welcome to hardtalk. i'm stephen sackur. doctors take an oath to "do no harm". we trust them — we have to — to do all in their power to diagnose and treat us and, if they possibly can, make us better. but sometimes they can't. what should doctors do when confronted with terminal illness that brings with it great suffering? well, my guest today is a doctor who believes in assisted dying, and it is personal for henry marsh, a leading brain surgeon who has an advanced form of cancer. should death ever be the desired outcome for a doctor? henry marsh, welcome to hardtalk. thank you. you received a cancer diagnosis last year — so i think i have to begin by asking, how are you? well, i'm pretty well, all things considered. and as a doctor, of course, i know how bad things can be. i was diagnosed a year ago now with what's called advanced prostate cancer — not necessarily terminal, but it's spread beyond the prostate. and my psa, which is a marker of the severity of a disease, and the probability of recurrence and ultimate death was very high — 130. only 5% of men have a psa as high as that. so, obviously, this was deeply upsetting and shocking at the time. and i've been having to come to terms with it since then. it's quite a long and complicated story. as a doctor, of course, i spend all my life living in a world of death and suffering. but right from the start of your career as a doctor, you learn detachment. you have to be. you try to find a balance between compassion and detachment. but when it comes to you, obviously, it feels utterly different. and the more i thought about it initially, as panic—struck as we all are, it struck me the really important thing was not... i'm 71, i've had a good life. although my family obviously want me to live longer, and i want to live longer, i've achieved as much as i can. i'm very privileged and lucky, in that sense. i've got no bucket lists. and it seemed to me what was really critical was actually what my dying will be like, rather than when it comes. and the irony here is that prostate cancer typically spreads to the bones — mine hasn't yet — and typically the spine, where it causes paralysis. and i must have treated and operated upon hundreds of men with prostate cancer which has spread to the spine. and it is not a good death, in my opinion. i didn't actually look after them in their terminal disease. one ortwo, i did, for sort of different reasons. but you end up paralysed, doubly incontinent, unable to care for yourself. and it can be quite a long, drawn—out process. is this knowledge that you have a help or a terrible burden and hindrance to you? i don't know. i don't know what it would be like if i didn't have this knowledge. but it seems to me i would find it very helpful at this stage, when i'm still quite well, to know that if my ending was going to be particularly unpleasant, that it need not be. in fact, i have my own suicide kit, as i've written about in one of my books. but i'd much rather die legally, officially helped by a colleague, when i have to kill myself in private, which is deeply distressing for one's family. i'm going to stop you here because there's so much that's so powerful and interesting about what you've already revealed of your own situation. but it just. .. to start with, i'm intrigued that you are, at this point, so focused on what your death will be like, rather than the process of — to use the cliche so often used with cancer — rather than fighting the disease. oh, well, that's a waste of time. i mean, i've had treatment. i need to get on with my life, do the things i want to do, which is mainly writing and seeing as much of my grandchildren as i can. i'm lucky the treatment�*s been all right. i mean, the effects of chemical castration — i could do without them, but they're not that bad. i don't believe in all this fighting cancer business. i'm fighting the side—effects of the treatment, but that's a different question. but i'm a doctor. i've seen so many people die, many of them younger than myself. they wanted to live, go on living, as much as i want to go on living. so i'm, in a sense, fatalistic about it. i want to ask you about that experience of yours and what it means to you, because i just wonder, now that you yourself are in this terribly difficult position, knowing that you have a potentially terminal illness, has it made you reflect on the way you treated your patients who were in a similar position? and, looking back, do you think you might have done things a little differently? the answer is yes. i mean, it's such a common observation from older doctors, who say, as i now say... i was just recording a lecture for colleagues in america this morning, talking about this very point. it's such a common observation. it wasn't until i became a patient myself that i really understood what my patients were going through. now, as i said, we have to have a balance between compassion and detachment as doctors. if you were truly empathic and felt everything your patient felt, you couldn't do the work, you know? you'd be so over—invested emotionally? exactly, but to find that balance is very difficult. but what concerns me most of all now is if... you know, we don't have legal assisted dying in this country — many other countries do, and if there's time, we can talk about that later. but it is quite likely, if i am unlucky, that i will suffer quite a lot when i'm dying. i may not if my suicide kit works. but why should i have to suffer? because, you know, the opponents of assisted dying in this country are a very vociferous minority of palliative care doctors and christians. why should i have to suffer? and the answer they come up with is, "well, because other vulnerable people "will be bullied or pressurised "into applying for assisted dying "if it was legal in this country." yes, let's just be clear on the terms here. you talk of assisted dying. the word i associate with this is "euthanasia". are they very much the same thing? well, euthanasia got a bad name because of the nazis�* euthanasia policy with disabled people in the 1930s. so, the phrase people use nowadays is assisted dying or doctor— or physician—assisted suicide. and it comes... which is, sorry to interrupt, but... it is euthanasia. well, it's a form of euthanasia and it is illegal, quite clearly illegal... in this country. ..in england and wales. there is a law, i think it dates back to 1961, which makes it plain you can be imprisoned for up to, i think, 1a years. 1a years, that's right. so in theory, if you buy somebody plane tickets to go to zurich, to the dignitas clinic, you could, in theory, end up in prison for 1h years. now, having said that, there are many ways of legalising assisted dying. it's quite a complicated area. you can have it, as in california, where the patient has to take a lethal drink themselves. there's proof they want to do it. but it means, of course, if you can't swallow, if you're paralysed, you can't do it, so it's actually quite discriminatory. or in countries like switzerland, belgium and holland, who have more what i call liberal policies — with intractable suffering, if you have motor neurone disease, where you might live for years and you don't want to live like that, you can have it. and then you have the more restricted forms you have in some of the american states like oregon, where you have to have a terminal diagnosis of six months. now, purely personally, that would be fine for me if i end up paralysed from my prostate cancer spreading to my spine. but my own feeling is there's a much greater need and much more suffering in people who have an intractable illness like motor neurone disease, something like that. and that is recognised in countries like switzerland, belgium and holland. well, i want to go into this in a little bit of detail because it fascinates me that you come at this both as somebody now suffering from cancer, but also, a doctor of many years�* standing in a host of countries, but i'll name a couple — belgium and the netherlands. a medical professional is allowed to be involved... yes, that's right, and can give a lethal injection. indeed. yes. you are a doctor. you wrote a book, do no harm, which explored the ethics of being a brain surgeon. is there any ethical world that you've ever occupied where it seems to you right that a doctor should be actively involved in seeking an outcome which is death? yes, of course. the role of medicine is to reduce suffering as much as to prolong life. you don't prolong life at any cost. and legally in this country, we're fully entitled, under the mental capacity act of 2004, to say, "i no longer want any treatment." if the doctor says to you, "another course of chemotherapy "might help you live a bit longer, "but it might have many unpleasant side—effects," you're legally fully entitled to say "no". so you can say legally, "i want to stop." but you can't say how orwhen, orwhere. so it is deeply inconsistent. you are now supporting another — i say another advisedly — attempt in the british parliament to get this 1961 law changed. this was last attempted in 2015. it was voted down by a very big majority of elected members of parliament. the mind of parliament appears to be made up that it does not like the idea of assisted dying. things have changed over the last six years, partly... the point is, this is no longer an evidence—free zone. we have evidence from countries where assisted dying is legal. but the objections to it, which were all hypothetical, don't seem to apply. and if you read, as i have done, the hansard account of the debate in parliament six years ago, it was appalling! there were lies and untruths being told. complete nonsense. well, let's go through some of the arguments, because these aren't just about the uk. this is a universal ethical argument. you say the arguments against are all hypothetical. yes. some are just deeply moral. some are concerned with this word "dignity" that you and others in the sort of "dying with dignity" movement, as it's called, have co—opted. you want the word "dignity" to belong to you. but there are many ethicists who say that's fundamentally wrong because it implies that there's something intrinsically undignified about living with terminal illness and living with pain. not necessarily. the point is there are many ways of dying. you know, there's no single way of dying. we're all the same when we're dead, and the last few hours or days are more or less the same. but there are many, many ways of dying and some are deeply undignified. are they, though? says who? who are you to define somebody else�*s indignity? well, i can tell you... i mean, if you read my second book, there's a story of a man i cared for who was dying from multiple faecal fistulae. i mean, i don't want to go into it. a lot of these things aren't talked about in public, because actually, they're really very distressing. the idea that death is a sort of peaceful fading away, it... well, there is palliative care, and it has so advanced now in so many different areas. yes, but, i mean... it is a lie — to put it in extreme terms — that with good palliative care, dying is always easy. any palliative care doctor willadmit, if you nail them to the floor, that that is not the case. yes, we need more palliative care in this country. palliative care was invented in this country, it's something to be immensely proud of. i've got some very good friends who are palliative care doctors, but it still doesn't resolve the problem of autonomy and dignity, and the fact that some dying is very unpleasant, despite good palliative care. does it matter to you that some people who, unlike you, have lived long term with severe physical disability and challenge, and problem — they don't like the idea of assisted dying? that's fine, but this is not... i looked after large numbers of gravely disabled patients as a neurosurgeon, and i was more often deeply impressed how long—suffering and brave they were about it. but the point is this — assisted dying is not about licensing doctors to kill patients. the opponents to assisted dying have somehow recruited some of the disability organisations into the idea that this is all about bumping off disabled people. well, no, i'm not sure it's as simplistic as that. here's the words of the disabled crossbench peer baroness campbell. yes, yes. i'm sure you've had discussions with her. she says, "disabled people want to trust our doctors to do "everything in their power to help us live a good, "pain—free, dignified life until we die, "without the burden of wondering if they think it "would be in their best interest and ours "if we accepted their option of assisted dying." well, ifind that deeply insulting as a doctor, to think that doctors are thinking about their best interests are wanting to get rid of patients. i mean, that's absurd. and, again, where is the evidence? you may think it's absurd, but that is what some people are thinking in response to your insistence that assisted dying become legal. i accept that. then i say, "well, look at the evidence of countries "where it's available. "is there any evidence that this is happening?" well, interesting you should say that. ijust explored a little bit the debate in, say, the netherlands. now there are people intimately concerned with the netherlands�* initiative — and i think it goes back to the early 2000s — to legalise assisted death. there are voices who say it is worrying, the way it�*s worked in this country. because it was initially designed only to allow assisted dying for those in the most unbearable pain in the course of terminal illness. but it seems, to some, as though the definition has been expanded. it�*s become something more — described by one professor theo boer — as "becoming a kind of project which people are managing in terms of allowing a dignified death." but that wasn�*t the original intention. well, first of all, there are always going to be arguments about it, obviously. secondly, you can design your legislation to avoid that problem. one of the big problems here — there have been only a very few rare cases in holland where the assisted dying was granted on the grounds of intractable depression and mental illness — you can design your legislation so you don�*t have it. you know, you�*ll say you cannot get assisted dying if the diagnosis is fundamentally a psychiatric one. but there have been extremely vexing court cases in both the netherlands and belgium. one or two, one or two. but it only takes one or two to plant the idea that, actually, it sounds... the way you describe it, it sounds so simple, so clear—cut. it�*s not. in fact, in the real world, it�*s not. it�*s not clear—cut. but, in the real world, a lot of people have very miserable deaths. you only have to read the book published recently by the dignity in dying campaign, i think called last rights — terrible stories of what goes on in this country. now, every time i operated, there was a risk i�*d make things worse. i mean, that is the nature of medicine — it is uncertain. and it�*s almost you have an essentially utilitarian ethic — "will more people benefit than will suffer?" and you apply that ethic even to the process of assisted dying? yes, i think you have to. so, in some cases, somebody could be assisted to die in circumstances which, upon reflection, were wrong. i think... a mistake. yes. that�*s horrible. no, that is the nature of medicine. you know, you can never be certain. and in retrospect, you may say, "well, that wasn�*t right at the time." but even then... you know, there is no evidence that this is a significant problem in the many countries where this is possible. and the idea that this is kind of suicide on request... in canada, for instance — the law�*s only come into action recently — if you request assisted dying on the grounds of intractable suffering, palliative care is mandated, and there�*s at least a 90—day delay before it might be agreed. and again, at the moment, there is no control. we have assisted dying in this country — it�*s called terminal sedation. it�*s deeply hypocritical. if people are suffering a lot in their final death, which many people do, you give them such large doses of opiates that it speeds the end. and there�*s this total pretence, of, well, "we are not intending to kill the patient," even though the treatment you�*re giving them is actually hastening their death. and the problem with this is it leaves entirely in the hands of the doctors as to when to do this. it cannot be discussed with the patient or the family openly, cos then it�*s against the law. so it is medical paternalism of its worst sort. you�*re not a religious man, are you? no. does it matter to you in any way that religious people of many different faiths find what you are advocating deeply objectionable? well, that�*s fine. they don�*t have to have it. but they can�*t... i don�*t tell religious people how they should live again. again, for them, it�*s not as simple as that, because if your law were passed, they would see it as deeply tainting and toxifying a culture. well, first of all, i think they�*re wrong, and there�*s no evidence that�*s happening in countries where this is the case. and secondly, they have no right to inflict their faith, their religious beliefs on other people. i think i have to, before we end on assisted dying, talk to you about your suicide kit. oh, yes, yeah. well, you smile at me. but first of all, it�*s a very bleak thing to talk about. and second of all... i don�*t think it is. i mean, bear in mind, as a doctor, i�*ve been living with death and dying all my life. and i think the challenge we face is to die well and with dignity. and we all know... my father died from dementia at the age of 96, and one of... i should say, assisted dying does not solve the dementia problem. i�*m not advocating for a moment that people without mental capacity should have any sort of assisted death. because that is another concern. i know it�*s another one. at that stage, i say no — it�*s far too complicated. but my point about the suicide kit is, i mean, you�*re very honest and frank, as you have always been, about your career and your view of medicine. you�*re honest about it existing, but you�*re also honest to say that you�*ve got a colleague on standby who will help you. yes, well, i�*m worried it might not work. i need backup. but then you�*ll be criminalising him or her. that�*s his choice. you�*ve discussed that? oh, yes, of course. and most doctors of my generation, we... you know, it�*s not something you talk about in public, but you often ease the passing. and that became increasingly difficult after harold shipman. and also, because of more and more attention to this. and the mess over the so—called liverpool care pathway. these are very, very difficult areas. but i think we need to talk about them as openly as possible. and death... we all know we�*re going to die, you know, sooner or later. and it is extraordinary how we constantly are in denial of that fact. i�*m like that still. ithink, you know, "i�*ll be saved. i�*m going to be all right at the end." it�*s one of the biggest motivations for religious faith, is the idea of life goes on after death. because it�*s hard—wired into us by evolution. ok, i mean, it�*s called "evolutionary theory". but when we�*re young, we want our... our dna needs to be preserved and if we don�*t look after ourselves carefully, our children won�*t survive, and then we�*re lumbered into old age with this deep wish to go on living. well, all i can say is that, as you talk to me, you seem just as energetic, passionate, and vital as ever. and, given that, i want you to reflect on something which we�*ve all been concerned about in terms of our health and our health care systems in the last 18 months — and that is the impact of the covid pandemic. now, you�*re no longer a practising surgeon and doctor... no, but i�*ve kept in touch with colleagues. ..but you�*ve kept very closely in touch. what do you think the lessons are of covid, particularly when it comes to balancing out the interests of different demographic groups within our society? the young and the old? this is a huge, huge problem. i mean, the fact of the matter is covid was mainly a lethal illness in people in their 80s. something like 85%. now, none of us could live in a society where we say, "over 85? go away and die." and that great barrington declaration, saying the lockdown was a bad mistake, was completely unrealistic and wrong. but the problem is, of course, in the modern world, more and more people are living into old age, and the greater part of all our lifetime health expenses are towards the end of life. and i�*m hearing endless stories of elderly parents of friends of mine — just had one last week — where they get ludicrously over—treated in the hospital. but it�*s terribly difficult. but is it going to...? you know, that reality which you�*ve just accounted for, is it going to ultimately overwhelm a system of health care like the british system, the national health service? i think it could well do. what do we do about it, then? well, ithink i think, for a start, probably, my own feeling is, yes, i agreed with the government having a dedicated tax to spend more money on the health service. i disagree with that, that the burden is taken, borne by young workers. i think pensioners like myself need to pay higher taxes. so changing demographics are one reason that you think our universal health care system, which of course is free at the point of use... is at risk. would you use the word "unsustainable"? well, i don�*t know. i hope it�*s not, because i�*ve worked in many countries where essentially health care is private. these are poor countries, where if you want half—decent health... this is like north sudan and ukraine, and nepal, places like that. and it�*s awful when doctors basically have to work for money. and i was lecturing in karachi a while ago and my colleagues, who were mainly british—trained, said, "you�*re so lucky working in the nhs. when you see a patient, all you have to ask is to know what�*s good for the patient. when we see patients, we have to ask, �*what can you afford?�*" i would hate for... i think the nhs is absolutely crucial, but it does need to be properly funded, and it�*s not. it�*s as simple as that. and your fear is that there�*s no conceivable way in which, given changing demographics, it can ever be...? is that what you�*re saying, or is itjust a case...? it depends on the economy, basically. you know, that ultimately is economics. you know, if the economy does well, we can afford better health care. but it is a huge problem. and there are no easy answers to it. as with climate change, there are no easy answers. if i may, i want to bring you back to the deeply personal as we end. you clearly, having spent a career confronting death in others, now have spent the last few months really looking death in the eye from a very personal point of view. and has it made you feel dark, low, miserable? no, not at all. no, no, i mean... well, 10% of the time, yes. and i had some very bad times to begin with, but i�*m lucky — i�*m well at the moment, you know? and what i have to constantly remind myself of is that, even if i knew i only had six months left to live, it would make no difference to the way i�*m living now. and that, to me, is an enormous privilege, and i�*m very fortunate. henry marsh, we have to end there, but thank you very much for coming in to the hardtalk studio. my pleasure. thank you. hello. well, it�*s going to be cold for another day or so, and after that, things will turn a little less cold, but there�*s a big low pressure out there in the atlantic. you can see the cold fronts sweeping across the uk. behind it, that speckled cloud, the shower clouds, some of them wintry, carried by a pretty cold current of air coming off the north atlantic. but i think come the weekend, this next low pressure — this is another one — will come our way and will also warm things up a little bit, but until then, still the risk of snow and ice through the early hours and into friday, mostly but not exclusively northern parts of the uk. so, here�*s the weather map, the forecast early friday. you can see wintry showers across the pennines, the highlands, parts of northern ireland, too. temperatures close to freezing early on friday, so icy patches possible. again, mostly across the northern half of the uk and the south, it�*s just a little bit too mild. on the whole, not a bad day for many of us across eastern areas of the uk. out towards the west, we�*ll have those showers and a good old breeze at least for the first half of the day. then in the southwest, we�*ll see a spell of rain sweeping through during the afternoon, so cardiff and plymouth, possibly portsmouth, will be wet for a time on friday before it dries out. here�*s the next low pressure. that�*s the one that�*s actually moving through right now, but this is the next one on friday. and here�*s the weather front, the cold front that moves through during the first half of saturday across the uk. rain and wind — a really unpleasant picture early in the day, but notice that it does tend to dry out at least somewhat second half of the day on saturday, although it could stay wet across eastern areas. you can see the temperatures back into double figures, so it�*s not going to be quite so cold, but the wind will make it feel pretty nippy. and then, sunday, actually we�*re in between weather systems — one out there in the north sea, this approaching. we�*re in between, so sunday isn�*t looking too bad at all. temperatures will be a little lower, between, say, 5—8 degrees for the most part, maybe a little bit milder in cornwall and devon. but on the whole, out of the two days, i think sunday is looking better. and thereafter, it really does turn just that little bit milder with temperatures perhaps reaching 13 degrees in some southern and southwestern areas. bye— bye. this is bbc news with the latest headlines for viewers in the uk and around the world. heavy gunfire in kazakhstan�*s largest city, as russian—led troops arrive top help stop a wave of unrest that has left dozens of people dead. the president will address the nation later. the clashes are taking place just a few hundred metres away from where i�*m standing now. you can hear the sound of shooting and explosions. the australian government rejects claims that novak djokovic is being "held captive" after the tennis star was denied entry for failing to meet covid vaccination requirements. # sweet land of liberty...