Psychiatrist: Why I Oppose Leadbeater’s Bill

Professor Allan House writes:

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.

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 e.g. 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.