it to all be over. None of them have ever come to me and tried to present that as a cost-saving equation.'
If or when assisted dying becomes legal, will it feel difficult for Chiplen? 'It will feel really jarring,' Chiplen says. 'At the moment we have clarity. We are not allowed to do anything to hasten death. But when you look at other countries where assisted dying becomes legalised, I'm slightly shooting myself in the foot here, but there does tend to be a shift in acceptance.'
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In New Zealand assisted dying came into effect in 2021. Many hospices opted out of offering it for ethical reasons. Chiplen cites a study in the journal BMC Palliative Care in 2023, where one New Zealand medic argued that this opt-out was patronising: 'The organisation says we believe that people should have a good death, but only as we define what a good death is.' Chiplen and Baker agree that palliative care specialists should be the leaders on assisted dying, not some third party, as some have suggested. Her main fear is that the new system would not be funded enough to make it safe or compassionate.
'I'm fairly pragmatic,' she says. 'I would not judge anyone else for seeking assistance with dying and I can absolutely see why some people would go down this route. My role is to support the community we serve.'
Neither of them are religious. Could Chiplen imagine any scenario in which she would want assisted dying? 'This is a very personal view. My frame of reference is my family. I find it hard to imagine choosing to leave them a second earlier than I have to.' What if life felt intolerable? 'Tricky to know,' she says.
What about Baker? 'Like Fiona I worry about being public about this, as there's a lot of judgment about it, but yes, I can imagine considering it,' he says. He would like to die feeling as much 'himself' as possible.
Meanwhile, they both say their jobs make them savour life. Baker has been inspired into extreme adventuring, such as polar ice swimming. 'It made me aware of my own mortality,' he says. 'Like a lot of people I thought, that will never happen to me. But we see people on the worst days of their life, when things happen very quickly. One minute, one week, they're well, and the next, they're here for end-of-life care. Nothing's given. I'd not necessarily be so clear on that if I didn't see it every week.'
Chiplen is not, she says, doing any polar ice swimming. 'Sometimes this job puts pressure on you,' she says. 'Time's precious and you've got to make the most of it. But we all have to still put on the washing and get the kids to school. I try and just find joy in the little things every day.'
