Tag: physician assisted suicide

  • August 22, 2026

Old wine in old bottles: the resurrected Terminally Ill Adults Bill

The assisted suicide Bill introduced as a PMB by Lauren Edwards MP comes in exactly the same form as it had when it was Kim Leadbeater’s Bill and left the Commons to go to the Lords (the old wine). And it comes with exactly the same misleading marketing announcements (the old bottles).

Old wine…

The means of establishing eligibility are inadequately specified. Multimorbidity and frailty in the elderly, and physical-mental comorbidity, make assessment far from straightforward for the non-specialist. The Mental Capacity Act with its presumption of capacity is too blunt and non-specific for this purpose. There are numerous potentially remediable needs (social, psychological, functional, environmental) intervention for which might lead to a change of mind, but there is simply no need in the Bill to explore their presence.

Comprehensive and competent assessment is inadequately mandated. The qualification and expertise of the doctors involved is not specified. There is no account of the involvement of non-medics who are often in reality part of end-of-life care teams. The three-person panels described in the Bill are nothing like the multidisciplinary teams that are now routinely part of clinical practice.

Safeguards are inadequately integrated. The three-person panel is too hands off, only coming into play once the key decisions have been made. There is no requirement to talk to a family member. There is no clearly specified independent oversight of the practice of involved staff.

Oversight of the system is inadequately specified. There is little data collection of the sort that we have come to expect for example from the National Confidential Inquiry into suicide and (now returned) homicide. Such oversight as there is, is not independent. The coroner is now excluded from investigating the assisted suicide despite advice that medical examiners are not in a position to take on the work.

Inadequate attention is paid to how assisted suicide will work in the NHS if it is to be delivered (as apparently envisaged) as part of end-of-life care. The role of Hospice staff, palliative care teams more generally or nursing homes where many people spend the last months of their lives are not considered at all and the possibilities of individual or organisational opt out uh sidestepped.

In old bottles…

Not only are the problems with the Bill all the same as they were, its promotion comes with all the same misleading marketing claims. Here are some of the commonest:

The Bill only needs to come back like this because its progress in the Lords was blocked by a small number of ideologically opposed peers.

This line is repeatedly used, sometimes with the modification that the only objectors are religious zealots. It’s a ploy to sidestep a discussion of the objections raised by all the official bodies that were consulted. In truth it wouldn’t matter if every amendment had been proposed by just one peer, what matters is whether the proposed amendments helped overcome the objections raised. That after all was the promise. In fact no important amendment at all was accepted by Lord Falconer and his allies and of course there is none in the re-presented Bill.

The new law is designed to end suffering when somebody is dying

This claim has been a cornerstone of promoters of the Bill such as Dignity in Dying. They routinely exaggerate the horrors of natural death and are adept at using emotive case studies. But suffering does not feature at all in the Bill; amendments requiring for example assessment and treatment by a specialist palliative care service have been rejected.  It is telling that in Oregon requests include the rationale “inadequate pain control, or concern about it”.  Even so it does not feature in the top five reasons cited despite cancer being by a long way the commonest underlying illness.

It is the other 75-80% of recipients that worry experts in end-of-life care because they know people, not all of whom are facing imminent death, are asking to end their lives for reasons like a sense of being a burden, or loss of dignity or loss of independence and they know from clinical experience and research studies that these concerns are strongly associated with vulnerabilities other than simply approaching the end-of-life: poverty, loneliness, family tensions and lack of supportive relationships, mental health problems and especially a tendency to recurrent depression. Supporters of the Bill simply don’t engage with this evidence,

It’s the safest and most robust assisted dying law anywhere in the world (Lauren Edwards)

This claim raises two questions. The first is what measure of safety or robustness is being quoted and the second is whether assisted dying legislation elsewhere in the world is really the appropriate comparator.

In relation to the first question there are a number of metrics that might be used, such as error rates – for example the number of people who die under the legislation without meeting the relevant criteria – untoward incidents such as being given the wrong drugs or delayed or distressing death, unsafe practice, a non-trivial consideration given what we know about how few doctors participate and how idiosyncratic practise has emerged in other countries.  In relation to the second question we might ask whether a more appropriate comparator would be routine clinical practice given that the proposal is to embed assisted suicide in the NHS.

The truth of the matter is that supporters of the Bill don’t know how safe practice is in other countries because adequate data are not collected. It is for that reason that claims of safety are never accompanied by data.

The Bill is widely supported and has a democratic mandate

In fact support for assisted suicide or euthanasia comes from relatively superficial public polling seeking a yes/no answer to structured questions about the general principle. The more information people receive about the practicalities the less enthusiastic they are. Of course the truth is that the Bill itself is not widely supported because just about nobody has read it outside the small group with particular interests in the topic. Even in the debates in the House of Commons it was clear that some of the Bill’s supporters had not grasped the detail of the legislation or its consequences.

Who’s at risk, who might benefit?

All this puts people at risk in direct and indirect ways. Those vulnerable to the direct effects of the Bill are those who do not really have a free choice because they are pushed in a particular direction by external or internal influences or because there are no ready alternatives due to the lack of adequate service provision.

Those vulnerable to the indirect effects are those put at risk by changing attitudes to suicide. Promoters of the Bill are keen to avoid describing it as legitimising assisted suicide but that is what it is. They are likely to make the legally incorrect and logically indefensible claim that what is proposed is something other than assisted suicide and the ethically indefensible claim that it is offensive of opponents to suggest otherwise. Once we accept that assisting some suicide is acceptable- and supporters have made it clear that reasons such as poverty loneliness or a sense of burdensomeness can be acceptable reasons-then we have taken a large step in the direction of abandoning our responsibilities as a society.

Why is this happening? It is not about improving end-of-life care which major lobbying groups like Dignity in Dying have never shown the slightest interest. If improving end-of-life care were the aim there would be no logical reason to reject all amendments (despite claims that of course that wouldn’t happen in the Lords as it had in the Commons) coming as they do from entirely well-meaning and not ideologically opposed groups. But that is not the aim. If we get away from simpering about compassion what emerges clearly is that the Bill is designed to promote what its supporters call choice and autonomy. That is choice for those able to exercise it, presented as something like a consumer choice – hence the celebrity endorsement, merchandise and advertising slogans. Related is the idea of dignity, in one way something that should be attributed to all living things but in the real world a concept that is saturated with the idea of social status. Those endowed with dignity are able to choose how they live their lives and how they manage their deaths – ensuring what Philippe Ariès called the Tame or Beautiful Death.

The motivating ideology behind the Bill is a sort of libertarian individualism which either doesn’t recognize or doesn’t care about those in society for whom “choice and autonomy” is constrained by psychological and social factors beyond their control. Canada beckons – where nearly 5% of all deaths are now by lethal injection and the idea of terminal illness as the only criterion is a distant memory. That’s more than 30,000 people a year in the UK.

  • September 9, 2025

Terminally Ill Adults (End of Life) Bill: how safe are the safeguards?

Leadbeater’s assisted suicide Bill is now with the House of Lords – 2nd reading due to take place on 12 September. On 2nd September I was with a number of experts present at a meeting organised by Baroness Finlay of Llandaff, one of a series aimed at informing peers about the detail of the Bill. Here is a summary of my own presentation, available as a handout on the day:

Safeguards in the proposed legislation

The Terminally Ill Adults (End of Life) Bill introduces a set of circumstances in which it becomes legal to assist the suicide of somebody with life-limiting disease.  One purpose of safeguards in the Bill is to ensure that assisted suicide is available only to those who meet the prescribed eligibility criteria. Safeguards are also required to ensure that the procedures outlined in the Bill are followed to a high standard and that the Bill is having the desired outcomes. Wider claims are made about the effect legislation will have on other risks faced by people with life-limiting illness.

The structures and processes defined in the Bill are located in healthcare services and involve medical practitioners, so the appropriate benchmark for safeguards is not existing international legislation on assisted suicide or euthanasia but safety standards that are equivalent to those found in current UK clinical practice. Safeguards should cover everybody to whom the Bill might apply. For example although the Bill refers to terminal illness, prognosis is notoriously difficult and a fifth or more of those given a 6-month life expectancy may in fact live for years1. Inadequate pain control or concern about it (itals added) is not in the top 5 reasons given for seeking assisted suicide in Oregon2 – which is often cited as a model for UK legislation. Safeguards therefore need to apply not just to those who are facing imminent death or who have uncontrolled pain, but also to those who might have years to live and have no major symptoms.

Safeguards in other areas of clinical practice

Ensuring safety in clinical practice involves: use of standardised (clearly defined) procedures for assessment and intervention that are widely supported by research, ethical guidelines (for example on informed consent) and clinical experience; practitioners who have the experience and expertise necessary for the procedures being undertaken; careful documentation of procedures followed and their effect including untoward events; oversight and regular appraisal of the practitioners involved; oversight and monitoring of the programme function and outcomes – sometimes called clinical governance.

How do safeguards in the two contexts match up?

Clinical assessment – there is no requirement in the Bill that the coordinating or independent doctors undertake any assessment at all of remediable psychological or social influences on the individual’s wish to end their own life, or that they consult family or health professionals who might be aware of such circumstances. This is at odds with standard approaches to assessing a person’s wish to take their own life and with NICE guidelines3 on assessment of similar presentations in other settings.

Clinical experience and expertise – no context-specific skill or experience (such as medicine of old age, end-of-life care or psychiatry) is specified in the Bill for either of the two involved medical practitioners. It is not entirely clear in the Bill if a physician assistant may take one of the “medical practitioner” roles. We know from other jurisdictions that in reality only 1-2% of clinicians are willing to undertake the practical roles specified in the Bill (the majority are GPs) so lack of specified expertise is an unsatisfactory necessity for supporters, to enable implementation of an assisted suicide programme.

Clinical intervention – internationally there is no standardised regime for assisted suicide and none of the drug regimes currently in use has regulatory approval. Side effects and complications are common4 but recording them is not mandated in the Bill. Setting up a medical device and assistance in its use are mentioned but without detail – in other countries this is the means by which euthanasia is effected, either initially or if oral medication fails to lead to death in a timely manner. The supervising medical practitioner does not have to remain in the room with the individual in the time between ingestion of drugs and death.

Clinical oversight and appraisal – The proposed three-person panel will not function like an independent multi-disciplinary team and again has no obligation to undertake its own detailed assessment as a way of corroborating the coordinating doctor’s decisions. There is no specified experience or expertise for the psychiatrist on the panel. An independent psychiatrist may have been consulted about the person’s mental capacity but there is no requirement to follow their advice. There is no mention of annual appraisal of the doctors involved, required in other areas of practice by the GMC.

Clinical governance – careful audit will, as in other jurisdictions, be all-but impossible because of the paucity of data being collected on the individual’s past physical and mental health, psychological state, social circumstances or recent experiences. Very limited data will be recorded on the clinical processes followed and none on complications or side effects. There is no mechanism by which family or others can raise concerns or complaints and no requirement that they are consulted at all; in Oregon 5% of assisted suicides occur without the family being informed2. The commissioner responsible for establishing the programme will monitor “the extent to which the Act has successfully met its aim” and for noting any concerns that have been raised, but there is no specified mechanism by which concerns can be raised.

At the level of investigation of the most serious concerns, automatic referral to the coroner is excluded by the Bill, and participant clinicians are exempted from criminal or civil liability – and presumably therefore professional responsibility.

Does the Bill offer indirect protections to others?

There is no evidence that assisted suicide legislation reduces unassisted suicide by offering a better alternative. To take one example suicides have increased by 20% in Oregon in the last decade. The proposed UK system will not replace travel to Switzerland for assisted suicide, since an estimated half of those who make the journey would not be eligible here5. In the UK,  in the 15 years to March 2025, there were 199 referrals to the Crown Prosecution Service following assisted suicide – 0.003% of all suicides. Five were successfully prosecuted (despite stringent public interest exclusions) and eight were referred onwards for prosecution for homicide or other serious crime6. The Bill does not propose decriminalisation of assisted suicide generally and will not (and should not) make police investigation unnecessary in all cases.

How safe are the safeguards? The professional perspective

Much of the public and parliamentary debate, and opinion polling, has been conducted as if the only issue is the acceptability in principle of physician-assisted suicide. It is not – the immediate question is whether the specific Bill before parliament is sufficiently robust to guarantee the safety of vulnerable people. Official medical opinion is clear on this point – the Royal College of Physicians, Royal College of Psychiatrists, Royal College of Pathologists (for medical examiners), Association for Palliative Medicine and British Geriatric Society have all said that it is not7. Their positions are not ideological ones but reflect concerns about a poorly drafted Bill that fails to provide adequate safeguards for the protection of vulnerable people.

  1. White N, Reid F, Harris A, Harries P, Stone P. A systematic review of predictions of survival in palliative care: how accurate are clinicians and who are the experts?. PloS One. 2016 Aug 25;11(8):e0161407;  Orlovic, M., Droney, J., Vickerstaff, V. et al. Accuracy of clinical predictions of prognosis at the end-of-life: evidence from routinely collected data in urgent care records. BMC Palliat Care 22, 51 (2023); Assisted dying row as patients given six months to live often survive for three years: One in five people given six months by NHS doctors is still alive three years later, figures show Janet Eastham Acting Religious and Social Affairs Editor Daily Telegraph 21 January 2025
  2. https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year27.pdf
  3. National Institute for Health and Care Excellence (Great Britain). Depression in adults: treatment and management. National Institute for Health and Care Excellence (NICE); 2022. https://www.nice.org.uk/guidance/ng222;  Self-harm: assessment, management and preventing recurrence NICE guideline [NG225]Published: 07 September 2022 https://www.nice.org.uk/guidance/ng225
  4. Worthington A, Finlay I, Regnard C. Efficacy and safety of drugs used for ‘assisted dying’. British Medical Bulletin. 2022 Mar;142(1):15-22.
  5. Brewer C, Hopwood MC, Winyard G. Assisted deaths in Switzerland for UK residents: diagnoses and their implications for palliative medicine and assisted dying legislation. BMJ Supportive & Palliative Care. 2024 Feb 1;15(2):259-61.
  6. https://www.cps.gov.uk/publication/assisted-suicide
  7. https://www.rcp.ac.uk/media/rpcbqz4v/rcp-and-rcpsych-joint-statement-june-2025.pdf; https://www.rcpath.org/discover-pathology/public-affairs/royal-college-of-pathologists-statement-on-the-terminally-ill-adults-end-of-life-bill.html; https://www.bgs.org.uk/bgs-position-statement-on-assisted-dying; https://apmonline.org/wp-content/uploads/APM-Position-Statement-on-Assisted-Dying-October-2024-v2.pdf
  • April 21, 2025

The dark ideology behind the assisted suicide campaign

The Terminally Ill (Adults) Bill introduced to the Westminster Parliament at the end of last year seeks to make physician assisted suicide legal in the UK. From the start the legislation, introduced as a Private Members Bill by Kim Leadbeater MP, was recognized as problematic – with numerous ambiguities and gaps where important practical detail was missing. At the first debate in the House (the so-called second reading) MPs were encouraged to vote in favour even if they had misgivings: flaws in the bill as presented would be carefully considered and dealt with at committee stage. What followed instead was a pantomime of manipulation and incompetence.

Of the fifty experts called to give oral evidence to the public bill committee only six were opposed to assisted suicide. Many of the questions were soft-ball invitations to air unsubstantiated claims about the safety of what was proposed and the unalloyed success of implementation in other countries. Witnesses from Belgium, The Netherlands or Canada on mute of course. Proceedings were rushed so that committee members could not have had time to study carefully the more than 420 written evidence submissions.

I was invited to give oral evidence to the committee – initially one of only two psychiatrists, both giving evidence as individuals with relevant expertise. The committee had declined to invite the Royal College of Psychiatrists despite the legislation requiring a change to the Suicide Act (1961) and therefore to national suicide prevention strategy.  No need, said the bill’s co-sponsor Kit Malthouse MP, since we have already invited the General Medical Council – apparently unaware that the GMC is an overarching body regulating medical practice while the RCPsych is a membership body overseeing the training of and representing the interests of psychiatrists. A public outcry led to a U-turn and as a result I was one of three, all seen on different days.

My session was interrupted by Leadbeater who wanted to assure the committee that there is no association between what she is promoting and suicide. The people she is interested in, she says, are not suicidal, they don’t want to die but they are dying – they just want to choose how and when. But the legal definition of suicide makes no reference to the person’s circumstances, only to the act itself. The opening sentence of Leadbeater’s bill says that its purpose is to “Allow adults who are terminally ill…to request and be provided with assistance to end their own life…”.  And Clause 24 of the bill seeks to change the Suicide Act 1961 – which makes encouraging or assisting suicide an offence – to exclude the deaths she proposes in her bill. There can really be no doubt that what is proposed is assisted suicide, and since “suicidal” means “relating to or likely to lead to suicide”, then people requesting assisted suicide are by definition suicidal. What Leadbeater says is wrong legally and logically, so why does she keep saying it?

What is assisted dying? A 2021 Survation poll sheds light on what “overwhelming public support” means.

One possibility is that she is using a campaigning tactic. Assisted suicide and euthanasia have traditionally not been popular ideas with the public and the assisted dying euphemism avoids direct acknowledgement of what is being proposed while having the advantage that a lot of people are unclear what it means in practice. It is also possible that Leadbeater simply doesn’t know the facts about unassisted suicide. In other words she is doing more than deploying strategic vagueness, she is voicing a belief that people who die by suicide in other circumstances are fundamentally different from people who will die by assisted suicide if her bill passes into law. The facts suggest otherwise – for example data from the National Confidential Inquiry into Suicide show that people who have what it called major physical illness and who die by suicide may well have the same characteristics as those who die by suicide and do not have such a physical illness. And why not – there is nothing about having a life-limiting physical illness that protects you from other risk factors for suicide.  Exploring the presence of such risks isn’t intrusive, dangerous, excessively bureaucratic, offensive or unreasonably time consuming – so why will Leadbeater not include it in the bill’s safeguards?

Assessment in Leadbeater’s bill is limited to mental capacity and coercion. That is, whether the individual is able to make a request for assisted suicide, not why they might want to. This framing has been tested repeatedly in committee, for example in relation to undue influence short of coercion, financial worries, psychological problems such as depression or sense of burdensomeness, and severe anorexia. It has proved impossible to get the bill’s supporters to agree to any significant change that would require exploration of and a response to remediable psychological or social influences on the decision to ask for assisted suicide. Proposed amendments are routinely defeated by a block vote and dismissive pushback comes in the form of protests about bureaucratic barriers or deliberate attempts to derail the proceedings. In the end what has emerged, both from observation of committee proceedings and (eventually) from direct questioning of Leadbeater, is that psychological and social assessment isn’t included in the bill because it doesn’t matter what the answer is.

At the core of this position is a libertarian or hyper-individualistic privileging of personal choice to the exclusion of all other considerations: it doesn’t matter why the choice is being made, only that it is being made by an “autonomous” individual.

Leadbeater’s campaign is heavily supported and influenced by Dignity in Dying, an organisation that is estimated to have spent more than £25 million on this project since 2005, when it changed its name from the Voluntary Euthanasia Society. To some extent the nature of their ideology is obscured behind the name change and the marketing techniques they use – slogans, slick advertising campaigns, specious opinion polls and celebrity endorsements – and the ill-informed incompetence of much of the debate taking place at committee stage.

The same obfuscatory function is served by another striking feature of the public debate, which is the extraordinary prominence given to the views of media personalities such as Pru Leith and Esther Rantzen. Leith, Rantzen and others have no particular expertise in the management of life-limiting illness or in understanding what influences suicidal thoughts and feelings, so why are their opinions so routinely reported?  The answer is that their role isn’t simply to promote assisted suicide, the product they are promoting is the way the decision should be made. The celebrity endorsement message is twofold – personal opinion and anecdote is more important than careful appraisal of evidence, and meeting the personal preferences of some individuals is more important than concern about the personal vulnerability of others.

Sarcopod days

A few months ago there was a story circulating about a young woman whose “life began when she was allowed to die”. That is, she changed her mind after being offered euthanasia in the Netherlands. The language is worth noting. Was she really not living before the offer of euthanasia? Dignity in Dying would say not – assisted suicide and euthanasia is “not about shortening life it’s about shortening death”. Even allowing some rhetorical leeway, it is difficult to read this as other than a judgement about lives not worth living. There is a cruel twist in the tail of the assisted suicide campaign. Extreme individualism typically prioritises the wishes of privileged individuals over community or societal needs, and especially over protection of the most vulnerable. Here however we are invited to accept without explanation the request for assisted suicide not because the person making the request is of especially high social worth but because they are leading a sort of un-life, something so self-evidently valueless that there is no need to explore why they don’t want it.

2024 brought the world the Sarcopod – an individual gas chamber in which you can suffocate yourself by pressing a switch to replace the air supply with nitrogen. Initial concerns seem to have focused on the lack of regulatory approvals for the machine rather than the grotesqueness of the idea. Meanwhile Dying with Dignity Victoria has announced an exciting new scheme – The Young Ambassadors, “young people from across Australia who are passionate about improving access and quality of end-of-life choices, including VAD.” They will “Inform young people about end-of-life care choices available to them, including VAD.” And “Connect young people navigating end-of-life care, their carers and families to relevant support and services.” VAD (Voluntary Assisted Dying) means assisted suicide and euthanasia – both now legal in Australia.

Nobody who follows what is going on internationally can possibly imagine that Leadbeater’s bill represents the last we will hear from the assisted suicide and euthanasia lobby.  It is the first step onto a road down which we are being shepherded by radical libertarian ideologues with a chilling agenda for societal change that is far from the liberal reform claimed by their supporters.

  • April 5, 2025

Safeguards in the redrafted Terminally Ill (Adults) Bill: still woefully inadequate

Just before the second reading of the Kim Leadbeater’s Terminally Ill (Adults) Bill I made a note of the ten questions I would want answered before I could be convinced – at even a minimum threshold of certainty – that all safeguards had been carefully thought about and introduced.

Now the bill is back, to be presented at report stage and then voted on at 3rd reading within the next few weeks. My questions weren’t originally conceived to give a score, but to give an idea of how far off the bill is I have gone for a score out of 10, with half marks for a partial response and no marks if the response has been left to later regulations or a code of practice to be written by the Secretary of State – marks only for what’s on the face of the bill.

My conclusion = 2/10, straight fail – resit needed. Here’s why…

1. How is safe, competent medical practice ensured? Score 0

Experience elsewhere indicates a need for expertise in elderly care, palliative care or psychiatry. True independence is hard when only 1% of doctors are willing to participate.

…expertise of two main doctors left to SoS. The psychiatrist on the panel can come from any sub-specialty and needn’t be of consultant status. No requirement for expert assessment even if applicant identified as have a learning disability or as being liable to detention under the Mental Health Act.

2. How will safe “assistance” be ensured? Score 0

What drugs can a doctor administer for unpleasant side effects, delayed or unachieved death? What does use of a “medical device” and assistance in using it mean?

…Nine of this clarified at all in the bill

3. How will informed consent be ensured? Score 1/2

Consent in health care requires informed understanding of what is proposed, its potential complications and side effects, and alternative interventions.

…the bill indicates that the nature of the substances to be provided and their action must be explained but says nothing about side effects or complications. The doctor is required to discuss the person’s wishes in relation to complications without requiring that the nature of such complications has been previously explained in detail.

In relation to explaining the nature of the proposed procedures there are three under-specified areas:

  1. the nature of assistance in use of a medical device is not clear – for example in the case of somebody sufficiently disabled that they require a proxy signatory;
  2. what actions can or cannot legally be taken in the event of greatly prolonged time to death or even failure to die, especially if the person has been rendered unfit by initial actions;
  3. GMC guidance lists other examples of information that might be relevant as including “whether an option is an innovative treatment designed specifically for the person’s benefit.” Since there is no standardised medication regime with regulatory approval for use in physician assisted suicide and there is wide and changing variation in practice3 then any proposed prescription seems to fall within this remit.

4. Is there adequate ability for healthcare professionals and organisations (such as care homes) to opt out? Score 1/2

…The bill makes it clear that individuals need not participate beyond explaining to the applicant where they go if they want assisted suicide but does not allow for organisational opt out.

5. What aspects of assessment are mandated? Score 0

There is more to assessing somebody who wants to kill themselves than checking mental capacity and lack of coercion – a comprehensive personal and social history; interviewing a family member or close other; the GP and, as relevant, a key specialist.

…The bill sticks with the absurd and dangerous idea that all that’s needed is to check whether somebody is competent to make a decision, not why. No further information gathering is mandated.

6. What requirements are there for integrated medical record keeping and review? Score 1/2

What detailed recording of the assessment is mandated?

…The coordinating doctor is now required to ensure that their assessments and declarations are included in the medical record, but not that any more substantial assessment or further exploration has been undertaken.

7. How will clinical practice be supervised or monitored? Score 0

Adequate oversight can’t easily happen in a standalone service.

…Particularly important given that it has emerged that assisted suicide may be organised in the private sector. There is no mention at all of appraisal of medical practice. Oversight by the panels does not mandate an independent assessment of the applicant by each panel member (as happens eg in mental health review tribunals) and the commissioner’s review  will be bureaucratic, to ensure the letter of the bill is followed. No means of checking on concerning medical practice.

8. Requirements to monitor and report outcomes of the programme, for audit and quality control. Score 1/2

What wider psychological and social features will be recorded of those who die by assisted suicide? Is there a formal mechanism for responding promptly to adverse events?

…The bill requires that an annual report by the commissioner and that must include a note of persons who have died by assisted suicide and who had protected characteristics (an irony that escapes the drafters) but not how they will be identified. “Any other description of persons…” to be specified by the Secretary of State, a challenge since collection of the relevant information isn’t mandated.

9. Monitoring impacts on others. Score 0

Family outcomes and the impact on staff may be long-lasting.

…Doesn’t get a mention.

10. Is there a formal complaints and feedback process? Score 0

…Doesn’t get a mention. The medical examiner is required to interview a family member but the examiner isn’t mentioned in the bill, there is no requirement for the commissioner to share information with them and there is no mechanism for their findings to make their way into the process.

  • November 24, 2024

Marketing assisted suicide

A striking feature of the current UK debate about assisted suicide legislation is not the substance of what is being discussed but the way in which it is discussed. Here I outline some of my own observations.

First things first – what is assisted dying?

The Dignity in Dying campaign has argued for years that what it calls assisted dying is not the same as what is called physician assisted suicide in many other countries. The rationale is that assisted dying refers to people who take their own lives at a time when they can be considered to be dying, while assisted suicide refers to people who take their lives at a time when they are not believed to be dying. There is no justification in law for this distinction and indeed the campaign is aimed at changing the Suicide Act 1961 to decriminalise assisted suicide. It is as illogical an argument as the one that says people seeking assisted suicide are not suicidal – as if there is something called being suicidal that is different from wanting somebody to help you kill yourself.

Some of the slogans and jargon used by campaigners echo this fallacious argument. Even the acronym MAiD refers to medical assistance in dying rather than medical assistance to die. The slogan “It’s not about shortening life, it’s about shortening death” nods at the same logic, as if the last six months of one’s life are really the first six months of one’s death. Of course, this line is rather undermined by the Right to Die slogan – the claimed need for assistance to die (as if any of us had a choice) going against the suggestion that the only recipients will be those who are already dying.

What’s the argument?

Rather subtler is the appropriation of words like compassion and dignity. “Compassion” and “compassionate” are used freely as if all other deaths are a horror show and all opponents of assisted suicide are heartless in consigning people to what journalist Polly Toynbee has called a torture chamber. It has been a masterstroke to appropriate the word dignity to assisted suicide (Death with Dignity, Dignity in Dying, Dignitas) with its dual referents of avoiding demeaning experiences and maintaining personal standing. Its success depends of course on not mentioning the realities of the process of assisted suicide. So campaigners make no mention of complications associated with the assisted suicide process (distressing symptoms like retching, long delays in dying, recovering consciousness). In fact this is of a piece with a certain evasiveness about the nature of the assisted dying process more generally (see my notes on the Leadbeater bill)

Negative campaigning about palliative and end of life care form a part of the repertoire of assisted dying campaigners. It has elements of omission and commission.  It does not refer to research that shows a huge majority of people regard palliative care services as treating the dying with dignity and respect. Few go quite as far as journalist Polly Toynbee (again) who has claimed twice in the Guardian newspaper that a research report from the Office for Health Economics estimates that 17 people a day die in what she calls unrelieved agony or unimaginable pain when in fact the research did not quantify pain at all.

Another tack is simply not to mention palliative and end of life care at all. Baroness Meacher got the ball rolling with her remark that “Some people have to choose between suicide, suffering or Switzerland.” Less alliteratively and more inaccurately Kim Leadbeater announced the launch of her bill by saying” Today, somebody with a terminal condition and very little time left has only bad options. They can suffer in misery and often in great pain as their illness takes their life and dignity from them; travel to Switzerland- usually alone – if they are wealthy enough to pay for it; or take matters into their own hands…”

Marketing rather than critical appraisal of the case

Campaigners frequently site opinion polls suggesting the majority of the public is in favour of assisted suicide. It’s a claim that deserves some scrutiny. I have been impressed by how many people I discuss this with have a ready opinion and how few of them have reviewed any of the International evidence or reviewed the recent bills – McArthur in Scotland, Falconer in the Lords and now Leadbeater. So this idea is encouraged by polling – that you can have a view “in principle” without knowing what is being proposed in practice. It’s a bit like saying you approve Brexit or reform of the NHS “in theory” without knowing what they actually entail.

George Gallup sitting at his desk, working out how to get simple answers to complex questions.

There’s a reason such polls are popular with organisations like Dignity in Dying. It is not widely recognised that opinion polling has its origins in marketing. For that reason it was criticised early after its appearance for its tendency to reduce complicated matters to facile either/or stances: an early critic said:- ”Doctor Gallup does not make the public more articulate, he only estimates how in replying to certain questions it would say yes or no or don’t know. Instead of feeling the pulse of democracy Dr Gallup listens to its baby talk.” More recently it has been said that like advertising, “political polls are increasingly associated with attempts to manipulate public opinion, tailor messaging in superficial ways, and inform public relations strategies.”

Even more obviously out of the marketing playbook is the use of celebrity endorsement. It seems to go almost without questioning that actors, writers and TV presenters, and now even the daughter of a TV presenter, should have their views given prominence by the media. Why? The question is not why such public figures think what they do, but why their views are so widely broadcast. The answer resides in market research. Celebrities have an effect on the attractiveness of a proposition in a number ways. One way is by direct association with their own perceived attractiveness – what I call the “Why would I want to smell like Johnny Depp?” question. Another is that they give cultural meaning to the product they are endorsing. In the case of assisted suicide what they’re endorsing implicitly is not what they are endorsing explicitly – not the assisted dying process itself but the nature of the debate, one in which personal opinion is more important than careful critical appraisal of evidence and personal choice is privileged to the exclusion of other considerations.

Why it matters

The style of debate outlined above does not encourage critical appraisal of such evidence as there is, and its polarising influence means that important but nuanced arguments are not aired properly. For example, if there is a tension between allowing individual choice for some people while exposing other people to risk then how do we evaluate that trade-off? In other words, how much damage to one group of people is justifiable in the name of benefit for another group? There is another unresolved question that is reminiscent of the so-called ecological fallacy. Because a whole population is exposed to assisted suicide legislation we cannot assume that the proposed beneficiaries of the legislation (those who would otherwise have to face an unpalatable death) will actually be those who avail themselves of the opportunity of assisted suicide. We are pretty clear that unassisted suicide rates don’t go down; do we know about rates of undesirable deaths of other sorts?

My conclusion – marketing tactics have brought with them a superficial approach that has an undesirable influence on the form and content of debate in an important area of public health policy. It is much to be regretted that they have been embraced so whole-heartedly by proponents of assisted suicide.

  • November 21, 2024

Kim Leadbeater’s assisted suicide bill: who is vulnerable? where are the safeguards?

When MP Kim Leadbeater published her recent private members bill, which aims to decriminalise assisted suicide under certain criteria, she announced that it included: “the strictest safeguards anywhere in the world”. What she did not do (apart from not saying what a low bar that is) was explain specifically what those safeguards are or how they match the vulnerabilities of the people whose safety they are said to be protecting. It is these questions that I want to explore here, starting with the question of what vulnerability means in this context.

Assisted suicide legislation: who is vulnerable?

Taken on its own terms, the bill seeks to allow assisted suicide for anybody who meets certain illness criteria and who is making a personal choice to take their own lives, regardless of their reasons. So the main tests in the bill relate to the illness criteria (progressive, irreversible disease predicted to lead to death within six months) and personal choice (decision-making capacity and lack of coercion or undue pressure from another person).

It’s a narrow understanding of free choice, resting on a simplistic dichotomising of the population into a mentally competent, articulate, clear and uncoerced group and a muddled or coerced group without mental capacity. There is in truth a continuum, with a large ignored group occupying the ground between the two poles. Are there people in this grey area who can be seen as vulnerable in the context of a request for assisted suicide and if so, what is the nature of their vulnerability?

What all vulnerable groups caught up in the assisted suicide process will share is constrained decision-making. That is – the decisions available to them are limited as a result of external circumstances or as a result of their own inner state of mind.

Concern about some of the external constraints has already surfaced in discussions about Leadbeater’s bill. For example the limitation on possible decisions created by lack of comprehensive high quality palliative care including pain relief. Other external constraints include limited practical and financial freedom such as poor housing or an inability to live fully independently without practical and financial support from others.

Internal constraints are more difficult to recognise for the non-specialist. They include a sense of burdensomeness, aloneness and lack of confidence in the presence of mutually supportive relationships, hopelessness for the future and low mood. These features arise typically in response not just to an immediate physical illness but to the accumulation of life experiences. They feature strongly in thinking about suicide more generally, and therefore in exploring opportunities for suicide prevention.

When I talk with people who work in areas like mental health, disability services (including learning disability) or end of life care I find that they recognise these constraints and particularly the internal ones and can readily furnish their own examples. By contrast I find that these are vulnerabilities largely ignored by active campaigners for assisted suicide and in general not well recognised or understood by them. A result is that opponents of legislation are asked for illustrations and in response they often use broad descriptive categories of people likely to be vulnerable such as those living with disability or with significant mental illness. The riposte is – don’t worry they are excluded in the bill. This doesn’t address the more general problem about vulnerability nor in fact does it protect the disabled or those with severe mental illness because they are only excluded as long as they don’t have an eligible physical disorder. Once they do of course their vulnerabilities come fully into play.

With these ideas of vulnerability in mind we can ask questions about safeguards. They need to take into account that suicide will be assisted by medical professionals who undertake an initial assessment which involves clinical judgement and then are actively involved in a clinical intervention involving prescription and shared administration of potentially lethal drugs. So the benchmark is what one would expect to find in any setting where competent, conscientious doctors are working in a safe environment.

Oregon 2023 – world class safeguarding. 30/367 (8%) of deaths from prescriptions more than a year old. 141/560((25%) don’t know what happened next, even when 41/141 (29%) the person is dead.

The doctors and the intervention

The process requires two doctors who are expected to be independent.  It can however be hard to attract doctors to the work: in Oregon last year only 1.1% of all registered medical practitioners issued a lethal prescription. There are 571 registered GP’s in Leeds as I write so that would be 6 people. The coordinating medical practitioner is allowed to choose the second doctor and if they do not like the result they can approach a third doctor to obtain a second opinion. The expertise or experience required of either doctor is not specified.

There are two aspects of the act of assisting suicide itself that are hardly mentioned. One relates to the nature of assistance. An attending doctor can attach a “medical device” to deliver the fatal drugs and can assist the individual in using it. Given that an individual may be so disabled that they can use a proxy to sign the relevant documents it is difficult to know how this could work without it being a form of euthanasia. For example, can a proxy switch on the medical device?

A second question is this: the assessing doctor must discuss with the person their wishes in the event of complications arising in connection with the self-administration of an approved substance. There is however no indication of what the doctor is supposed to do with the resulting information. A doctor is required to stay with the person from the time of ingestion to the time of death – what are they supposed or allowed to do in the event of greatly delayed death or of the person waking up after being asleep or unconscious?

The assessment

Assessment of somebody expressing desire to take their own life usually involves careful review – of the reasons for the wishes, explored in more depth than simply check listing a number of ideas like lack of autonomy or lack of enjoyment in life; recent other life events or difficulties; household and financial circumstances; the situation of family and close others including their understanding of what is happening; and an account of past and current mental health problems including current mood. Of all these only an assessment of mental state is required and then only to exclude mental illness so severe that it is impairing decision-making capacity.

There is no requirement to talk to or even inform a member of the family or close other. Neither is there a requirement to seek the opinion of the GP or of a specialist such as a psychiatrist, except on occasion to confirm the presence of mental capacity.

Monitoring of the process

There is no requirement on the doctors involved to keep a full written record of whatever assessment is undertaken.

The person requesting help with their suicide does not have to sign a consent form of the sort used in other areas of the NHS – one that explains for example what the main complications might be.

It is suggested that a High Court judge will oversee the immediate process but as a number of expert commentators (see eg Munby and Chacko) have observed it is clear neither exactly what they will do apart from check paperwork nor whether it is feasible to expect the High Court to be able to undertake this work.

There is no requirement to keep a full record of or report side effects or complications associated with administration of the fatal substances, or of the time to death or of failure to die and in these circumstances of what the attending health professional did.

There is no indication of what would count as adverse events otherwise and no requirement to have an oversight system that allows for rapid response to severe adverse events.

All medical interventions (vaccination, general anaesthetic, antibiotics…) have complications and their safety is judged by balancing benefits against risks. If the risks are too great for any potential benefit then the intervention isn’t acceptable in medical practice. In this bill, as in all other assisted suicide bills, there is no mention of tracking untoward processes, no hint of what unacceptable rates of complications or protocol violations might be,  and there are no associated stopping rules to be applied either to individual doctors or to the assisted suicide programme as a whole.

There is no formal complaints or feedback procedure.

Can the detail be added later?

The answer to criticisms of the bill is always – don’t worry, it’ll be sorted out in committee.  Theoretically it could be but in reality it is a safe bet that it won’t be. There are two reasons why assisted suicide and euthanasia programmes internationally all have these problems. First, if all the amendments suggested by my commentary were included it would place participating doctors in an impossible position. They would be required to prescribe lethal medication and oversee death at the same time as exercising a duty of care and fulfilling their obligation to prevent suicide. Second, assisted suicide is not really about ensuring best care for everybody but about legislating so that one group of people can get what they want, in other words a libertarian privileging of individual choice. Sponsor of the bill Kim Leadbeater has made this clear on a number of occasions when she says personal choice is at the very centre of her bill.

A final note

There are of course other concerns raised by this bill that cannot be dealt with by any amount of re-drafting. There is the wider coarsening of societal attitudes to ageing, to end of life care, to the disabled. And there is the challenge to our approach to suicide prevention more generally when we stop saying all suicide is a tragedy we should work to prevent and start saying – not all lives are worth living and we will help you to end your own. There are other ways to express compassion besides helping people kill themselves.

  • November 29, 2023

Marketing medical assistance in dying and the privileging of personal choice

One of the defining features of a functioning state is usually taken to be that the state holds a monopoly of violence – especially violence towards its own citizens. There are however a number of situations in which the state sanctions killing, or at least does not punish it. Putting aside the activities of the armed forces and police, the other common situations fall under the umbrella of what might (surprisingly) be thought of as the public health. They include, in jurisdictions where they are allowed (not criminalised): termination of pregnancy, suicide and euthanasia.

I discern a number of influences at play when decisions are being made about the exact circumstances under which the state will allow ending of life. There may be others, but as a starter my list is:

  • The degree to which the life under consideration is regarded, by the person living it, as so burdensome as to no longer be worth living;
  • The social value of the life under consideration – that is, how others view the individual per se or as a result of any condition from which they suffer;
  • The practical, technical or emotional difficulties inherent in the process of ending the life – what we might call barriers to implementation;
  • The degree to which differences of opinion have to be taken into consideration in arriving at a final decision.

These sorts of ideas are encapsulated in enabling legislation, of course each being given different weight according to the exact circumstances.

I was recently listening to a talk about medical assistance in dying (MAID) given by the historian Kevin Yuill during a meeting in Jersey. Yuill introduced me to another angle on this, which is thinking about the motivational influences: not how the decision is made but something like why it is being made at all. Yuill suggests that in the history of euthanasia and assisted suicide, the main motivating factors have been ideas about utility and compassion. Utility has featured most brutally in pro-euthanasia and eugenicist ideas about ballast existence and while compassion could be instrumentalised in support of these endeavours, it also has a more altruistic side. More recently however, an appeal to autonomy has come to dominate: euthanasia and suicide (assisted or not) are argued to be, in the right circumstances, individual choices which should not be blocked by authoritarian government actions.

This proposition struck a chord – when I speak with friends and colleagues about MAID, the response of those who support it is that it is a personal choice that they would like to be able to make for themselves if they were in a position where it was relevant. If they have thought further, it is only to consider briefly (and dismiss as avoidable) the slippery slope argument.

And the appeal to autonomy describes neatly how the campaign for medical assistance in dying (which in the UK means physician-assisted suicide) is being framed. What is going on in the public debate about MAID legislation is not that supporters are contributing to a dispassionate assessment of the pros and cons of a momentous change in the law – with potential direct and indirect harms being considered as well as potential individual benefits. Instead the idea is promoted (marketed) that MAID is evidently something people will want to choose and that preventing that choice is wrong. The emotive case histories/horror stories, celebrity endorsement and misrepresentation of the alternatives as the quiet dignity of assisted suicide versus giving oneself up to the horrors of end-of-life or palliative care, are all designed to arouse anger about a right denied.

When the exercise of personal choice becomes the paramount consideration we are in a society where the individual’s wishes overshadow questions of the public good. Now how could that not strike a chord…

  • February 8, 2023

Medical assistance in dying is another name for physician assisted suicide

The rebranding should not blind us to the risks involved.

The argument for what is now called ‘assisted dying’ is often framed in terms of personal autonomy – the right to choose the time and mode of one’s death.

Individuals included in media reports as pressing for that right are typically mentally competent, educated, and supported by a partner or family member who affirms their desire to die. Campaigners pressing for change suggest (at times in strikingly gothic terms) that if their wishes are denied, the likely alternative is a difficult death during which pain is inadequately treated and distressing symptoms are mismanaged. ‘Assisted dying’ is thereby positioned as a form of patient-centred care – a death with ‘dignity’.

Put like this, the case can seem incontrovertible. Who wouldn’t want a ‘dignified death’ in which their own wishes were central to any decisions about their treatment? But this is a narrow and unbalanced way of framing the discussion; it fails to communicate the full range of questions that arise when thinking about serious illness. “Assisted dying’ is a euphemism for physician assisted suicide; it involves prescribing lethal drugs to somebody who will then self-administer them to end their life. Framing the practice like this gives a different perspective that is masked by the rebadging as assisted dying. What we know about suicide more widely becomes relevant in informing what we think about doctor-assisted suicide.

People living with severe, persistent physical illness can of course feel that their condition is intolerable. Indeed, research shows that about one in ten describe having thoughts that their life is not worth living, or that they might be better off dead. And suicide rates in people with a severe health condition are double those of the general population.  Even so, recent data from the Office for National Statistics suggest that in absolute terms fewer than 10% of suicides are in people with a severe health condition. Some of the study findings come as a surprise; for example of 17,195 suicides identified from 2014-2017, only 58 (0.3%) were in people with what the study called low survival cancer. This is about three times the general population suicide rate but accounts for only 3 in every 10,000 of those recorded as having low survival cancer in the study period. In other words the great majority of people (more than 99%) with negative thoughts about their circumstances do not take their own lives.

What does research into suicide in the wider population suggest might make suicide more likely? Many of the leading risks are social – loneliness, living alone, low income and lack of employment, and a lack of social support. A history of problems with alcohol or drugs is also common, especially in men. So is a history of mental health problems – typically not psychotic illness but recurrent episodes of depression. More than half of those who take their own lives have a history of previous self-harm. These risks are also prominent when suicide occurs in the setting of severe physical illness, even among those who are simultaneously in contact with mental health services.

Suicide associated with severe physical illness occurs most commonly in the first year after diagnosis, especially in the first six months. This observation is in line with research showing that rather than intolerable and untreatable symptoms it is concerns about the future and loss of independence that motivate many requests for physician-assisted suicide.

US psychologist Thomas Joiner has outlined an influential interpersonal theory of suicide that makes much sense of these findings. He outlines three risks for suicide – thwarted belongingness (closely-related to the idea of lack of social connectedness), perceived burdensomeness, and acquired capability (overcoming the fear of death). Thinking about suicide in this way helps us to be clearer about the nature of suicide in the physically ill and therefore ‘assisted dying’, which is a risk for exactly those people whose suicide we are used to working to prevent, by actively helping people to “acquire capability”.

The response to these concerns rests upon assurances that only carefully selected cases will be accepted into a programme of assisted suicide. We can have no confidence that such “safeguards” will be adhered to.  For example in one study from the Netherlands, 12% of those accepted failed to meet the criterion of there being no alternatives for palliative treatment and 7% were not reported has experiencing unbearable suffering. I have yet to see a statement from supporters of medical assistance in dying about their opinion on what is an acceptable error rate in the system.

There is another reason for concern about doctor-assisted suicide – less tangible perhaps but with far-reaching consequences. It fundamentally changes our approach to suicide, Under the Suicide Act 1961 an act “intended to encourage or assist suicide” is a criminal offence. There are no exclusions – it is an all-encompassing approach that is reflected in our National Suicide Prevention Strategy. What is proposed is a radical overhaul of the way we approach suicide – a move away from trying to prevent all instances to a world in which we attempt to prevent suicide except when we decide to make it easier.

We are facing in medical assistance in dying a privileging of personal preference over social concern. It represents not just a modification of individual clinical practice but a societal intervention designed to change how we think about and respond to suicidal wishes. I find it hard to believe that the longer-term consequences, intended or otherwise, will be of universal benefit to those most in need of our care.

error

Subscribe to keep updated!