Assisted dying can be a ‘gift’, says campaigning doctor who has helped patients die

Dr Ryan Spielvogel hadn’t spent a lot of time thinking about assisted dying before it became legal in California.

Only when the End of Life Option Act was passed did he give it some consideration. He could see how, in theory, offering assisted suicide could be considered “compassionate care”. But he still wasn’t certain.

Only after he’d helped his first patient to die did he become an “ardent champion” for it.

“My first patient was an intensely powerful experience for me, and it was very obviously important to him,” Spielvogel recalls. “He was so determined and clear in his decision, and why he was wanting this, and they weren't things that I could argue against. It was subjective, because suffering is subjective.”

The patient was an elderly man in his 80s, dying from a wasting disease. He was, says Spielvogel, an “intensely independent individual” for whom living out the last of his days bedridden was “his version of hell”.

They got to have this celebration of life for him while he was still alive... And that was the last day

“He didn't want to remember his life by his last moments, and he didn't want that to be how his family remembered him either. He wanted to go out on a high note.”

Spielvogel admits that had he been in the same position, he’s not sure he’d have felt the same. “But it wasn’t about me… And so, who am I to question his values?”

The man was a perfect candidate for assisted dying – he had the cognitive capacity to make the decision, was able to clearly articulate his reasoning, and had a terminal diagnosis. Spielvogel prescribed the assisted dying medication after their second session (by law in California a patient must request assisted dying twice) and the man died the next day.

When Spielvogel followed up with the man’s family later, his daughter described the experience as “beautiful”. Family and friends had gathered, and they had held a memorial while the man was still there to see it. That evening at sunset, his patient took the medication, drifted off to sleep, and passed away. Tears still come to Spielvogel’s eyes as he tells this story; the raw emotion still hits him eight years on.

“It was one of these moments where everything just seemed so clear. It was this paradigm-shifting, pivotal moment for me as a doctor, realising just how much of a gift this was to the patient… They got to have this celebration of life for him while he was still alive, while he could still participate, while he was still with it. And that was the last day. That's what their memory of him ends with, that beautiful day, instead of the long slog to death which otherwise would have been.”

Spielvogel, having now helped countless patients to die, has travelled around the world to share his experiences. This week he’s been in the UK, visiting Westminster, where Labour MP Kim Leadbeater’s Terminally Ill Adults (End of Life) Bill is being taken forward, and Holyrood, to support Lib Dem MSP Liam McArthur’s Assisted Dying for Terminally Ill Adults (Scotland) Bill.

The Scottish Parliament’s Health, Social Care and Sport Committee has already started its scrutiny of the proposals, and is currently in the middle of evidence-gathering. McArthur will be the final person to speak to the committee in early February, after which MSPs will deliberate the general principles of the legislation.

How the vote will go is unclear. There will be no party whips and MSPs will be free to vote with their conscience. Some of them have already announced their support, others their opposition. MSPs on both sides have highlighted concerns, including on the lower age limit, safeguards for disabled and vulnerable people, and the possibility of coercion.

At the end of the day the parliamentarians have to be comfortable with the bill

Some of the arguments against have been well-articulated by Labour’s Pam Duncan-Glancy. When the proposal was first lodged in 2021, she warned it would be “dangerous” for disabled people. “We need to make sure living is better for disabled people than death. That means properly funded care, accessible housing, equal access to health care and jobs and so on. My fear is that, bluntly, all of that costs more and the government haven’t committed nearly enough money to it,” she said. She has also voiced concerns about the definition of ‘terminal illness’.

Better Way, a campaign group calling for MSPs to vote against the bill, has highlighted other issues. Spokesman Dr Miro Griffiths says: “The proposed safeguards in Liam McArthur’s Bill could not prevent coercive control of vulnerable patients, which is often insidious and hard to detect. People would also feel pressure to end their lives when they can’t access sufficient support from the state. In a society that’s riven by inequality, assisted suicide would be a dangerous step.”

Beyond that, there are concerns about the possibility of the law becoming more lax in the years after it enters the statute books, thus widening the pool of people who are eligible.

But organisations in favour of a change in law highlight the first parliamentary vote is purely on the principle of assisted dying and later stages can address the above. Spielvogel says MSPs should feel “comfortable” with the legislation. “By and large, the approach from legislators [around the world] is to be on the more conservative side first, see how it goes, and then amend it to improve access... I think that's appropriate. I don't think there's anything wrong with that approach because if you go too far in one direction, that's not good either.

“I do think that at the end of the day the parliamentarians have to be comfortable with the bill.”

Asked what he believes the most important safeguards are, he says its beneficial to have two doctors working with a patient to ensure eligibility and provide support, and requiring more than one meeting with a doctor is likewise useful. He is less convinced about the need for a lengthy waiting time between those two meetings. California ended up reducing its own mandatory waiting period from 15 days to 48 hours after data showed several patients were “dying the deaths that they didn't want” in between time.

On the question of a lower age limit, he thinks this should be “culturally determined” – though he says he’s never personally seen anyone below their mid-20s access assisted dying.

As for concerns about disabled people, he argues the data shows this community is less likely to opt for assisted death. “The data is people who access assisted dying are by and large able-bodied – to the point that they're over-represented. If anything, people with chronic disabilities are underrepresented in the population of people going for assisted dying.

“It's a concern that should be top of mind when people are first putting a bill like this out there, but again, they’re not pioneers here [in Scotland]. They can look at the reports from all the countries where this is legal and realise it's not actually borne out in practice.”

And while coercion is a “valid” concern, he says he’s never been aware of this happening. In fact, he says, the opposite is more often true. “I have never, ever seen a case of coercion. It’s something that people bring up often who are concerned before assisted dying becomes legalised. It does not happen, but what does happen is family members bully their loved ones out of it.”

Ultimately for Spielvogel, it’s about giving people a say in how they die. “I think it's important to remember that anywhere where this is legal, and this would be the same for Scotland, it’s a choice. One option. It wouldn't be for everybody, but having the choice for everybody allows them to make the decision that’s right for them.”