He had to do something. So he went to the courts. The legal claim he filed on that frigid winter day would put Wade on a quest no father should have to face: saving his daughter’s life from a Canadian health system that at times appears more committed to delivering death than protecting health. By taking legal action, he managed to delay Marge’s death for a while. But he is set to lose the battle.

Wade and Marge aren’t the real names of this story’s subjects. The case is under a Canadian publication ban issued by a provincial court in Alberta, leaving Marge’s family reluctant to speak on the record. Yet with the pro-euthanasia Liberals re-elected to power in Canada and assisted-suicide legislation swiftly clearing obstacles in Britain and New York state, among other jurisdictions, their story must be told: for it highlights the slippery-slope expansion of the categories of patients deemed eligible for suicide-by-doctor, once the practice is legalized.

After the January notice came the details. The last physician to assess her for assisted suicide, a family doctor practicing with the Alberta Health Services (AHS), took fewer than 24 hours to review and approve her application. And although the neurologist treating her for fatigue and pain assessed her as “normal”, another family doctor, unknown to her parents, declared her to be terminally ill. The clinic at which this family doctor practices referred UnHerd’s request for comment to AHS, which told UnHerd that “as this is before the courts, we are unable to provide comment”.

“She tells us that she’s getting [Medically Assistance in Dying], and of course we freak out”, Wade tells me. “I was new to MAiD. I didn’t know anything about it.” He describes his daughter, Marge, as an intelligent young woman. He loves her, and he was saving money for her to be independent, to move her from the family home to her own apartment. She was healthy, but convinced she was sick.

Her only diagnosed conditions were autism and ADHD, which made it difficult for her to keep in touch with her friends during Covid lockdowns or to hold down a job. Her life was nocturnal and online, and that worried him, as did the sort of online peer pressure that bears down especially on younger women. Wade says: “For the last eight years, she has spent a lot of time online researching medicine and adverse medical conditions”. She slept through the day and stayed up most nights until 4 a.m. or later as she accessed “online support groups and chat rooms with other people who share her sickness”.

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Canada has become a warning light for the limits of enforcing safeguards for euthanasia. Even though hundreds of reported violations of Canada’s criminal law on euthanasia were never fully investigated by authorities, Marge’s story is different. She has thus far refused to make public the diagnosis on which she based her application for suicide. Her father, however, insists that it’s her autism that has caused to her become fixated with being sick — terminally so.

In Canada, intellectual disabilities or mental illness alone are no reason for people to receive MAiD. That’s unlike the Netherlands, where at least five people with intellectual disorders younger than 30 cited autism as their primary motivation for euthanasia. Canada is supposed to be different — at least, until 2027, when the country will expand the law to approve assisted-suicide requests for cases of mental illness alone.

As it is, to qualify for euthanasia in Canada, you need any two physicians or nurse practitioners to say you meet the eligibility requirements. You must be over 18 years of age, mentally competent, eligible for health care, and have a “grievous and irremediable” physical illness or disability. Marge’s autism, her parents have argued in court, means that his daughter “is vulnerable and is not competent to make the decision to take her own life”.

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By Kathleen Stock

It was 2021 when Marge first filled out the form — without telling her parents — asking to die. AHS, the public health-care system, connected her with two physicians. Although one physician deemed her eligible without any diagnosed physical symptoms, according to Wade, the second denied her application, presumably because she had no terminal illness. She seems to have only met some of the requirements, although it is impossible to know for sure without access to her MAiD assessment. Alberta’s policy was that in the case of a tie, the suicide would not proceed.

But Marge was determined.

In 2022, she went doctor-shopping. She found another physician, an Alberta family practitioner, who intervened and supported her (their clinic didn’t reply to UnHerd’s request for comment). Unknown to the family, this doctor signed a change in her “Goals of Care Designation”, which is the medical standard used in Alberta to indicate how severely ill someone is. The doctor switched it to the most extreme category, which in some Canadian provinces indicates the likelihood of imminent death; that was almost three years ago.

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The following year, in 2023, she applied for assisted dying a second time. Once again, the two physicians consulted disagreed. (The clinics at which these two practice didn’t reply to UnHerd’s request for comment; AHS declined to comment, citing the court case.) This time, however, the so-called MAiD navigator, who sherpas patients through the process, connected Marge with a third doctor as a “tiebreaker”. The chosen physician was the same one who had approved Marge’s MAiD application the first time, and did so again, within 24 hours.

It was only then that her parents found out from Marge that she had been approved for assisted suicide. Her parents pushed back. Tempers flared. And the MAiD navigator claimed that Wade was a “safety risk given his threats” fewer than two weeks before she was set to die.

Her father couldn’t understand how any doctor could think Marge was qualified to die. “I thought MAiD was for, like, you’re dying anyway. So, we’ll just speed it up because you’re suffering. That’s what I thought it was for”, he tells me. “And I’m thinking, well, how could this be for Marge?” So, the day before her “MAiD provider” was meant to pay a final house visit, when a physician and a nurse would bring the lethal but now routine injection of a sedative, a coma-inducting agent, and a neuromuscular tranquilizer, Wade filed a last-minute court challenge. He claimed that Marge did not have a “grievous and irremediable medical condition”, that her only diagnosed illnesses were mental, not physical, and that her second tie-breaking assessor was not independent.

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That day, an initial judge granted the temporary injunction to block physicians from ending the life of Wade’s daughter. But then the case went to trial.

This was the first time anywhere in North America that a legal assisted suicide for a non-terminally ill patient, approved by any two physicians, was stopped by a court, at least in its preliminary stage. The judge, Justice Colin Feasby, of the Court of King’s Bench, Alberta, ruled that Marge’s father had a reasonable cause of action that the correct protocols around assisted dying weren’t followed. Marge had no terminal illness. Neither of the MAiD assessors appeared to be experts on Marge’s autism. And the independent assessor appointed as tiebreaker wasn’t, either.

Once it came to ruling on the substance of the dispute, however, the judge wouldn’t consider whether Marge qualified for assisted suicide; no evidence was accepted on even naming the condition for which she was approved. Any criminal prosecution, the judge ruled, could only happen after Marge is dead: “Parliament has put its trust in doctors and nurse practitioners, and it is not for this Court to second guess that choice.”

In Britain, Kim Leadbeater — a member of Parliament whose proposal to legalize the practice is set for a critical vote in the House of Commons this May — recently claimed that “there would be an injunction” by the parents of a person with a learning disorder if their child was choosing to die for the wrong reasons. In response to this, Wade says, “I know it won’t work”. When his injunction was thrown out, the judge ruled that his doubt didn’t matter. “As a court”, Judge Feasby held, “I can’t go second-guessing these MAiD assessors … but I’m stuck with this: the only comprehensive assessment of this person done says she’s normal”.

The ruling was no surprise. Since the Supreme Court of Canada decriminalized euthanasia, scarcely any judges in Canada have found problems with euthanasia safeguards. Rather, past rulings reinforced that MAiD wasn’t expansive enough. The 2019 Truchon v. Canada case expanded the practice to include nonterminal illnesses. Failing those who weren’t dying, the ruling said, would be tantamount to discrimination against people without a terminal illness.

One of the two plaintiffs, Jean Truchon, a 51-year-old euthanasia advocate with spastic cerebral palsy, requested to die because he was suffering from a severe disability that prevented the use of his arms. Yet Truchon also told a friend that he would have chosen to live if he received adequate support at home.

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The Trudeau government chose not to appeal the decision, despite opposition from virtually every prominent disability-rights organization in Canada.

In Marge’s case, too, Canadian disability groups mobilized against the ruling; they agreed with Wade that disabilities shouldn’t be compared to a terminal illness. At stake is a future where disability supports are neglected for immediate and cheaper death-on-demand, only for those whose disabilities are too profound or serious for the state to support.

In September, some of the largest Canadian disability groups launched a constitutional challenge against euthanasia based on nonterminal disabilities. The suit claimed it is an “appalling injustice” to offer suicide just on the grounds of disability. “It is not just wrong”, says Krista Carr, the executive vice president of Inclusion Canada, in an email to me. “It is discriminatory and violates our most fundamental rights.”

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Yet even if that constitutional challenge triumphs, it will be too late for Wade. He says he has spent more than $150,000 in legal fees, half of it through credit-card debt; a further legal appeal would have to come from money he doesn’t have. But the expense did not bother him: “This is just money. We can make it. We can’t go to the store and buy another Marge. I don’t regret it at all.”

His legal challenge failed, but it restarted Marge’s assisted-dying process from the beginning. He tells me she had applied again. Meanwhile, in April 2024, Wade appealed the court’s decision, which delayed any further assisted-suicide approval until October that year, when his appeal case was to be heard. But Marge began starving herself that June, so he dropped the appeal a week later.

More recently, I received another message from Wade. Marge’s third application to die had been approved. Wade waits, angry and terrified, to receive the scheduled appointment of his daughter’s death. It could happen anytime.

Last year, 79-year-old Norman Jopling went to the GP about severe pain in his skull after knocking his head, and was diagnosed with tension headaches. He then suffered a subdural haematoma — a bleed on the brain — and ended up spending months in hospital, unable to speak, walk or move his arms.

And then there’s the case of Emily Chesterton, who made an appointment at her GP practice in October 2022 because her leg was hot and swollen, and she was short of breath. She was sent away with “anxiety” and a “calf sprain” on two separate occasions. The evening of her second visit, she died. She was 30.

These three tragic cases have one thing in common: none of these patients ever saw a doctor. Instead, they were seen by a “physician associate” (PA).

Introduced to the NHS in 2003, PAs were meant to make doctors’ lives easier. They are trained to physically examine patients and take medical histories — and are often the first people to see “undifferentiated” patients (those arriving in either hospitals or primary care without a prior diagnosis). They can therefore play a significant role in determining what treatment a patient gets, even though they are not medically qualified. Where a doctor would have to spend at least 10 years of study and practice to call themselves a GP, a PA undergoes just two years of clinical training.

And herein lies the problem. Even a medical student would likely have recognised that Emily Chesterton was experiencing a pulmonary embolism — which can be easily treated with blood thinners. A recent inquest concluded that she would have survived had she been sent to hospital. The inquest that followed Benedict Peters’s death similarly concluded that it was a “concern” that he was never seen by a doctor.

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Worryingly, Emily did not even realise that a doctor had never examined her, as is the case for many patients. A PA could be assisting with your knee replacement, putting you under general anaesthetic, or putting a needle into your spine. They could even be the only “medical professional” that your child sees in A&E. And you may not even realise: six weeks ago, a survey by the British Medical Association (BMA) found that a quarter of respondents mistakenly believed physician associates are doctors.

Even doctors themselves are not immune to this confusion. When I accompanied my father on a hospital appointment recently, what I now know to have been a PA introduced herself as “one of the team”. She was wearing scrubs and a stethoscope with no obvious ID badge explaining her role. It was only when I started asking questions related to my father’s medication, and she seemed unable to answer, that I asked her outright if she was a doctor.

I don’t doubt the rationale for introducing PAs. Doctors are overworking, and a huge chunk of our time is taken up with administrative tasks that you don’t need a medical degree to perform. As a hospital doctor, for instance, you’ll spend at least 30 minutes every morning creating “the list” — a summary of who your patients are, which ward they’re on and which bed they’re in — before hunting down a printer that works so you can distribute it to the entire team. You’ll then have to locate all the notes on your patients — which should be kept around their beds, but tend to be scattered around the ward. Finding them can also take 30 minutes.

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PAs could be hugely helpful in keeping paperwork in order, and there are also plenty of clinical tasks they could be trained to perform. Doctors spend untold hours on clunky Windows XP computers requesting blood tests, for example. Or, if we need to cannulate a patient ourselves, searching for all the necessary equipment, it can take 20 minutes. Again, there are so many ways PAs could make this task easier.

And yet, last week, a survey of 18,000 doctors run by the BMA found that the majority believe PAs are adding to their workload, with only 21% saying they are helpful. Many doctors spoke of having to check their PAs’ work.

Because PAs aren’t really qualified to diagnose patients, let alone treat them. The two-year clinical course to become a PA is very much an overview of medicine. It involves as little as two weeks learning about the entirety of, for example, Obstetrics and Gynaecology. To secure a place, you once needed a “science-based” undergraduate degree, but even that requirement has now been dropped completely. Many of the top PA courses have a 100% pass rate, suggesting either exceptional teaching or poor academic standards. It’s hardly surprising that, when the Government announced in November that it planned to increase the number of PAs from 4,000 to 10,000, doctors expressed concerns about patient safety.

It’s also worth pointing out here that a newly qualified PA in London is paid more per hour than a newly qualified doctor. The former can expect a starting salary of £44,000, for 37.5 hours a week. Junior doctors regularly work around 48, for a starting salary of £32,000. The rationale behind this discrepancy was originally that PAs, unlike doctors, were unlikely to ever have “pay progression”, but that was years ago; nowadays, PAs can see their earnings increase with experience. I’ve seen job ads offering £70,000.

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I say this not out of resentment, but to demonstrate that increasing the number of physician associates is not, on the face of it, a particularly good use of money. It could also hamper attempts to boost the number of experienced doctors in the NHS.

Since the overhaul in their training 10 years ago, junior doctors have had to “rotate” every four-to-six months until they reach consultant level. Rotations usually require recent med-school graduates to move around the country and switch specialty. PAs, on the other hand, theoretically remain on the team permanently. If a consultant trains a PA to perform a lumbar puncture, or chest drain, or even to be their assistant during a hip replacement, then they will personally benefit from the time they put into training that person. Crucially, they probably won’t have to retrain someone else in a couple of months’ time.

As a result, it’s now not uncommon to find junior doctors doing admin on the ward while PAs are in out-patient clinics or surgical theatres with the consultant. The result, perversely, is PAs getting all the experience that junior doctors need.

The government claims that PAs are merely filling rota gaps because we just don’t have enough doctors. But though it is planning to increase the number PAs, it is doing little to address the bottleneck in opportunities for much better-qualified medical professionals. The NHS’s long-term plan is for consultant anaesthetists to each supervise three Anaesthetic Associates — the equivalent of a PA — simultaneously. Meanwhile, there are nearly 3.5 doctors applying for every anaesthetic training post — a necessary path to consultancy. This bottleneck exists across almost every specialty.

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Given these stark facts, how can the NHS — as the chief executive of the General Medical Council has urged it to do — tackle the perception that PAs are replacing doctors? Indeed, how can it deny that replacement was the plan, when official minutes obtained via an FOI state that “there is an ambition to increase PA numbers in the UK and to make sure that maximum value is derived from them as medical role substitutes”?

And how can they explain why some NHS trusts are actually including PAs on senior doctor rotas? I’ve heard reports of PAs being given responsibility for the stroke bleep — the pager that a consultant doctor specialising in strokes is supposed to hold at all times, so that other doctors can contact them urgently when they need advice. This could lead to the absurd scenario of an emergency department consultant being forced to go to a PA for advice.

Then, at the end of last year, the government announced plans for the GMC to regulate PAs. Billed as a “patient safety boost”, this move has criticised for potentially “blurring the lines” between doctors and PAs. Because what patient will be able to tell the difference between Mr John Smith, GMC number 12345 (an orthopaedic surgeon) and Mr John Smith, GMC 23456 (a PA)?

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When challenged, it’s common to hear NHS managers justify PAs as bringing “diversity” and “a different perspective” to medical teams. But patients don’t want a different perspective. They want the right treatment. And diversity is only valuable when everyone has received training that qualifies them to undertake the tasks they’re expected to perform.

The evidence that PAs risk harming patients is mounting. A recent FOI request of Leeds Teaching Hospitals has revealed that PAs have ordered over 1,000 treatments that expose patients to ionising radiation, such as X-rays and CT scans, which can only legally be ordered by doctors. And new data from Scotland implicates PAs in a number of “never events”. These are, as the name implies, “wholly preventable” events that should never happen: performing a procedure on the wrong body part, maternal deaths from haemorrhage, incorrectly placing a nasogastric tube.

A price can’t be put on the lives that could potentially be lost if the PA to doctor ratio continues to tip. But the cost of compensation is measurable. Where doctors must pay for their own medical indemnity insurance, which compensates patients harmed by medical negligence, PAs do not; when they make mistakes, it is the NHS itself that pays. Last year, the service spent £2.6 billion compensating victims of negligence; how much more could it have to pay if it succeeds in adding 6,000 PAs to the workforce?

It’s a sign of how desperate the NHS is that it is allowing itself to increasingly depend on physician associates. Doctors are burning out at record rates: we need help. But instead, less qualified members of NHS staff are taking on more and more of our responsibilities, because hiring them is easier than tackling the root causes of the service’s malady. To give patients the care they need, sweeping reform is necessary: of administrative systems, of junior doctors’ rotations, of career ladders. Instead, what we have are physician associates — at best a sticking plaster, and at worst a danger to the NHS.

“My previous births have been fast,” I said, when I went into labour with my third, “so I’d like to come in now.” I was speaking to the woman at the midwife-led unit that is the only option where I live. (If you need a caesarean section, you have to be transferred to next town.) “Third babies are notoriously difficult,” was her response.

What an odd thing to say to a woman already in labour. The “notoriously” suggested it wasn’t based on any actual evidence, but rather a kind of folk wisdom. It felt as though I was being warned not to tempt fate, not to assume that this baby would just pop out. I saw myself being categorised as one of those arrogant women who presumes to know her own body, only to be taught a harsh yet much-deserved lesson. “Third babies are notoriously difficult” sounded not unlike “third-time mothers shouldn’t get above themselves”.

In fact, I have never been particularly cocky about childbirth. When I was pregnant with my first child, back in the days when the Right-wing press were still obsessed with famous women being “too posh to push”, I wondered if I might be able to get an elective caesarean myself. I did not particularly care about childbirth being a wonderful experience, or about “doing it well”. I didn’t care if the Daily Mail thought I was a joke.

What I cared about was not having a child who would face the same difficulties as my brother, who was starved of oxygen at birth. This has had serious consequences for him, and for the rest of my family. Just how serious is hard to gauge. He was born traumatised; there has never been a before to compare the after with. What there has been instead is the hazy outline of an alternative life, one that runs parallel to the one he has now. It’s a life that began with the problem being identified sooner, with him being delivered quickly, perhaps by emergency caesarean. The difference between this and his actual life comes down to something small: mere moments, mere breaths.

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I was born three years after my brother, in a larger hospital, where my mother was induced and monitored carefully. There is something very strange about being the sibling who had the safe birth. It feels as though I stole it. There is a constant sense of guilt, as if my life — my independence, my choices — constitutes a form of gloating. “This is what you could have had.” Everything I do feels like something owed to my brother (do it, because he can’t) but also something taken from him (you shouldn’t have done that, because he should have done it first).

Still, my family were fortunate, insofar as my brother didn’t die. Current reports on the Nottingham maternity scandal reference 1,700 cases, with an estimated 201 mothers and babies who might have survived had they received better care. What strikes me, reading them, is the enormous gulf between the cost of a disastrous birth and the trivial, opportunistic way in which childbirth is so often politicised — with mothers themselves viewed as morally, if not practically, to blame if anything goes wrong.

As a feminist who concerns herself with how the female body is demonised, my interest in debates about birthing choices is more than personal. I have read books railing against the over-medicalisation of childbirth, aligning it with a patriarchal need to appropriate female reproductive power. I have also read books protesting the fetishisation of “natural” birth, suggesting that it infantilises women, that it implies women deserve pain. To be honest, I find both arguments persuasive and dismaying. Both are right about the way in which misogyny and professional arrogance can shift the focus away from meeting the needs of women and babies. I feel a kind of rage that we are told to pick a side.

Representations of the labouring woman are so often negative: the naïve idealist, the “birthzilla“, the birth-plan obsessive, the woman who is “too posh to push”. This latter stereotype has gone hand-in-hand with a veneration of vaginal births, and stigmatisation of caesareans, that has had sometimes disastrous consequences. Midwives at the centre of the Furness General Hospital scandal were reported to have “pursued natural birth ‘at any cost’”, referring to one another as “the musketeers”; at least 11 babies and one mother died. But their approach was sanctioned by their employer: the 2006 NHS document “Pathways to Success: a self-improvement toolkit” explicitly suggested that “maternity units applying best practice to the management of pregnancy, labour and birth will achieve a [caesarean section] rate consistently below 20% and will have aspirations to reduce that rate to 15%”. Proposed benefits to this included “a sense of pride in units”.

Responses to maternity scandals now express horror that such an anti-intervention culture ever arose — responses in the same press that denigrated women such as Victoria Beckham and Kate Winslet for not giving birth vaginally. Instead, newspapers now stoke outrage over “natural” treatments during NHS births, such as burning herbs. Women have been shamed for having caesareans, but they have also been shamed for wanting births with minimum intervention — as though they are selfish and spoilt for seeking control over such an extreme situation.

In his memoir This Is Going To Hurt, former doctor Adam Kay writes disparagingly of women who arrive at the delivery suite with birth plans:

“‘Having a birth plan’ always strikes me as akin to having a ‘what I want the weather to be’ plan or a ‘winning the lottery’ plan. Two centuries of obstetricians have found no way of predicting the course of a labour, but a certain denomination of floaty-dressed mother seems to think she can manage it easily.”

Wanting to have some control over your experience of labour — which will hurt you and could kill you or your baby — is not akin to some messianic aspiration to control the weather. And in his mockery of the woman who wants whale song and aromatherapy oils, ironically, Kay deploys the same silencing techniques that might intimidate a woman out of seeking the very interventions he so prizes. What he and others do not seem to grasp is that their arrogance is a problem, regardless of which course of action they champion. It makes women feel they can’t speak, for fear of inviting hostility at their most vulnerable moments. It’s true that none of us knows our body well enough to know how we will give birth. But, looking back, I find it utterly insane, not least given my own family history, that one of my biggest worries during labour was “please don’t let anyone get cross with me”. Then again, I don’t think that fear is unrelated to the desire to remain safe.

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By Tanya Gold

Birth is not a joke. It is not a place for professional dick-swinging or political one-upmanship. I cannot describe — and, as I am not my mother, cannot fully understand — the shame of feeling that you “let down” your child before they drew their first breath, that they will forever suffer because of it. You watch an entire life unfolding and that feeling is there, every single day. This is the fear of the women in labour who are characterised as either idiots mesmerised by fantasy homebirths or cold-hearted posh ladies who can’t take the pain. If things go wrong, they are the ones who will bear the consequences, reflecting every day on what might have been, if they’d only done more.

When people discuss their siblings, my mind does wander to the one I don’t have, the one who was born safely. Perhaps he would have a job he loved, or one he hated, but in any case a job. Perhaps he would have a partner. Perhaps he would have children, and I would be their aunt. Perhaps we wouldn’t get on, wouldn’t even speak, but he’d have a life of his own. I know he thinks about this too. I wonder if the professionals who presided over his birth have thought about him since.

My third labour was not, by the way, “notoriously difficult”. My third son arrived into the world safe and well. No one can say why him or me, and not my brother. Mothers may long for control over birth, for which we are mocked; but we do not have it, for which we are blamed. Politics still takes precedence over our needs, and the needs of our babies.

The 21st century narrative couldn’t be more different. To mark the National Health Service’s 70th birthday, in 2018, Nicklaus Thomas-Symonds wrote a new preface to his biography of its architect, the Labour MP Aneurin Bevan. Like most contemporary paeans to the NHS, Thomas-Symonds’ lavishes praise on its staff, both past and present. “Those who work in our National Health Service have made it what it is today,” he wrote, “and we should always thank them for their remarkable commitment to public service, often carried out in the most difficult of circumstances.”

This view of the NHS, which turns 75 this week, is even more pervasive now than it was then. During the pandemic, politicians, journalists, and patients commended the devotion of doctors with such regularity that it became cliché. Most discussions of healthcare in the UK present NHS workers as heroes, or at the very least unusually committed to their jobs. The recent news that doctors will be taking industrial action this month has been framed by the sympathetic press as a difficult decision made in the interest of patients’ safety. Supporters on social media argue that the medical profession is driven not by personal greed, but by its unwavering commitment to the British public. In February, Jeremy Corbyn repeated a familiar claim: “Doctors devote their lives to the needs of others.” Medicine is not like other professions, the story goes; working for the NHS is different from any other job. Unlike the rest of us, they don’t do it for the money, they do it because they care.

All this seems complimentary. The people praising NHS doctors are sincere, often expressing gratitude for care they’ve personally received. But the insistence that doctors are saints actually does a lot of damage. Not only does it harm medics themselves, it also does a disservice to patients.

The origin of the myth lies in the 19th century, when doctors launched something of a PR campaign to give their image a dramatic makeover. They marketed themselves as different from the quacks with whom they were competing for patients in a busy medical marketplace. Trainee physicians were reminded perpetually that the medical “calling” was very different from that of other professions. In 1890, Governor J. Proctor Knott issued the doctoral address to the graduating class at the Kentucky School of Medicine: “No other calling,” he said, “demands a more absolute self-negation than the one you have chosen. No other vocation — not even the sacred ministration of religion itself — requires a more constant exercise of the higher faculties of the human mind, or a more earnest devotion of the purer and nobler attributes of the human soul.”

By the end of the century, medical organisations had begun to describe their work using the romantic language of heroism. In 1900, surgeon Frederick Treves spoke at the annual meeting of the BMA, using military rhetoric to describe his profession: “So as one great surgeon after another drops out of the ranks his place is rapidly and imperceptibly filled, and the advancing line goes on with the still same solid and unbroken front.”

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Despite these efforts, the poor reputation of doctors survived into the 20th century. In 1937, A. J. Cronin published his novel The Citadel — an attack on self-serving healthcare professions. He particularly targeted those at the top of the medical hierarchy, the “grandees” whose driving concern was money, and who encouraged illnesses in their “wealthy, idle, hypochondriac, and mostly female patients”. The Citadel was an extraordinary success, selling over 150,000 copies in its first few months. Clearly, it struck a chord with the British public.

Just over a decade later, on 5 July 1948, the NHS was founded. It did a huge amount for the medical profession’s reputation, though not initially. The BMA was one of the most vociferous opponents of the proposed NHS, not wanting medics to be relegated to the status of “salaried” workers. “The medical profession is,” declared the BMA, “opposed to any form of service which leads directly or indirectly to the profession as a whole becoming full-time salaried servants of the State.” Nye Bevan had to “stuff their mouths with gold” to get them on board: he allowed consultants to continue taking on private patients as well as NHS ones.

The mythical status of the NHS we recognise today didn’t emerge until later, in the early Seventies — in part due to the decade’s economic and political pressures, which prompted people to campaign in defence of the welfare state in ways they hadn’t felt they needed to before. The myth was also a product of subtle but deliberate NHS propaganda, in the form of TV hospital dramas, nurse recruitment films, and medical romance fiction.

As the health service grew in popularity, the public image of medics also slowly improved. But in 1978, their freshly-minted reputation was put to the test, when NHS doctors first went on strike over pay and working conditions. Indeed, some doctors were opposed to their colleagues taking industrial action, because they thought it compromised their high-minded principles. A consultant surgeon wrote in 1976: “Doctors have to decide whether medicine is to remain a profession with ethics or to become an industry with strictly regulated hours of work.” He criticised the strikes by arguing that the withdrawal of services would “make nonsense eventually of any idea of vocation”, which was “over and above job satisfaction”. That same year, another consultant wrote to the government to argue against industrial action, which had “immediately put the doctors on a par with the trade unions and other workers”. These ideas are still around. In 2016, the Telegraph argued against industrial action by junior doctors because their “vocation in life” is “to care”. Imagine saying the same thing of the striking civil servants.

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Is liberal society making us ill?

By Gurwinder Bhogal

Then again, it does make sense for healthcare professionals to think of themselves in these terms. Many medics really do feel a sense of devotion to their profession and to their patients. They do often take an oath. And if doctors couldn’t cling onto the idea of exceptionalism, would any of them stay in the job? During the height of the pandemic, doctors and nurses were working impossible hours, under extreme pressures, and the very real risk of serious illness or death loomed over them. One in ten health workers in England during the pandemic had suicidal thoughts. There is still a palpable crisis of wellbeing among NHS staff, pay has stagnated, and the number of doctors fleeing the UK in search of better jobs elsewhere has sky-rocketed. And Rishi Sunak’s plan to boost the workforce, announced on Friday, seems squeamish of acknowledging the true challenges to retention. Is it any wonder that doctors try to find meaning in a romantic ideal of their work, rather than just focusing on the day-to-day drudgery and dehumanisation that so often characterises employment in the NHS?

But politicians who characterise doctors as saints often do so to deny their right to industrial action. They don’t need better pay or working conditions, or so the argument goes, because their jobs are so meaningful. Members of the public who buy into the myth, even if they are well-meaning, obscure the bleak state of the NHS. During the pandemic, we clapped for health workers because there was little else we could offer them. You could text CLAP to 70507 to donate £5 to NHS charities, knowing that the service itself was inadequately funded. The public was unable to provide the NHS staff with the protective equipment they so desperately needed — but it could tell them they were heroes.

Doctors cannot live on saintliness alone. Poor pay and conditions means it is often hard for medics to stay professional — let alone heroic. How can you devote yourself to patients, or even show them compassion, when you can only speak to them for seven minutes at a time? In 2022, 51 million GP appointments lasted less than five minutes. 94% of NHS doctors surveyed said short appointment times put patients at risk and one in three GPs admitted they have failed to properly diagnose patients due to time constraints.

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By Jane Smith

We also need to recognise that some doctors are bad at their jobs, no matter how much time and money they’re given — just as some teachers and civil servants are also no good. But the medical profession’s glowing reputation makes it hard to confront this fact. While doctors are frequently targets of abuse, sometimes they treat their patients poorly. Not all doctors are competent, and their vaunted position in today’s society can make it a lot harder for patients to have their complaints heard, for abuses to be taken seriously, and lasting improvements to be made. In 2013, the NHS Ombudsman found that patients were often “too frightened to complain” about problems with their care.

Doctors are just people. If we just thought of them not as heroes but simply as skilled professionals doing their jobs — sometimes well, sometimes not so well, sometimes in impossible circumstances — we could level out the power dynamic between them and patients, making it easier for the latter to get their voices heard. Doctors, too, would be better equipped to advocate for themselves. And the NHS as a whole might be forced to stop falling back on the myths of medicine’s heroism, stop relying on its workforce’s goodwill, and reckon with the radical reforms needed to make the service fit for purpose in its 75th year. Some doctors might be reluctant to let go of their romantic ideals. But surely a slight drop in social status is a price worth paying for a comfortable working life?

As time wore on, and first my mother passed my grandmother in age, then I did, my mother told the birth story less and the death story more. As they entered their eighties, both with chronic illnesses, she and my father spoke often of the easy morphine shot and the effortless, paternalistic, shouldering of responsibility of the doctor who administered it. It seemed more outlandish and yet more enviable with each year. “That Dr Shipman,” my father would say, sighing gustily. “Caused all sorts of problems.”

“Dr Shipman did murder rather a lot of his patients,” I’d remind my dad. And it wasn’t just the subsequent regulation of doctors and their bags which discouraged people from dying at home. Preferring hospital as a place of death has been a trend for more than century: my grandmother, in 1967, was already a bit of an outlier. Hospital seemed — was — safer, cleaner, the right place to be. Until, that is, the pandemic. Deaths at home in the UK spiked immediately in lockdown, as you might expect. And they haven’t fallen since. Almost 90 more people than usual died at home every day last year, a fifth higher than in a typical year. That constitutes, as Cambridge statistics professor Sir David Spiegelhalter put it, “a major change” in national habit.

But, Spiegelhalter went on, we don’t know why this change is happening as it “hasn’t been studied sufficiently”. We keep no records of why someone died at home. It might be by choice — most people will, like my parents, state a preference for dying at home when asked — but relatively few individuals set out their wishes in a formal Advanced Decision.  Even when they do — my parents had three each, including one in a pot in the fridge — there is no national protocol for dealing with them.

Looking at causes of death does not help much, either. Most people take Covid to hospital. A little of the increase, we are beginning to learn, comes from the ambulance not arriving on time, but not much. The great majority of deaths at home derive from the same sort of slow, chronic conditions that end most lives in hospitals: heart disease, cancer, old age. The leading causes are dementia and Alzheimer’s disease, with diabetes being the most common contributing factor. There is no special reason, there, for a sudden and lasting change in behaviour.

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Perhaps we should be looking elsewhere, not with the patient but with the carer. Anyone dying of dementia at home needs an especially dedicated one. And diabetes — imagine, as my mother would have said, the washing. (Domestic work was always on my mother’s agenda. I never did it to her satisfaction.) Think, my mother would say, and my mother always had a point, of the sheets. Think of the woman washing the sheets.

The sheets matter because it may well be the carer rather than the patient who decides the place of death. They are the ones who call the final ambulance, whatever their loved one or their Advanced Decision may say. They may do it because they hope to give their loved one more time, or a pain-free death, but they may also do it to relieve the unspeakable strain on themselves, and to love, not just care, for someone in their last days. It’s not just the sheets. Modern, post-Shipman, deaths are more prolonged than my grandmother’s. Without that morphine shot, longer and more demanding nursing might have been required.

If a carer can’t cope with that though, there is now often little alternative to hospital. “It’s always been the National Hospital Service, really,” my mother would say, meaning that emergency and high-tech medicine had always taken precedence over social care from the inception of the NHS. Almost in step with her aging, she had seen first the doctor with the black bag disappear, then the remnants of the cottage hospitals and district nursing system. In her ever more frequent stays in hospital, she had seen the bed-blocking results; she had been, to her rage and sorrow, a bed-blocker herself. Here life was saved in hospital by high-tech medicine, but she also experienced loneliness and loss of agency which made her never want to go back. That was what the Advanced Decisions chilling in the fridge in 2020 said: no resuscitation, no interventions, and above all, please, no hospital.

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But how were we to achieve this? More particularly, how was I, isolated with my parents by lockdown, to achieve it? In 2020 there seemed to be nothing at all between an isolated, high-tech death surrounded by people in space suits, and one at home with — what? Only horrified, squeamish, cack-handed me? Surely not. I tried not to think about it, but my parents did, most days. I promised, often, to try my best.

But when my mother’s health went into crisis in January, at the very height of the 2021 Covid spike, the GP called an ambulance and I put her in it. My mother consented on the grounds she was only going to have her heart checked in the day ward. I consented because I was too scared not to. It wasn’t just that I was far out of my depth with the nursing — and the sheets. I wanted a hospital not for her but for me: a place where the responsibility, moral and practical, would be taken from me, where people more expert than I would know the right thing to do.

My mother never came home. Separated from us, her documents, and her own mind as she floated off in an infection, she was subjected to everything she had stipulated against — operation, ventilation, feeding tubes — before contracting Covid and dying alone. We saw her once more, on a visit during which my father also contracted Covid. It was the very opposite of what she had wanted: a death in your own bed with your daughter downstairs talking to the doctor, your daughter making the tea, your daughter managing, for once, the sheets.

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Hundreds of thousands of people died in similar fashion that year: in hospital, alone, relatives at best on an i-pad; an unknown, gloved hand to hold. Their families suffered, according to a thoughtful study by the Marie Curie Trust in 2021, “complicated grief”: trauma, degradation, loss of agency and connection, guilt. Complicated grief is a good phrase. I don’t have one of my own. At the time, I experienced extreme helplessness, while my father talked of my mother’s departure as the “kidnapping”.

But perhaps complicated grief could also be called iron in the soul: when my father, a few days after my mother’s death, collapsed with what I now know was myocarditis, I was able to refuse hospital care. I had his exquisitely clear Advanced Decision in my hand; I’d talked it through with him many times, but it may have been my mother’s experience which actually stopped me. I still wanted to call the merciful hospital, but my complicated grief told me it no longer existed. My complicated grief steeled me instead to do the work, practical and emotional, of letting someone die at home.

There must be hundreds of thousands of us in the UK with complicated grief, an epidemic of it. I wonder, even, if there are enough of us to be causing the change of national habit that Sir David Spiegelhalter spoke about; if experience of post-lockdown hospital is making 90 extra people a day unable to surrender their relatives to the hospital. I think it’s possible. I’d join the Marie Curie Trust though, in thinking we should examine the increase in deaths at home rather than hospital. It’s a choice we all come to, and we shouldn’t be making it in despair.

The best advice I could offer that student was anecdotal. My time in obstetrics and gynaecology was over 20 years ago, but I remember very clearly walking into my first delivery room, taking a deep breath, and repeating to myself, silently, “I’ve got this, I’ve got this, I’ve got this”. At the critical moment, when the baby started to crown and, in an almost cosmic sense, explode into the earth’s atmosphere, I realised: “I have so not got this!”

I had been on the vascular ward where people had lost their limbs. I had taken patient histories only to return later to discover they had died. I thought I had seen everything. But nothing prepares you for O&G. When I was at medical school, students typically experienced a few days on a labour ward, and over a period of several weeks would be expected to assist in around a dozen deliveries. While this may not sound like a huge number, I was competing with eight or nine fellow students, each of whom had to get their dozen in. I was also up against a group of student midwives with their own quota. This hectic status quo, which at the last count oversaw 681,560 live births in the UK, accounts for a less than friendly level of competition among students, exacerbated by a culture of tribalism on maternity wards.

This internal politics put lives at risk. An obstetrician friend often talks of being sidelined or ignored by midwives, while midwives have complained to me of a hierarchy that seeks to undermine their independence. Throughout the country, the battle between doctors and midwives for “control” of the delivery room results in poor decision-making. Mediation is needed in severe cases, but senior hospital managers are often too busy watching their own backs to intervene. It’s a dynamic that causes injuries and fatalities.

When all goes to plan, the aftermath of childbirth should be joyful. Too often, it isn’t. Shortly after my baptism of fire, I was involved in the delivery of a child with foetal alcohol syndrome. I could see instantly from the child’s cataracts and cleft lip that there was a serious problem — but knew from my training that there was very little I could do to help. In this instance, the health service was in no way to blame. But there are times when the institution I’ve dedicated my working-life to does jeopardise the health, and futures, of our most vulnerable patients: newborn babies.

In September, an inquiry began into a hospital not far from where I work. Nottingham University Hospitals’s maternity unit is facing allegations that dozens of babies have died or been left with serious injuries after receiving inadequate care. NUH, which runs Nottingham’s City Hospital and Queen’s Medical Centre (QMC), has already paid out millions to the families of 30 babies who died and 46 infants who were left brain-damaged. It is also being prosecuted over the death of Wynter Sophia Andrews, which could have been prevented had she been delivered sooner. An inquest found she had died from hypoxic ischaemic encephalopathy — a loss of oxygen flow to the brain during delivery — after she was born by Caesarean section at the QMC in September 2019.

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The chair of the NUH inquiry is Donna Ockenden, a well-respected midwife who led the damning review of the Shrewsbury and Telford NHS Trust (SaTH). Once held up as a beacon of good practice, it is now seen as enabling the “worst scandal in NHS history”. Ockenden identified 201 stillbirths and neonatal deaths that could have been avoided had better care been provided. Nine mothers also died as a result of SaTH’s failings.

The 234-page Ockenden report, published in April this year, catalogues a litany of failings that occurred between 2000 and 2019. The Trust lacked everything from “safe staffing” to “robust support for families”. There was also a “failure to follow national clinical guidelines on a range of issues such as monitoring foetal heart rate or maternal blood pressure, management of gestational diabetes, and resuscitation”. Following publication of the report, West Mercia Police were said have identified 823 cases at SaTH between 2003 and 2022. It bears repeating: this is a medical trust that had been celebrated by the NHS for having high standards.

It’s no surprise, then, that it’s not the only trust with a maternity ward that systematically fails. A disturbing number have been caught out recording baby deaths as “stillbirths”, in what many argue is an attempt to avoid scrutiny. East Kent University NHS Foundation Trust, University Hospitals of Morecambe Bay NHS Foundation Trust, Warrington Hospital, Milton Keynes Hospital and Wrightington, Wigan and Leigh NHS Foundation Trust — the list is endless. A Stockport NHS Foundation Trust obstetrician recently told a coroner that he had been pressured by an NHS manager to claim a baby delivered in the hospital was stillborn. Dr Mark Tattersall said it was done out of “loyalty” to the trust (his NHS manager denied this). This is the language of the mafia — not a taxpayer-funded, state-run healthcare system.

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That midwives feel too frightened to escalate their concerns to doctors, and senior clinicians fail to take action even when cases are escalated, speaks of a system that is not only unprofessional but immoral. Have we learned nothing? Over 20 years ago, the Bristol heart scandal revealed that a combination of ineptitude, arrogance and an old boys’ culture had contributed to dozens of babies suffering brain damage and death following cardiac operations by surgeons. None was prosecuted. Fail to pay your TV licence, and you can go to jail. Fail in your duty of care so that babies die, and nothing happens. There are simply no consequences for the worst and serial offenders within the NHS, and so a culture of mediocrity prevails.

According to the Care Quality Commission (CQC), two out of five maternity units in England are providing “substandard care to mothers and babies”. This troubling review comes off the back of another damning inquiry, Dr Bill Kirkup’s three-year investigation into mass failings at East Kent Hospital Trust’s maternity care. From 2009-2020, 45 babies who died under the trust’s aegis might have survived had they received “nationally recognised standards of care”.

The truly shocking range of scandals, exposes and investigations to hit the NHS’s maternity services is another sign of the service’s dysfunctional relationship between management, staffing and patients. It also raises doubts in the minds of trainee nurses, midwives and doctors — including the student who asked me for career advice. They are not only concerned about the overall prognosis for the NHS, but also worry that obstetrics and midwifery, while essential and worthwhile fields of practice, may be poisoned chalices.

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In that past year alone, 600 midwives have left the NHS; England is currently short of at least 2,000. One nurse recently told me that having been a midwife for ten years and delivered “thousands of babies”, she returned to nursing in 2020 because her maternity unit had become “too difficult to work in and unwelcoming”. She describes an atmosphere that was “intimidating” for both staff and expectant mothers, with heated differences of opinion and petty grievances between midwives and obstetricians aired in public. “The culture was terrible,” she says. “I just couldn’t take it anymore. I felt depressed going into work.”

Those with a clinical interest in childbirth, such as my student, thus have a right to be concerned about their future prospects, both professionally and psychologically. But everyone who works in the health service should be worried about this staff shortage. Senior hospital managers use two key metrics to analyse the effectiveness of their organisations within a given period: activity within the emergency department and activity within the labour ward. If both are full to the brim on a Monday, it’s going to be a tough week.

Which begs the question: would I advise my student to go into obstetrics, now that the NHS waiting list tops seven million and the Royal College of Nurses’ 300,000 members are planning to take industrial action? Ask me again in nine months’ time.

“It has been shown that if those extra 100,000 people had lived to a ripe old age, they would’ve cost us even more in pensions and social security than they did in medical treatment. So financially speaking, it’s unquestionably better that they continue to die at about the present rate!”

Anyone who’s worked in the National Health Service for more than a few months would, depressingly, recognise this kind of equation.

Those episodes were first broadcast in 1986, when the tobacco tax generated £4 billion in revenue for the government and smoking-related diseases did indeed cost the NHS £165 million a year. Last year, the tobacco tax raised £8.7 billion for the government — but smoking-related illnesses cost the UK healthcare system £2.5 billion per annum. Nevertheless, a smoking ban has never been seriously considered. Behind the gallows humour at the heart of Yes, Prime Minister lies a bleak fact: the state is happy to kill off the weak to balance the books, or even make a profit.

This cavalier attitude to death rather defined the Government’s attitude to the pandemic, as it spread through hospitals and was encouraged into care homes, pushing the NHS to breaking point. In hospitals, we’re battling it still. When Omicron started spreading at the end of last year, we were told it wasn’t as dangerous as previous variants — but that might just have been because patients and the public were more vigilant. Now, vigilance has waned. With most Covid mitigation measures nothing but a memory, hospitalisations could spiral out of control again. And it’s now predicted that, because of a lack of exposure during lockdown, flu deaths will be very high this year. This winter, according to The Lancet the return of influenza as a major public health issue appears “inevitable”.

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Don't go to A&E

By Emma Jones

Then factor in the cost of living crisis. People are not going to be able to heat their homes. People are not going to be able to put food on their tables. People are not going to be able to put fuel in their vehicles to go to work to earn money. People are not able to afford prescriptions. People are going to have to choose whether to feed themselves or their children. Isolated, vulnerable people are going to be more isolated and more vulnerable. Abused people are going to be more abused. 

Emergency departments throughout the country are starting to seem Dickensian. I routinely see patients admitted with combinations of multiple problems: severe respiratory illness, loss of sphincteric function, terrible hygiene and general self-neglect. Paramedics are having to wear specialist kit to cope with lice, scabies and faecal matter — and incinerate patient property in keeping with protocols.

All of this will put immense pressure on the NHS — which is in a terrible position to deal with any of it. After a recent bout of Covid (yes, even doctors get it) left me utterly drained, I dragged myself into my department because — like the rest of the NHS — it is suffering from unprecedented staff shortages. A staggering 40,000 nurses have quit in the past year, many due to stress and poor pay. (Those remaining are deciding whether to strike.) Resignation rates far outstrip recruitment. Sick leave, meanwhile, is running at an all-time high, with some 60,000 healthcare and social care staff suffering from Long Covid. Working conditions for those working are verging on untenable.

The A&E department where I work is representative, in that it is falling apart. Ambulances get stuck outside for hours. There is no patient flow, and therefore no capacity; there are not enough GP appointments, so problems aren’t treated early and people show up on our doorstep far more seriously ill; and there is a dearth of community services. In the past two years — since before the second lockdown — I have seen more severe cases than in the rest of my career. Recently, I had a patient who had telephoned his GP complaining of a sore arm, which was thought to be a muscular or skeletal problem. In fact, the man had been suffering from angina, and the sore arm was referred pain. The situation soon escalated: he had a massive heart attack. We worked on him in A&E, but to no avail. Had the patient had a face-to-face consultation with his GP, things may well have been different.

This summer, we experienced “excess” non-Covid deaths in the region of 1,000 a week in England and Wales — in other words, far more deaths than would usually be expected for the period. Many of them, it seems, were related to lung, heart and circulatory diseases. Research by The Kings Fund healthcare charity revealed that the pandemic era has seen life expectancy in the UK fall by a magnitude that “has not been seen since World War II”. Second only to the US, the UK’s pre-pandemic life expectancy was lower than in many comparative countries for males, lowest for females. In the first 12 months of the pandemic, it fell by over a year for the former, and just under a year for the latter.

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If deaths this summer were way beyond the average, the prognosis for this winter is bleak, given this lethal cocktail of health and socio-economic issues. According to the Government’s own research, for yet another week, “statistically significant excess all-cause mortality by week of death was observed overall in England” — and autumn has only just begun. The nation is about to be plunged into a winter during which people can’t protect themselves, comfort themselves, warm themselves or feed themselves.

Our hopes rest on a new Health and Social Care Minister, Thérèse Coffey. She is, it’s said, in “listening mode”. She has already made remarks that sound great. Everyone is going to be able to see a GP within two weeks, she says, without explaining exactly how she’ll achieve this. (Currently, some people are unable to see a GP at all.) Coffey has also said that nurses won’t get a pay rise. In fact, she’s advocated working for no money at all, unabashedly calling for a “national endeavour” to support the NHS, which “includes encouraging more volunteering across the health service”.

Coffey has proposed tweaks to the NHS pension rules to “allow” retired staff (who are probably well shot of the health service) to return to work if they want to (why would they?). But why the focus on clinicians at the end of their careers? The General Medical Council (GMC) is reporting that two-thirds of junior doctors are “worn out” at the end of a working day and morale among trainee nurses is at an all-time low. Coffey’s plan should throw them a lifeline; instead, it doesn’t mention them. Our healthcare system is dreadful and dilapidated because of this government’s failure to invest — not only financially but also in terms of the time and brainpower needed to sort out the situation — and the same Government is still failing to do anything meaningful about it.

The cherry on top is the fact that Coffey seems poised to bin its plan to tackle smoking. It is no coincidence, perhaps, that she herself smokes. We live in a world in which “optics” matter — particularly in the socio-political sphere — and Coffey, like Jim Hacker’s chain-smoking, tobacco-lobbying health minister, aren’t good. She’s obese. She drinks. She’s known to be cosy with the tobacco industry. And she’s anti-abortion.

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Still, there are signs that somebody, somewhere in Coffey’s department, understands the most pressing challenge facing departments like mine: one of the priorities in what has been titled “Our plan for patients” is the Adult Social Care Discharge Fund, the aim of which is essentially to free up beds. In my region, we can’t seem to get any patients out the hospital and into social care — because there is no social care. If Mrs Smith on ward seven has her pneumonia treated quickly, and she turns the corner beautifully, and she’s off supplemental oxygen and on oral antibiotics, and all the paperwork has been filled out by the junior doctors for the social care assessment — all that happens is she gets into the queue for social care quicker. The queue gets ever-longer. Mrs Smith remains in hospital.

It is hard for hospital managers and clinicians to remain motivated in the face of this absurdity. Making things more efficient within the hospital doesn’t actually speed up the process of getting patients out of hospital. It just gets them onto these waiting lists quicker.

Even the best British satirists might struggle to lampoon it, so dark is our current situation. The other night, while I was on call, the sister in charge let slip that only one or two beds in the emergency department would free up that evening. This is a continual problem where I work: the number of beds available in any given 24-hour period is always far outnumbered by the number of patients requiring clinical admission. Allocation is a simple mathematical equation. On this occasion, the sister followed up her update with another: “We’re expecting a couple of deaths…”

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In other words, the only way we can get new patients into our emergency department — and the only way we can get existing patients into the community — is if people die. This health “target” unsurprisingly doesn’t get openly discussed. But it’s there, nonetheless, in the back of management’s collective mind, reminiscent of Sir Humphrey declaring, “it’s unquestionably better that they continue to die!”

If this is the NHS’s new normal, and the Secretary for Health and Social Care is happy to accept it, then that’s a sad indictment of her stewardship. But her party sets the tone. We’ve been here before with this government: in April 2021, Boris Johnson said he would rather see “bodies pile high” than take the UK into a third lockdown. The UK currently has a body count of 205,000 Covid-19 deaths, and the Tories seem all too comfortable with this — which doesn’t bode well for the coming winter.

Without adequate support from the Government, the NHS will be forced to keep relying on a shameful, unofficial “beds for death” policy. Staff shortages will snowball. The new generation of clinicians is already battling with severe financial and mental health issues. And they’re not stupid: they know exactly what their employers are depending on, to free up beds. That these young people are trained, pressurised, and ultimately programmed to operate within an NHS that relies on human misery to create capacity is yet another sign of a healthcare system at breaking point. To make a dent in these systemic problems, the service urgently needs money and personnel — not a spate of excess deaths.

The BBC series is the NHS flying a tattered flag. It contrasts the maternity units of the NHS with the soothing hotels that are private London clinics. The TV show is a travesty of the book, which I suspect the BBC considered unfilmable, though it would have made for a better, and more chilling, piece of art.

The memoir is riven with self-hatred, and hatred for female bodies. It contributes to the already swollen canon of female shame. Its gaze is so masculine the TV show had to invent a leading female character out of nothing, for balance. Kay’s original women are a collection of constituent body parts, no more. They exist to be judged and be saved. Their experience is laughable.

It is not like that from the other side of the screen. I remember, after my son’s birth in a London teaching hospital, my abdomen swelling with paralytic ileus after an emergency caesarean section. Paralytic ileus is a frozen bowel. It is quite common after abdominal surgery. I begged a junior doctor to help me, since I was vomiting shit into a bowl. He turned away, vexed, and I staggered back to bed.

My journalistic instincts saved me. The next time I vomited into the bowl I took it to the nurses’ station. I was swollen and gassy, and it seemed to take an age to get there. I put the bowl down and said something like: “Is this normal?” I was taken to a high-dependency ward, my stomach was syringed, and I was given a drip, and that saved my life. It didn’t occur to me to complain. I had taken too much morphine during labour — I am a recovering addict and I lied to a midwife to get morphine, about which I am profoundly ashamed — and so it was partially my fault. And I had a live baby.

I think I also had PTSD from the experience, and that is why I didn’t have another child. I don’t think they are allowed to tell you that to have a first child at 40, when obese, is dangerous. It is all dangerous, particularly for black women, who are four times more likely to die during pregnancy in the UK than white women. None of it is laughable unless you yearn for denial.

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Kay himself is in denial. In his memoir, when a baby dies, he “went for six months without laughing”. But he plays it for laughs. He became a comic when he left medicine, shortly after this baby died. “When cornered,” he writes, “I would reach for my red nose and clown horn and bring put my anecdotes about objects in anuses and patients, ‘saying the funniest things’”. This passage comes at the end of the memoir, and it is a fragment of the book he should have written.

But he can’t write that book because it would be too truthful, and it is not the book people wish to read. Instead, we have his disgust, for instance, for old women. He hates the urogynaecology clinic: “a bunch of nans” — defined, with the use of “nan”, by their child-bearing — “with pelvic floors like quicksand and their uteri stalactite-ing into their thermals”. No matter their predicament, the misery is all his: “And then a patient sneezes, you have to get a mop and bucket.”

We have his disgust for the sex worker who has a Fireman Sam sponge trapped inside her. She needs to repress her menstruation so she can have more clients, and more money. (She does not know the contraceptive pill will do this for her. The insertion of the Fireman Sam Sponge was pitiful, not laughable.) Stolen or not — I have no idea how Kay approaches patient confidentiality — I would love to read her story. Instead, we read of her smell: “I imagine every bunch of flowers in the hospital suddenly wilted.” “Christ knows,” he adds, “how she explained the change in [Fireman Sam’s] appearance to her children.” It is vexing too that the sponge, “had been schnitzel-ed flat by her clients’ pummellings”.

Women are reduced, consciously or not, to a series of stinking and repulsive orifices with imbeciles attached to them. The misogyny — the dehumanisation I am sure kills women — is relentless. At one clinic the women are, “crotchety as a pen of wet hens…they grunt their way through their appointments”. He is similarly glib about the woman who sleeps with three men in one night and asks if, under these circumstances, the morning after pill will still work.

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Another sex-worker, a stripper he meets at a stag night, has “Trichomonas Vaginalis…the tell-tale green discharge residue on the stripper’s vulva”. A woman with an open abdomen is “a horrendous Teletubby”. Another has a “grossly swollen vulva from a mistletoe contact allergy”. A woman was admitted who placed a Kinder Egg containing an engagement ring for her lover inside her, and it got stuck. It is, for Kay, “unexpected, disgusting”. It was a mistake, and it wasn’t supposed to be public. It wasn’t public, until she had the misfortune to meet Adam Kay.

He mocks, too, women who seek to control their terror in their own ways: the woman who tries to eat her placenta but eats instead her blood clots by mistake; the woman who arrives with a “nine-page birth plan, in full colour and laminated”. I think of why she did this, and how she felt when she did — I remember folding my unborn son’s clothing again and again, like a charm — but Kay has no time for this.

One anecdote exposes the depth of his self-deception. He sees a teenage girl who tried to trim her labia, because she thinks it is too big. Kay is horrified: “How long,” he asks, “until we are seeing girls stapling their vaginas tighter?” The answer is a year. His colleague meets a woman who superglued her vagina on her lover’s insistence, to make it tighter. Yet what woman reading his memoir could feel anything but horror for her own body, its secretions and its magic?

Kay, whose father was a doctor, regards medicine with Oedipal rage. I don’t think he ever wanted to do it. He has valuable testimony on the plight of junior doctors, and the chaos of parts of the NHS, but he confuses righteous anger with his own pain and, in doing so, makes a bonfire of the privacy and dignity of his patients. Saving their lives is only his permission to despise them. He is utterly oblivious to the intensity of female shame; in his metier and his chronic self-absorption, he courts it, but he still thinks himself decent. When he says, “this is going to hurt”, he is not speaking of his patient, but of himself.

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You can’t expiate your pain at the expense of women at their most vulnerable. There is too much disgust with women’s bodies in the wider culture. Not maidens, of course (like babies, they are perfect) but women doing what their bodies are supposed to do. But even when Kay’s paper women do this — and they do nothing but this, with blood and screams — they do not feel real, because in his writing they do not have souls.

Even the invented female character for the TV show — a fascinating young woman, bright and diligent — is diminished, quite literally, by her appearance in his story. She dies and, if you consider his genre, it does make sense. Some women are turned into constituent body parts. But if you are important enough, you might make to corpse.

Surely the answer is something like this: we look to the end to make sense of the whole. This is where things come together, or not. Where the point is revealed, where some sort of unity is achieved or isn’t. The end gives the story its meaning. Significantly, the word “end” can mean both last things and purpose.

As with novels, so too with human lives. We are story-seeking animals. Even in a post-Christian society, we retain some residual sense that how we end — how we die — contains a special significance for the meaning of our lives as a whole. And this is why there is something especially disturbing about the findings of a Lancet Commission report published this week, that argues we have over-medicalised death and have lost a sense of what a good one might look like.

Imagine if we were to take a look at the last few pages of the book of our lives. There we are, in a huge hospital, surrounded by masked medics and machines. We are not doing very much because we are all doped up. And due to Covid, not even in the presence of our loved ones. The ending is one of medical failure. “This situation has further fuelled the fear of death, reinforcing the idea of health-care services as the custodians of death,” says the report.

We die when the experts “cannot do any more”. It’s not much of an ending. This is not a criticism of the people we have tasked with keeping us alive. But more a question about what it is to live without a narrative sense of our own ending. For without some hermeneutic rhythm of beginning and end, our lives — like Arnold Toynbee’s view of history — are “just one damn fact after another”. There is no conclusion, no purpose, no narrative arc; just a succession of inconsequential events with our death having no more or less meaning than any other event. The contrast with the religious worldview couldn’t be stronger.

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Yesterday was the feast of Candlemas, the last day of the Christmas season. Jesus is taken into the Jerusalem temple as a child and an elderly Jewish gentleman recognises Him to be the promised Messiah, the light of the world. “Lord, now lettest thou thy servant depart in peace, according to thy word,” he exclaims, words that get sung as the Nunc Dimittis every day in churches and Cathedrals up and down the land. Or, in less floral language — I have seen what I wanted to see and I can now die happy.

Christmas, the celebration of a birth, ends with the anticipation of a death. Not just that of Simeon, but also of the child himself. “And a sword will pierce your own heart too,” Simeon tells Mary darkly, a reference to the agony she will experience when she watches her child – and He will always be her child – die in agony, executed by the Romans.

I have been taking funerals for 30 years, and they all have concluded with Simeon’s words. Earlier this week, I used them at the bedside of a parishioner to whom I gave the last rites. The promise they hold out is of a life that reaches some sort of conclusion, where the threads of our story come together.

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For those of us who are religious, this narrative arc is curated through a wider cosmic narrative in which human lives conclude in a return to the loving embrace of the Almighty. Across the West, these meta-narratives are mostly forgotten or have been deliberately abandoned. Life is now “one damn fact after another”. Death is of no more narrative significance than any other moment in time.

If you ask people how they want to die, they often say quickly and in their sleep. It is as if they don’t want to be aware of death as something that happens to them. And those at the bedside — if they are lucky enough to be able to be there — can sometimes co-operate with this sense of denial with well-meaning words of getting better, “you will be up on your feet in no time” and so on.

In this world, the book doesn’t have an acknowledged ending. From a religious perspective this all feels a little ironic. We are often told we are the fantasists about death, pretending it doesn’t happen with all that talk of everlasting life.

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At the bedside, priests often talk about death to those who are saying their goodbyes. And equally often, they are obstructed from doing so by family members who maintain it isn’t going to happen. Even at funerals, we are sometimes instructed to wear brightly coloured clothes, and to celebrate a life rather than mourn a death.

Atheists will say that we all need to face the fact that, ultimately, we are nothing more or less than food for worms and daffodils. That eternal life is a fantasy designed to give the clergy some sort of control over people’s lives. Auguste Comte said that the afterlife produced “slaves of God”. But atheism has arguably made us less able to talk about death, not knowing how it fits into the story of our lives. Instead of bravely facing death, too often the secular world ducks it.

When I die, don’t you dare come in a bright jumper. I want a church full of Sophia Loren look-a-likes under their black veils bawling their eyes out. These days, it is often secular death that refuses to think of death as real.

“How people die has changed dramatically over the last 60 years” writes Dr Libby Sallnow, co-chair of the Lancet commission and a palliative care consultant, “from a family event with occasional medical support, to a medical event with limited family support. A fundamental re-think is needed.”

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It is no coincidence that the 60 years the good doctor refers to here is roughly the time scale of what we might call contemporary liberalism (older, better versions are available) — that is, the rise of autonomy and self-determination as the ultimate matrix of moral value. I suspect that part of the reason we have become so inarticulate about death is not about increasing squeamishness. Our society has been reconstructed around the centrality of the “I”. The moral priority of individual choice has nowhere to go with death, something we mostly do not chose, and something that represents the absolute obliteration of this ever demanding “I”.

The great archbishop William Temple once wrote that the true aim of all religion is to “transfer the centre of interest from self to God”. When you centre your life on something that is more important than you, then your own death ceases to be the destruction of all you care about. The message of most religions is simply: “it’s not all about you”; it is a message both of challenge to the nagging demands of the ego and yet one of ultimate hope.

This is the very opposite of the liberal worldview, that predicates value upon the making of individual choices, and has no sense of what a decentred self might look like. In other words, contemporary liberalism has no way of looking death in the face, no way of answering it back with the words “where is your sting?”, no way of singing the Nunc Dimittis. No wonder we are all so afraid.

I hurry to my consulting room and briefly go over my schedule for the day — one morning clinic from 8.30 to 12, an afternoon telephone clinic from 2 to 5, and an hour for admin from 1 to 2. I have two scheduled coffee breaks as well, which I won’t use for coffee: I always try to schedule them after my trickier patients, so that when they inevitably overrun, it is not into another patient’s time. I am a trainee doctor, having qualified from medical school two years ago, so my appointments are 15 minutes long rather than 10 minutes, and I have time at the end of my day to debrief with a supervisor.

At 8.45, I go to the waiting room to call my first patient, Mrs Smith. She is hard of hearing and I don’t know what she looks like, so it takes a minute for her to acknowledge me. It takes a further two minutes for her to walk to the consultation room, because her ankles are swollen and she walks with a stick. By the time she has managed to sit down in the chair and remove her coat, nearly half of the appointment time has gone.

Mrs Smith starts to talk about the weather. I interrupt and remind her we need to keep on topic. As a medical student, I watched qualified doctors talk over patients in this way and thought naively that I would never be so rude. But it only took a few weeks of working in General Practice to realise that being brusque and firm is essential, unless you have hour-long appointment slots. Mrs Smith looks crushed. I suddenly remember that she recently had an appointment with my colleague following a bereavement, and that I am perhaps the only person she will speak to today. I constantly feel pulled in two different directions — forced to choose between doing the best for the patient in front of me, and doing the best for the patients waiting for me.

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She eventually tells me that she has come to see me about breathlessness. When I hear that word, a list of potential diagnoses pops into my head: infection, lung disease, fluid overload, cancer, or perhaps a more niche disorder I’ve only seen in a medical school textbook. To determine which seemed more likely would require me, at the very least, to take a 20-minute “history”, but if I want to examine her, that would leave us with around three minutes, not including the time required to write out any prescriptions and refer Mrs Smith, if necessary.

Mrs Smith seems slightly annoyed when I ask about her medical history: “Isn’t it in my notes?” She’s right — it probably is somewhere in her electronic record, but I haven’t had a chance to click through its entirety, and long gone are the days when GPs know each individual patient. On average, there is one qualified GP for every 2087 patients.

This ratio is worsening year on year, partly because the population is increasing, but also because the pool of full-time GPs is shrinking. It’s not surprising. In the UK, the average full-time employee works 35.7 hours a week; 48 is the statutory maximum. General Practice is often seen, even among doctors, as the ‘easy’ way to practice medicine: the equivalent of a 9 to 5. But full-time GPs work 48 hours a week, while “part-time” GPs work 35, not including the unpaid hours when clinics overrun, or the time spent on admin at home.

No amount of time ever seems to be enough, though. I was reluctant, for instance, to examine Mrs Smith on the bed, rather than letting her remain in the chair, because I knew it would take at least five minutes to get her on and off it. But my conscience got the better of me. As I assisted her onto the trolley, I mentally readied myself for complaints about waiting times later in the day. I can deal with angry patients; Mrs Smith’s health cannot deal with a misdiagnosis.

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Mrs Smith’s breathlessness, I decide, is most likely related to her heart failure, and that the best course of action would be to increase her diuretic dose to try and get some of the fluid off her lungs. But Mrs Smith has chronic kidney disease — which is common in the elderly — and increasing the diuretic dose might exacerbate it; I want to schedule her a blood test for the next week, to check. She takes out her diary, which I cross check with the phlebotomist’s diary — which feels like a bad use of my time. I find myself becoming frustrated.

As I begin teeing Mrs Smith up to leave, she bursts into tears and says it’s just so hard without her husband. Perhaps, I think guiltily, the breathlessness was just an excuse to talk about her bereavement. But I have seen one patient and I am already running 30 minutes late: I cannot comfort her now but offer a follow-up appointment to talk about how she’s coping generally. I have a free slot in 2 weeks. At the end of this consultation, I don’t feel like a good doctor; I feel like I rushed a grieving old lady with complex health issues. I tell myself to think about it later, when I have time.

By the time Mrs Smith leaves the room, my next three patients are already waiting, but I need to wipe down the chairs, bed and door handle: Covid is still with us after all. My next patient is Luke, a young man I have been seeing regularly due to his deteriorating mental health. He is unemployed, in serious debt and has recently split up with his girlfriend and moved in with his alcoholic father. We are both aware that his low mood and anxiety are mainly down to these circumstances — but I cannot fix them, so I have prescribed him an antidepressant and referred him for counselling.

Today, Luke is agitated. He tells me he is having serious thoughts about driving his car off a bridge. I screen for protective factors — a support network, a hobby, any hope for the future — but find none. Luke accepts my concern and agrees to be referred to the mental health crisis team. The person who answers my call is a trainee and wants to discuss the case with her boss. I am aware that the mental health team is as stretched as we are, but I can’t help but feel frustrated: it takes thirty minutes for her to call back. During this time, I do not feel comfortable asking Luke to leave my room, so we make awkward conversation as my patient list builds up.

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When the phone eventually does ring, I speak to a mental health nurse who insists that, because Luke has had previous suicidal ideation that he has not acted on, his latest symptoms don’t constitute an acute change. Luke does not need to be reviewed by their team, she tells me. I need to take responsibility for discharging him. I don’t feel comfortable doing this, so we go back and forth until she eventually agrees to contact Luke later that afternoon. As Luke grunts a thank you and leaves the room with his head down, I am not sure that I have helped him at all.

There is no time to dwell, however: I need to write a detailed entry in Luke’s notes. In theory I am doing this to provide an accurate history of his condition to help him get the best treatment possible from subsequent professionals. In reality, I am doing it to protect myself in court should harm come to him.

Fortunately, the rest of the morning’s cases are simpler: a child with a urine infection, a man with a fungal rash, a woman who wants a repeat prescription of her contraceptive pill. I rush through them, grateful both that I have a chance to catch up and that, if the patients are angry about their wait, they do not show it.

I finish my morning surgery at 1.15, over an hour late. As usual, I will have to eat as I go through my admin. Patients often wonder what I do when I am not actively seeing them. They don’t realise that I have to sign every repeat prescription request, even if the patient has been on the medication for years. I can do this well, or I can do it badly.

If I do it well, I will read through their entire list of repeat medications, making sure that another doctor hasn’t started them on any drugs that might inadvertently interact with the ones they’re already taking. I will check that they haven’t been on a medication for years that should have been stopped after a certain period of time. I will see if any checks are overdue. If any of those things are the case, I need to ‘action’ them — by sending a letter to the patient to ask them to come in for a check-up, or by writing to their specialist consultant about changing their medication.

If I did it badly, I would just sign.

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Next on my admin to-do list is to read through letters sent from secondary care. Today, I note that Mrs Jones, who I referred a few weeks ago with a breast lump, has been diagnosed with cancer. I call her to schedule an appointment to talk through everything. Finally, I catch up with my admin from the morning clinic that I didn’t have time to do during the appointment — like sending Mrs Smith’s referral.

The afternoon clinic is a telephone surgery, for which I am grateful. It means that patients won’t be getting agitated in the waiting room if I have another Luke or Mrs Smith, but can instead get on with their days as they wait for my call. I can also choose the order in which I call patients: I scan the afternoon’s list, scheduling simple prescriptions for acne and leaving a young woman with a recurrent sore throat until later in the day. I know that she is becoming fed up with the GP management of her condition and that the phone call is likely to be a difficult one.

Because it’s easier to read the guidelines for a condition during telephone surgery, by the time I phone her I am able to apologetically inform her that she does not meet the referral criteria for a tonsillectomy. The patient is angry. Her affliction is interfering with her job and private life; I know she cannot understand why the people who are meant to help her will not. I understand, but I am also affronted. It would be much easier if I could pass her on to the hospital, instead of prescribing another packet of throat lozenges, but I know that the referral will be instantly rejected. Of course, this is as much to do with the risks of surgery as the pressures on secondary care, but the patient does not care about that. As her anger dies down and she says goodbye, I find myself hoping she will eventually get fed up of calling. I admonish myself and decide to refer the patient anyway. At least then I can tell her I tried my best.

My final phone call of the day is with a patient who has some sort of pain somewhere, but it’s hard to work out where because there is a significant language barrier. I get put on to someone — a nephew, I think — who tries to explain, in slightly less broken English. In the end, I make the patient a face-to-face out-of-hours appointment with a colleague, and add a warning in her notes that it is not suitable to offer her a telephone appointment in the future.

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Before I leave, I have a debrief with one of the GP partners. I hover outside his door, listening for a gap between his phone patients. When I eventually enter, he has his head in his hands, but quickly springs to attention when he sees me — he is keen to train more doctors after all, and tries his best to shield me from the pressures, and focus on the positive aspects of a job he once loved.

But I know that he has stayed late each night this week and that in his spare time he obsesses over the — increasingly negative — Google reviews of the practice. I don’t want to take up his time, but if something goes wrong with one of my patients after I had chosen not to discuss their case with a senior, I could end up in hot water legally. So I rattle through my day while he nods and occasionally interjects with suggestions.

Once I get home, I try to relax, but thoughts continually flash into my head: didn’t you rush those “easy” patients a bit? Are you sure the diagnoses weren’t actually urosepsis and a malignant rash? If harm comes to them, they will blame me, and I will blame myself.

My phone buzzes with messages from colleagues from my previous rotation, a surgical job. They joke that I am living the dream, working 9 to 5 — that I spend most of my time sitting down and refer any real problems onto the hospital. I turn off my phone and head to bed. I have decided not to apply for GP training.

Proposition one: no one wants to die. As a rule, we prefer a diminished life to no life at all; because we think we will always have the little pleasures of life. And are there any pleasures other than little ones? That is a subject worth exploring.

Proposition two: no one wants to suffer. Suffer physically, that is. Moral suffering has its charms, it can even generate aesthetic material (as I have discovered for myself). Physical suffering is pure hell, devoid of interest and meaning, from which no lessons can be drawn. Life has been sketchily (and falsely) described as a quest for pleasure; it is, more accurately, an avoidance of suffering; and more or less everyone, given a choice between unbearable suffering and death, chooses death.

Proposition three, the most important of all: physical suffering can be eliminated. At the beginning of the 19th century, morphine was discovered. Many similar substances have appeared since then. At the end of the 19th century, hypnosis was rediscovered; it remains little used in France.

Ignorance of these facts might explain the alarming opinion polls which support euthanasia (96% in favour, if I remember correctly). Ninety six percent of people think that they are being asked the question: “Would you rather be helped to die or would you like to spend what remains of your days in appalling suffering”. The other 4% know all about morphine and hypnosis. Those proportions seem about right to me.

I’m going to resist launching into an argument for the decriminalisation of drugs here (and not just “soft” drugs); that is a subject on which I yield to the wisdom-filled observations of the excellent Patrick Eudeline.

Partisans of euthanasia like to gargle on words whose meanings they distort to such an extent that they should no longer even have the right to utter them. In the case of “compassion,” the lie is palpable. When it comes to “dignity”, things are more insidious. We have seriously deviated from the Kantian definition of dignity by substituting, little by little, the physical being for the moral one (and maybe even denying the very notion of a moral being), substituting the human capacity for action with a shallower more animal concept of good health — turned into a sort of pre-condition of all possibility of human dignity, even maybe its only true meaning.

Put in this way, I have rarely had the impression that I have manifested extraordinary dignity at any time in my life; and I do not have the impression that this is likely to improve. I am going to end up losing my hair and my teeth. My lungs will be reduced to shreds. I will become steadily more or less impotent, more or less incapable, perhaps incontinent and possibly even blind. Once a certain stage of degradation has been reached, I will inevitably end up telling myself (and I will be lucky if it is not someone else pointing it out to me) that I no longer have any dignity.

Well, so what? If that is dignity, one can very well do without it. On the other hand, everyone more or less needs to feel themselves necessary or loved; and, failing that, esteemed—even in my case admired. It is true that can also be lost; but one cannot do much about that; others play in this respect the determining role. And I can easily imagine myself asking to die in the hope that others reply: “Oh no, no. Please stay with us a little longer.” That would be very much my style. And I admit this without the slightest shame. The conclusion, I am afraid, is inescapable: I am a human-being utterly devoid of all dignity.

Part of the usual sales pitch for euthanasia consists in maintaining that France is “lagging behind” other countries. The preamble for the bill that will shortly be proposed is in this respect comical: looking for countries that France is allegedly “lagging behind,” they can only find Belgium, Holland, and Luxembourg; frankly, I am not impressed.

The rest of the preamble consists of stitching together citations from Anne Bert, presented as “admirably forceful”, but which have the unfortunate effect of raising my suspicions. For example, when she maintains: “No, euthanasia does not fall under the heading of eugenics.” On the contrary, it is obvious that the partisans of both the ideas are exactly the same people, from the “divine” Plato to the Nazis. Likewise, when she adds, “No, the Belgian law on euthanasia has not encouraged inheritance theft.” I admit that I had not thought of this, but now that she mentions it…

Immediately afterwards, she lets the cat right out of the bag by claiming that euthanasia “is not a solution of an economic nature”. There are, however, indeed certain sordid arguments that one only hears from “economists,” insofar as that term has any meaning. None other than Jacques Attali has insisted, in an already dated work, on the cost to the public purse of maintaining the lives of very old people; it is hardly surprising that Alain Minc, more recently, has gone in the same direction, Attali just being a stupider version of Minc (without even speaking of that clown François de Closets, who is something like the performing monkey of the other two, their Hanswurst).

Catholics will do their best to resist, but, sad to say, we have more or less got used to the idea that the Catholics always lose. Muslims and Jews, on this subject as on other subjects deemed “societal” (that ugly word), think exactly the same as Catholics; the media are generally in strong agreement about hiding this fact. I do not have a lot of illusions; these faiths will end up by giving way and submitting to the yoke of “republican law”. Their priests, rabbis, or imams will in future visit euthanasia candidates to tell them that yes, it is an ugly business, but tomorrow will be better, and that even if people have abandoned them, God will take care of them. Let us be honest about that.

From the point of view of the Lamas, the situation is without doubt even worse. Any attentive reader of the Bardo Thodol knows that death throes are a particularly significant moment in a man’s life, for they offer him a final chance, even in the case of unfavourable karma, to free himself from samsara, the cycle of rebirth. Any early interruption of death-agonies is thus a frankly criminal act; unfortunately, Buddhists rarely intervene in public debate.

There remain only the doctors, in whom I had placed little hope, doubtless because I am not very familiar with them; but it is undeniable that some of them resist and refuse to kill their patients and that they will remain perhaps the last barrier to euthanasia. I do not know where they get this courage; maybe it is only respect for the Hippocratic oath: “Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course”. It is possible. The public uttering of this oath must have been a significant moment in their lives. In any case their struggle is an admirable one, even if it is a struggle “for honour”.

The honour of a civilisation is not exactly nothing. But really something else is at stake; from the anthropological point of view. It is a question of life and death. And on this point I am going to have to be very explicit: when a country — a society, a civilisation — gets to the point of legalising euthanasia, it loses in my eyes all right to respect. It becomes henceforth not only legitimate, but desirable, to destroy it; so that something else — another country, another society, another civilisation — might have a chance to arise.

This essay appeared in Le Figaro on 5 April 2021. Translated for UnHerd by Dr Louis Betty.