On Assisted Dying

Introduction
Today the House of Commons are meeting to discuss and vote on amendments to the Assisted Dying Bill, following which it will go to a Third Reading and then on to the House of Lords to repeat the same process.

This is not the first time such a bill has gone before Parliament and select committees have also given significant consideration to the merits and consequences of such a change in the law.

I am writing this post to set out how I intend to vote and the argument/process involved in arriving at that conclusion. At various points over recent months journalists have asked me how I would be voting, but I have been unwilling to give them a response, foremost because I was genuinely still weighing up the different considerations, but also because I do not believe that with such a complex issue a simple ‘for’ or ‘against’ can really summarise our whole view of the topic, even if that is the only response the Bill will ultimately leave us.

The vote today will be a free vote and consequently there will be no attempt by any party to set out how an MP should vote on the issue. While MPs should always be open to voting against their whip where an issue is a matter of conscience, it does underline the fact that this is a decision we have all had to come to independently, approaching the decision in our own way.

For me, the starting point for most issues is to begin with the fundamental principles at their most basic level before going on to the more practical questions. In this case those fundamental principles are ultimately ethical ones. I should be clear that I do not mean personal morality based upon religious belief. While faith can add enormous value to the life of an individual, in a secular multi-religious society we simply cannot use the beliefs of any one person or religion to define the rules of that society. Instead we need to work from basic concepts to try to establish the ethical principles upon which a society is built.

Truth be told, I had thought that making up my mind on this would be easy. Assisted dying has always seemed to be the next great liberal reform and having been successful in the Private Member’s Bill ballot, I had considered proposing the bill myself, only being put off by knowing that I was too far down the list for there to be sufficient parliamentary time for full consideration of the bill. The issue of parliamentary time is something I will return to towards the end of this post.

In the process of considering this issue I have changed my views on what the right thing to do is, and the reason for doing so, more than once. In coming to a view, I have read through correspondence from Crawley constituents which have, in roughly equal number, argued the merits of both sides at length, from a range of perspectives, and often with heart-breaking personal stories about those they have loved and lost. In addition, I have benefited from access to information from campaign groups, expert panels, and extensive research. In my own independent research there are several sources I have made particular use of: the Stanford University’s Encyclopaedia of Philosophy, Open University’s The Reality of Assisted Dying: Understanding the Issues, and the final report of the House of Common’s Health and Social Care Committee inquiry into assisted dying/assisted suicide.

Ethical arguments
At its core, the ethical argument in favour of assisted dying comes down to two principles: personal autonomy and the minimisation of suffering. Whereas the ethical argument opposed to assisted dying is essentially the notion of the sanctity of life.

Personal autonomy is the belief that we should have control over our own lives and be able to live them the way in which we choose. It considers that as we are all individuals capable of making up our own minds, so long as our actions do not harm others we should be free to take decisions for ourselves. This desire for personal freedom appears to be intrinsic to humans and may be seen to reflect the nature of mankind prior to the existence of the state. It is therefore for those proposing limitations upon that right to set out sufficiently strong arguments to justify their imposition.

In the context of assisted dying, the autonomy-based argument is that as we all should have control over our own lives, part of this is having the right to decide how and when those lives will end. Where people don’t have the capacity to end their lives themselves or to do so without unreasonable suffering, there is a duty upon the state to help to enable them to do so in order to maintain that personal autonomy.

As a liberal democracy, the UK largely accepts the general principle of personal autonomy and expects that in most circumstances it is up to the individual to decide what happens with their lives. However, aside from a few extreme libertarians, very few people would accept an unlimited right to personal autonomy.

Indeed, we face extensive restrictions on what we can and cannot do. Most of these restrictions are to protect others from our actions and so can be considered a requirement of protecting the personal autonomy of others. However, there are still areas where we limit personal freedom, even where those individuals are fully aware of the consequences of what they are doing.

For instance, we might argue that two willing participants should be permitted to duel or that all restrictions should be removed around the consumption of all drugs and potentially lethal substances. We might in both of these cases say that the justification for the restriction of personal autonomy is the wider social consequences which emerge from such patterns of behaviour, but there are few decisions of any kind, particularly those dealing with life and death issues, which do not come with significant wider social consequences.

Perhaps more importantly, while suicide is no longer a criminal offence in the UK, society and the state not only discourage people from taking their own lives, but go to considerable lengths to intervene and to try to prevent individuals from being capable of doing so, including through physically restraining people and putting them into environments where suicide would be very hard to achieve. In so doing we massively infringe those individual’s personal autonomy.

We might seek to justify such a scenario by saying that such individuals are not of sane mind, but if the basis upon which we are making such an assessment is that they are not sane by virtue of desiring to end their lives then that poses problems for assisted dying.

The presence of a terminal illness may be viewed as presenting a rational argument for wishing to end suffering, although it would be hard to claim that anyone who seeks to end their own life is not suffering from pain they believe to be intolerable and enduring, the existence of those who are legally eligible for assisted dying overseas but who do not choose not to exercise such a right suggests not everyone in the same situation views assisted suicide as the rational approach. Indeed there are many disabled people who are deeply concerned with the corrosive connotations of the idea that conditions that they live with day-to-day–admittedly without a terminal illness–are considered by wider society to provide a rational basis for no longer wishing to live.

Nevertheless, even if we do not accept as a society that personal autonomy is the overriding consideration in all circumstances, it does not automatically follow that there is sufficient justification for personal autonomy to be overridden in this particular set of circumstances.

The second ethical principle in support of assisted dying is the desire to minimise suffering.

At the centre of this principle is the belief that humans owe a duty of care towards one another’s wellbeing, that humans would generally consider suffering to be a bad thing, and that therefore we have a duty to help others to avoid suffering.

In the context of assisted dying we would therefore say that if someone is suffering sufficiently that they want to die, that there is a duty for society to help bring an end to that suffering by helping that individual to end their life.

There will be those who argue that we don’t owe a duty of care to one another or only in so far as a ‘negative right’ that we do not do something which harms others rather than a ‘positive right’ that we actively work to improve their wellbeing.

However, as a social species, a sense of obligation to one another appears to be hardwired into us, starting with support for members of your family unit, then your community, and from there a more general obligation. Ultimately, our success as a species and the best prospects for the survival of all individual members stems not from some Darwinian survival of the fittest, but in humans investing in one another so that when they are in need they receive reciprocal support, enabling far more of us to survive any challenge through mutual support than even the most effective single member of the species could on their own. It is this network of mutual obligations from which enables the existence of a state and permits the level of specialisation upon which economies and other complex social structures can be built.

Of course, the extent to which people expect that obligation to be owed varies greatly (it’s essentially the difference of opinion defining our two main political parties) and it is possible to question how far that duty applies to assisted dying, although at least in the abstract seeking to minimise extreme suffering may well be the most basic empathic response we might expect from another human being.

The more interesting challenge to minimisation of suffering is what happens when there are several different alternatives as to how that suffering could be addressed. Is someone required to help to end suffering in the way that the individual affected wishes if alternative options may exist.

There are many people in our society who are suffering right now, some from physical pain, some mental, and some from a combination of the two, who are not affected by a terminal illness. While there will be those who will make the case that assisted dying is a more general right–a point I will return to later, most of the advocacy focuses on those with a terminal illness. Afterall, their lives are already ending shortly, so it seems less harmful. Of course, that doesn’t mean that people believe those who aren’t dying should be left to suffer, but instead we find ways to provide relief without requiring their death, regardless of what the wishes of the affected individual might be.

Yet, if in these cases we can find a way to alleviate suffering and meet the ethical requirements of minimising suffering regardless of the wishes of the patient, then presumably that would also apply in cases of terminal illness. The key word in that sentence being ‘if’.

On the opposing ethical side is the notion of the ‘sanctity of life’. While the term suggests an appeal to religion, it has a wider use in denoting the belief that human life has inherent value.

Whatever people’s religious beliefs, the concept appears to be universal, with every society having some notion that human life is inherently valuable and worthy of preservation, even at great cost.

Underpinning this is that same empathy that we feel for one another to end each others suffering, which drives people to make sacrifices to preserve one another’s existence. It is plausibly the most basic building block of human civilisation, enabling us to interact with one another safe in the knowledge that there is a universal taboo against ending human life. It can be found in the earliest sets of laws and in our own system it forms part of common law, predating all of our country’s written laws.

Of course, we can all think of countless incidences where individuals, groups and even states have ended lives, but just because it has happened does not in any way mean that people generally accept such actions to be right.

In our own system, our state also takes lives, but never as a goal in and of itself. A decision not to implement a safety measure due to cost may result in lives being lost as a consequence, typically with widespread criticism, but we do not view that as the state actively seeking to end life. There are also circumstances where deaths happen as a consequence of law enforcement or military action, but again killing is not the goal, but an unfortunate byproduct of other policy objectives, and rarely escapes condemnation.

Assisted dying asks the state to participate in the taking of life, something the Suicide Act currently views as a criminal offence. This will be the first time since the ending of the death penalty where the state would take on such a role and unlike the death penalty there are no wider considerations, i.e. the discouragement of others in seeking to commit crime, instead enabling death is the only objective.

It is true to say that doctors already help to end lives when it comes to honouring a DNR or withdrawing treatment, but in such circumstances they are not undertaking a positive action to take a life, but undertaking no action to safe a life. We already accept such circumstances as being different, we would not prosecute a person for manslaughter for failing to save someone from drowning in the way in which we would if they had pushed the person drownining into the water. This is a big shift from existing patterns of behaviour by the state.

From an ethical perspective, if we view life as having inherent value, assisted dying is prematurely ending an inherently valuable thing. Clearly, the quality of a life also matters, but in ending a life we are not improving its quality, quality as a consideration ceases to have any actual meaning for a life which no longer exists. To improve their quality of life we must improve the circumstances in which a person is living, not bring their life to an end.

People don’t have to believe any of this, but the idea of life having inherent value is a central notion to how most people approach the world, and beyond that how we expect governments to act. Once the taboo around the state ending life as a policy objective is removed, the potential ethical consequences are vast.

At a more minor end, it will affect how those involved in preserving life for those who are terminally ill see their treatment options, but at the more extreme end it does not take much for the arguments to be extended as far as eugenics.

If there is someone whose mental health condition produces unbearable suffering, or if someone is unable to physically enjoy the things we consider to be important aspects of life, on the basis of their suffering do we offer them assisted dying. Or those not able to issue consent, but where we reasonably believe them to be suffering without hope of it being addressed. What about where they are children? Or a disadvantaged group, whose life offers them little hope of joy in their lives, because society has deemed some genetic trait to disadvantage them?

When you remove clear natural ethical barriers, such as not taking human life, it is far harder to determine where we should draw the line. For our basic societal principles, the road from compassion to dystopia may well be far shorter than we think if we stop treating life’s inherent value as being a meaningful part of our law.

Terminally Ill Adults (End of Life) Bill
Before running through the most significant practical questions around assisted dying, it would be useful to be clear as to exactly what the assisted dying bill is proposing and what it is not proposing.

Assisted suicide is a process through which an individual takes their own life, but where this is enabled by others (the assumption is a medical professional), such as through by being given drugs to take or a button to control the release of a toxin intravenously. Euthanasia is where a person takes the life of another individual, this can be voluntary in the case of where someone has given consent or involuntary where no consent has been given. Assisted dying is a catch-all term used to describe both assisted suicide and euthanasia.

The Terminally Ill Adults (End of Life) Bill would permit assisted suicide in a limited number of situations and with a number of safeguards. The reason why we are using the term assisted dying rather than the more accurate definition of assisted suicide is due to the ongoing stigma against suicide, with concerns that this might prejudice people against the bill or be seen as encouraging others to take their own life.

Under the assisted dying bill, patients are explicitly giving their consent and are directly ending their own life, what the bill is doing is enabling others to help in that process.

We should be clear, that it is already legally permissible for doctors to administer drugs which might quicken the death of a patient under the doctrine of double effect. This states that so long as there is a positive medical reason to administer the drug other than the ending of a patient’s life, then even if it brings about a negative side-effect, including quickening the passing of a patient, it is legal to do so. Consequently, doctors caring for terminally ill patients are justified in using high doses of painkillers which will ultimately bring about the end of the patient, so long as they are doing so to address the pain rather than to end life, even if it helps to bring about that outcome.

This bill neither grants doctors legal protection for doing so, nor does it remove it, the protection of double effect will continue to exist in law no matter the outcome of the bill and it is not dealt with in this debate in any way.

The provisions of the bill are limited to adults with a terminal illness, whose condition means that they are likely to have less than 6 months left to live, and that the condition is not a mental disorder under the Mental Health Act (1983) or a disability under the Equality Act (2010). They must also have lived within England and Wales for a year and be registered with a GP in England or Wales. They must be capable of making the decision to end their own life, be doing so without any pressure or coercion, and have a ‘clear, settled and informed wish to end their own life’.

Medical professionals will be allowed to actively raise the option of assisted dying, but are not required to do so and if they feel unable to discuss it then they are required to refer the patient to another practitioner they believe would be willing to discuss assisted dying if that is what the patient requests. In such a conversation a medical professional must also discuss the diagnosis and prognosis, treatments and their effects, and palliative care options.

To trigger the assisted dying process the patient must make a formal declaration that this is what they want, witnessed by the ‘coordinating doctor’ responsible for coordinating the process and another person, and present two-forms of ID.

The coordinating doctor must then carry out the first assessment to check that the patient fulfils all the relevant criteria covered above, produce a statement to that effect, provide the patient with a copy of the assessment, and refer the patient to another registered provider for a second assessment.

A minimum of a week after the first assessment, the provider then undertakes a second assessment of the criteria, independent of the first doctor. Following both assessments, the patient can then apply to the High Court to determine if all the requirements of the law have been met. Should the patient be unsatisfied by the outcome then they can appeal to the Court of Appeal to make a determination.

The patient must then make a second declaration a minimum of 14 days after the court’s determination, repeating the same process of the first declaration. Following which, it is at this point a doctor who is satisfied that the criteria has been met can provide the patient with a substance to administer to themselves to end their own life.

Looking at countries which have already legalised assisted dying, if approved this would appear to be the most stringent process in the world for undertaking assisted suicide.

Practical arguments
There are many practical arguments both for and against assisted dying, of which I will try to summarise the key points which I have considered in taking a view, even if the list is not exhaustive. When discussing such a serious topic, and particularly when contrasted to ethical arguments, these often seem tasteless, but that doesn’t mean that they’re something we can ignore.

While it isn’t something I would have naturally considered, given that it has been raised in the course of debate around the bill, there is the question of cost. In many ways this isn’t directly relevant to the debate, particularly given that this isn’t a money bill and does not actually require assisted dying to be provided by the NHS, just provides the legal framework for it to do so.

However, it is very hard to imagine circumstances in which assisted dying would be more expensive to operate than the current system. Certainly there will be resourcing questions for the courts, but healthcare is incredibly expensive to the state and the greatest part of that cost is towards the end of people’s lives. The likelihood is that in people ending their lives early the system as a whole would actually save money, regardless of the costs of implementing the bill. Although, to my mind that would be an extremely poor argument for approving it.

More significantly, there is evidence that on balance it actually could lead to a better grieving process for families. While some of those involved in enabling access to assisted dying at present have experienced post-traumatic stress disorder, studies in countries which have already legislated for assisted dying have found that overall the grieving process can be improved, with explanations for this effect being the comfort derived from it being the outcome that the deceased wanted and the certainty around timing meaning that the loss has a less startling effect.

Beyond that there is a major system-wide argument for legislating on assisted suicide. While the Suicide Act is clear that a person is criminally liable if they aid in someone’s suicide, over the years the law changes in CPS guidelines and court rulings have departed significantly from the intentions of parliament in passing that act in the 1960s, ultimately enabling greater permissibility for people to aid people to access assisted dying. The back-door route to legislation leaves much to be desired in terms of clarity and lacks the democratic input provided by primary legislation, a new act dealing with the topic would help to address this.

Those are the key practical considerations in favour. The first practical consideration against, builds upon the last point.

While one can always make the ‘slippery slope’ argument apply in relation to any change in the law, in this case the scale of the shift is such that we need to consider how it may be interpreted in due course.

In the UK, we don’t really know what a law means in practice until the judicial system applies it to real world cases and, as already stated above, this can result in reinterpretation. One good example for this is the Abortion Act, which was similarly introduced as a Private Member’s Bill. Most people will probably be surprised to learn that in statute we do not have a general right of access to abortion, the right is limited to particular circumstances, with doctors required to make the assessment as to whether those requirements have been met. In law, access to abortion is an exception and not the rule. However, over the years they have been supported by the courts in reinterpreting the act into a general right of access.

Why is this a concern in this case? Because once passed, the safeguards in the bill are only as strong as the system chooses to enforce them. In the case of assisted dying, in countries with shared legal traditions to our own, people who are entirely physically healthy are now accessing assisted dying on the basis of self-defined intolerable suffering, in Canada this includes homeless people who are tired of being cold and hungry.

This is very hard for the courts to oppose. Mental and physical health are given parity of esteem in law and equalities legislation will struggle to maintain a limit on access to assisted dying to only those who have a terminal illness when the justification for that law is ending suffering which would otherwise continue until death. Arguably those without a terminal illness have to endure a far greater amount of suffering over the rest of their longer life. Once enacted, countries’ approach to legalising access to assisted dying have only ever become more permissive. If Parliament intends to enable greater access to assisted dying, then the bill should reflect that.

Furthermore, while the safeguards within the bill have been said to be the strongest in the world, and I have no reason to doubt that this is the case, the gulf between what is written on paper and implemented is significant. If we put aside the research showing that in existing assisted dying systems there is a wide-range of interpretation by professionals as to how the guidelines are to be followed, within the wording of the bill there are still grounds for concern.

The bill requires that doctors are sure that there is no undue influence on patients by others, but provides no clarity over how this is to be assessed, if it is possible to do so. Certainly, the increasing proportion of those over time accessing treatment in other countries who indicate that their chief concern is not wanting to be a burden on other people, suggests that this quickly becomes a significant factor.

Other issues with implementation of the bill, include that it is similarly hard to assess whether someone is in a clear state of mind to take such a final decision with no clarity over how this can be achieved, and that life-expectancy is fundamentally a matter of guesswork. I knew someone who received a terminal diagnosis in the 1950s and who I was still talking to in the 2010s. No doubt improvements in the profession over the following seven decades make such extreme cases less likely, but there are still many cases of people where the assessment was far wide of the mark.

So far, there have been no assessments of the efficacy of the drugs which are given to patients in other health systems. In the event of the bills passage this can hopefully be addressed prior to implementation, but until it has been it is worth noting that if the goal of assisted dying is to end suffering, then the suffering produced by the drugs must not be greater than that which might have been experienced through continued living.

The end result of this lack of testing is that patients can survive long after the administration of drugs, 137 hours in one case, which produces not only physical but mental trauma. A more harrowing example of this lack of testing is to be found in the administration of the lethal injection in the USA, where they recently had to change their formula having discovered that the sedative part of the drugs they administered was wearing off long before death, they failed to realise this was the case as the paralytic was effective, the end result was that a death which appeared peaceful to those watching was in fact the slow suffocation of a conscious prisoner.

Outside of the provisions of the bill itself the experience of other countries suggests that we should be concerned about the normalisation of suicide. Far from the claim that suicide rates would drop where people are able to access assisted dying, the overall rate of suicide has grown in countries which have made the change. No doubt there are a range of complex factors involved in this, but it is hard to believe that in making a national statement that ending a life early can be an acceptable course of action, that this does not affect wider societal views of suicide.

Palliative care systems have also declined in quality in every country except one which has implemented assisted dying and we should be concerned that once the option of an early death has been provided as an alternative to the slow process of dying without outside intervention, that it does not act as a reason to reduce support for palliative care, nor that people begin to see it as the default option.

Lastly, there is the question of the doctor-patient relationship. Dating back to ancient times, most famously the Hippocratic oath, we have held the notion that doctors’ sole duty was to health the sick and do their best to preserve life. With assisted dying we will for the first time be moving away from this and the question is how will this affect the doctor-patient relationship.

Will patients remain convinced that their medical professionals are doing everything within their power to help maintain their lives when they are also empowered to help end them? Professionals already report issues with trying to enable access to hospice care with patients unduly concerned that they may be given drugs to speed up their death without their consent in such settings, it is hard to believe that this will improve when doctors are actively helping to take lives.

Conclusion
While I have endeavoured to set out the various arguments for and against as I see them, I suspect that as the arguments gradually began to stack up on one side of the debate it is fairly clear to see how I now view the bill.

It is a decision I have wrestled with, but I have set out above the way I have worked to balance-out the competing arguments in my head in order to arrive at a conclusion. Some have suggested to me that if I find the issue so difficult, that I should remain uninvolved in the voting, but I really don’t think that is appropriate under the circumstances.

The burden of proof for implementing a change in the law always rests on the proponents, they need to convince people of the necessity of why that change is needed. For a legislator, if you are uncertain of whether a change is appropriate, then that case has not yet been successfully made, and you should vote accordingly. This principle is doubly the case when it comes to matters of life and death.

So, to summarise my position and the reasons for it. Of the two leading ethical arguments for assisted dying, autonomy and minimisation of suffering, I have outlined why autonomy has never been considered to be an unlimited right and consequently does not automatically entitle people to end their lives as a time of their choosing.

Minimisation of suffering is a stronger argument, but in all other circumstances we would not view ending a life as being an acceptable means of ending suffering and even with the terminally ill effective palliative care and the use of pain killers and medical sedation do provide alternative means of achieving the same goal.

Much as with autonomy, there are circumstances in which the state already does not hold the sanctity of life as trumping all other considerations. However, this would be the first area of policy since the end of the death penalty where ending a human life itself was the aim of the policy instead of a sad consequence of trying to achieve other goals.

In seeking to be compassionate, we risk opening ourselves up to far greater issues in law. Treating all lives as having inherent value is a central part of how society operates, when we remove this as a natural boundary we leave ourselves without a clear end point as to when the state will help to end lives, particularly as unbearable suffering is ultimately a subjective criteria which can be made to apply far beyond the terminally ill, all the way to justifying eugenics. We are already seeing this happen in legal systems built upon the same principles as our own where they have legalised assisted dying. Nothing in the legislation removes this risk.

When it comes to the practical questions, the arguments against instituting such a change begin to stack up very quickly. Whatever the noble aims of the bill and the attempts to establish safeguards, experience suggests that in practice what is set out on paper is not what is delivered on the ground, and that we will quickly move on to far more ethically questionable circumstances than the treatment of the terminally ill.

As a legislator I am being asked to not only take a position on the ethics of assisted dying, but the likely consequences of the passage of the bill, knowing that my vote–alongside those cast by my fellow MPs–will be determining a matter of life of death for an uncertain number of people. I have approached this question openly and attempted to learn as much as I can of the issues and implications of both a vote in either direction.

At the end of this process, I have come believe that whatever the good motivations of those proposing this bill, the ethical argument they have put forward exists only so long as effective palliative care is not delivered and that despite the carefully thought-out safeguards included within the bill, its implementation and the wider consequences will go far further than they have considered. On that basis, I do not believe that the case has been made for a change in the law, and I therefore believe I am obligated to oppose the passage of the bill through the remaining stages of the process.

Final thoughts
Whatever happens with the bill today, the correspondence I have received and polling around assisted dying suggests that the questions involved in this issue are of great significance to people and it was important that the debate take place.

Although I could not vote for the legislation at the Second Reading, given the level of public interest, I believe that it is important that it was able to receive detailed consideration at the committee stage, so that the pros and cons of the issue could be given the treatment they deserve.

While I believe that as a matter of conscience it was important that members be provided with a free vote, there are two unfortunate aspects to law being proposed as Private Member’s Bill rather than as a Government Bill.

The first is that Government Bills are drafted by a team of lawyers who are specialised in drafting legislation. Their absence from this process increases the risk that the bill is lacking in sufficient rigour for quite so monumental an issue.

The second unfortunate aspect is that Private Member’s Bills are granted very little parliamentary time for consideration. While the bill will still go through the same stages as any other bill, the overall time allocated for doing so offers far less opportunity for wider scrutiny than the overwhelming majority of UK legislation–although those serving on the Public Bill Committee have gone through the bill in far greater detail than almost any other legislation. Again, this risks unintended side effects, which might have been avoided if Government time had been allocated to the debate.

My last, and perhaps the most significant consideration in all of this, is that as a country we have to get far better at palliative care. This bill is being proposed in the shadow of a funding crisis in the hospice sector, with hospices closing or being scaled-back across the country.

If we are prepared to debate so significant a change in the law as enabling the state to end lives, then we must acknowledge that regardless of whether assisted dying is introduced, the palliative care system has to be capable of alleviating suffering to the maximum achievable extent.

At the most basic level this requires local NHS bodies to ensure that hospices across the country receive a financial settlement capable of sustaining their services, rather than constantly being squeezed-out by other priorities. Beyond that, a wider question over what resources and changes are needed to ensure that care pathways are capable of reducing suffering to an absolute minimum must now be a priority for decision-makers.