Tag: Suicide

  • 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.

  • 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.

  • November 2, 2022

A book about suicide research and a suicide researcher

Rory O’Connor is a health psychologist who has published extensively on suicide. He is also active in discussions about suicide aimed at the general public and about suicide prevention policy, especially in Scotland where he lives and works.

His book When it is Darkest: why people die by suicide and what we can do about it  is divided into four parts, covering the main facts (and misconceptions) about suicide, its main causes, what preventive interventions might be effective, and supporting people who are suicidal or who are living in the aftermath of the suicide of somebody close. Further resources are mentioned throughout and there is a list at the end. The emphasis, especially when considering causes, is on the psychology of suicide and includes a review of the author’s own framework for organising the disparate associations with suicide into what he calls the Integrated Motivational-Volitional Model.

O’Connor’s aim is to combine personal and professional perspectives. The style is informal, written in the first person. Interspersed throughout are anecdotes about his personal experiences, his contacts with people who have felt the impact of suicide in another or of feeling suicidal themselves, and his career in suicide research. At the same time it is in parts quite technical and ends with 48 pages of academic references, with a leaning towards his own research.

The book covers a lot of ground without being exhaustive or exhausting, especially of course in its review of prevailing psychological theories. And it offers a sustained attack against fatalism in the face of suicide and the apparent impossibility of eradicating it: we can move to understand more and to develop effective prevention strategies.

No book like this can be entirely comprehensive but there are some important gaps. There is too little on the personal and social impact of drug and alcohol misuse, either as a risk for the individual or as part of the reason people become isolated or alienated from social support. Mental disorder and its treatment may not be the most important part of suicide prevention but even so it deserves more consideration than it gets. Many of those who die have been in contact with helping agencies – GP, the mental health services, university counselling services or whatever – and there is not much here about how such services might do better or what families feel about this aspect of how tragedy might have been prevented. Suicide needs to be seen in social and cultural context if we are to focus public health interventions. Psychology can’t explain the wide regional variation in rates, and some of these wider issues feel undercooked. In a laudable attempt to combat negativism the effectiveness of suicide prevention interventions is overstated.

What about readership? It requires high levels of general and scientific literacy and that will limit its utility. The presentational style will not suit everybody. I personally didn’t like the idea of calling suicide The Big S.  I also wasn’t keen on the idea that suicide is not usually about the desire to die but about the desire to end suffering. After all “suicide” means death as the result of an act intentionally designed to end life, so this is a paradox that on close inspection just doesn’t make sense. There are few accessible books on suicide for the general reader (Mark Williams’ Cry of Pain is one, and the Help is at Hand booklet for those bereaved by suicide is excellent); this text will therefore find a place as a useful review for the interested and well-educated non-specialist.

  • October 25, 2022

Social media and mental health: we need much more attention to the detail of what regulation might entail

Coverage in the mainstream media of the findings of the Molly Russell inquest concludes that the case is now made for direct action on regulation. However, in these and other similar pieces there has been little discussion of what specifically such regulation might entail or of the challenges of implementation. Here is a sample from just one newspaper:

Why is it so hard to say specifically what should be done? For sure there will be resistance from the tech companies, but an additional dilemma is that much of the content under consideration (about depression, self-harm and suicidal thinking) is seen as helpful by those who use social media – valued for its 24/7 availability and anonymity and for the supportive nature of sharing and viewing user-generated content. The challenge therefore is to eliminate the negative impact of social media without blocking access to its helpful elements.

Although the main emphasis in discussions about regulation has been on harmful content, that is only one of three aspects of the problem to be considered.

A central issue is algorithmic pushing which increases duration and intensity of exposure. We know that people with existing mental health problems are more likely to spend long periods online and more likely to use sites with content related to self-harm, and there is some evidence that such extended exposure makes matters worse. So, what limits should be set on these quantitative aspects of social media viewing?

The question of what to do about algorithmic “recommendations” is confounded with one about content. It is generally accepted that it would be no bad thing if searches for key terms (self-harm, suicide and so on) were to trigger responses offering links to helpful resources, which raises the question of how to identify specific content as helpful (OK to recommend) or harmful (not OK). In relation to moderation of content, harmfulness is usually defined by terms like glamourising, normalising and encouraging. These words are used without definition and yet proposed as the main criteria upon which any duty of care will be judged. How are they to be defined and identified in ways that don’t just rely on individual opinion?

Monitoring and responding to problematic patterns of use is a key issue in debates about online gambling – how to achieve it without driving away those who resent the idea of surveillance and loss of privacy?

Journalists may not see it as their job to grapple with these questions. Here are three suggestions from non-journos whom we might consider as having something important to say:

The coroner in Molly Russell’s case issued a prevention of future deaths report:- in which he said:

“I recommend that consideration is given by the Government to reviewing the provision of internet platforms to children, with reference to harmful on-line content, separate platforms for adults and children, verification of age before joining the platform, provision of age specific content, the use of algorithms to provide content, the use of advertising and parental guardian or carer control including access to material viewed by a child, and retention of material viewed by a child.”

The government’s plans are to be found in its Online Safety Bill. At the point at which they published their last factsheet (April 2022) on the topic, this is what they had to say:

“Platforms likely to be accessed by children will also have a duty to protect young people using their services from legal but harmful material such as self-harm or eating disorder content. Additionally, providers who publish or place pornographic content on their services will be required to prevent children from accessing that content.

The largest, highest-risk platforms will have to address named categories of legal but harmful material accessed by adults, likely to include issues such as abuse, harassment, or exposure to content encouraging self-harm or eating disorders. They will need to make clear in their terms and conditions what is and is not acceptable on their site, and enforce this.”

The coroner’s report covers all three bases in some ways but shares an important feature with the much more limited Online Safety factsheet – undesirable content is identified by the single word “harmful” which is not defined apart from a suggestion in the factsheet that it is likely to include “encouraging” which isn’t defined.

Multiple charities with an interest in the mental wellbeing of young people wrote a letter to the then prime minister Liz Truss in October, in which they attempted to unpack the idea of harmfulness in a constructive way:

“We are writing to urge you to ensure that the regulation of harmful suicide and self-harm content is retained within the Online Safety Bill…[defined as]

  • Information, instructions, and advice on methods of self-harm and suicide  
  • Content that portrays self-harm and suicide as positive or desirable
  • Graphic descriptions or depictions of self-harm and suicide.”

The first two criteria look as if they ought to be amenable to careful definition; “graphic” is more problematic. One person’s clear and vividly explicit detail is another’s matter-of-fact account. Or does it mean – any image (depiction) at all, that is not shaded/pixelated or whatever – descriptions of how to look after or conceal your wounds for example?

There seem to me to be two risks here. The first is that decisions will be left to Ofcom and (presumably) to the courts. The second is (perhaps less likely) that the tech companies will decide they can’t be bothered with all this and will go for some variant of blanket suppression of interactions about self-harm and suicide. Neither is desirable: the former if it leads to the sort of adversarial debate that failed to clarify these questions during the inquest, the latter if it ends up denying access to helpful content. There is emerging research that can contribute and health professionals should lead in arguing for its inclusion in decision-making, so that a realistic balance is struck between risks and benefits of social media in an important areas of public health policy.

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