Particularly Concerned

Professor Allan House writes:

‘Assisted dying’ is a hot topic at the moment. Holyrood faces a debate on a Bill to change Scotland’s law from Liberal Democrat MSP Liam McArthur. At Westminster, Labour MP Kim Leadbeater is taking forward another proposal. As a psychiatrist with a special interest in the impact of physical illness on peoples’ personal lives and mental health, I’m particularly concerned about the debate.

Throughout my career, I’ve worked to help people struggling with the impact of serious illness who may feel overwhelmed, unsupported, or suicidal. My profession has had a united approach on this. We seek to alleviate suffering while protecting the vulnerable and suicidal. ‘Assisted dying’ – which in McArthur’s Bill means physician-assisted suicide – would cause a radical shift in practice.

In the debate about assisted suicide a common concern, even among those who support the idea in theory, is whether a particular piece of legislation can have sufficient safeguards to protect vulnerable people. I’ve studied McArthur's proposals closely and concluded that the safeguards outlined fail to offer any real reassurance to those worried about the risks.

To understand why, it helps to consider a case study. Picture a 45-year-old woman who’s lived with multiple sclerosis for ten years. She has had two relapses since her diagnosis but lives independently and uses a wheelchair for trips outside her house. Going to see her doctor one day, she says she feels like ending her life. How should the doctor respond?

Under our current approach, a doctor would seek to understand more. He or she would discuss the reasons for their patient’s thinking, her personal circumstances, and consider her history of physical or mental health problems. They would want to involve others such as a partner or next of kin. They may then advise a referral to a psychiatrist – especially if the doctor did not have expertise in responding to suicidal thoughts. Work towards a more hopeful outlook and rewarding life would follow.

Liam McArthur’s Bill proposes a fundamentally different approach to people with serious illnesses – the definition of ‘terminal illness’ in his Bill goes beyond conditions in which death is imminent. There would be no requirement to explore anything about a patient’s background, beyond confirming that they have a physical health condition. There’d be no requirement to consult a GP or a neurologist who might be managing a patient’s case or speak to next of kin or a close other. In fact, the first any of these people might know about a patient’s wish to die is after they’ve acted on it.

A doctor who is initially participating in assisting suicide would be required to involve a second doctor to make the same basic assessment. The two may consult a psychiatrist if they are uncertain about a patient’s mental capacity, but they are under no obligation to accept their opinion. Neither doctor would be required to make detailed notes of their contact with a patient as you would expect from any other medical involvement in a life-threatening situation.

The necessary expertise of the two doctors involved is unspecified in McArthur’s Bill and there is no requirement for specific training or supervision. The steps doctors can take to assist a patient’s suicide are similarly unclear. For example, the nature of the assistance they can provide in administration of a fatal drug dose. There is also no mention of the intervention a medical professional might make if death is attended by unacceptable complications or long delays. This is a huge ethical dilemma – does a doctor act to save or improve life, or do something to end it?

In relation to organisational oversight of an assisted suicide law, the details are similarly sparse. There is no mechanism for obtaining formal feedback from surviving family members or close others of the deceased, and there is no formal complaints procedure. A required annual report would do little more than provide basic details about the numbers of people whose suicides had been facilitated, with almost nothing said about their personal or social circumstances or health problems aside from the one listed as justifying the suicide.

There is an unresolvable dilemma at the core physician-assisted suicide legalisation: it requires doctors to prescribe fatal medication and oversee the resulting deaths while they are not responsible for the recipient’s healthcare more generally – with no apparent requirement to follow best medical practice, exercise a duty of care, and work to prevent suicide.

Liam McArthur’s Bill falls far short of containing the sort of safeguards we would expect in any other area of care for people with serious physical illness or those who are suicidal. In my view, it is a danger to vulnerable people and should not be allowed to pass into law.