Consider evidence, not just emotion on ‘assisted dying’

While making assisted suicide easier can be made to sound seductive, it is incredibly dangerous and open to abuse. A new bill in the British parliament is both unsafe and unnecessary, says Agnes Fletcher of Living and Dying Well

Dealing with the end of life; a terrible dilemma
Agnes Fletcher
On 16 July 2015 12:19

On September 11, Rob Marris MP’s Assisted Dying (No. 2) Bill will have its Second Reading in the Commons. According to Dignity in Dying, which has conducted an opinion poll on the subject, over 80 percent of the public would like to see the law changed.

At Living and Dying Well we believe that there is no compelling evidence for legal change. Even if there was, this Bill presents insufficient safeguards to protect the most vulnerable of us from the pressure of a new “duty to die” -- or indeed from direct coercion for financial gain.

At the moment, the Suicide Act 1961 is clear, effective, and protects us all. Committing suicide is not illegal, but as a society we make every effort to prevent it. And encouraging or assisting someone else to commit suicide is illegal.

We respond compassionately to people who feel suicidal, whatever the source of their distress, and whether or not we can resolve all the issues that they face. We have national suicide prevention policies and suicide watches in prisons. Once exceptions are made to that clear principle of not encouraging or assisting suicide, we are all more vulnerable.

The law works well. A handful of cases pass the desk of the Director of Public Prosecutions each year. Prosecutors’ guidance offers discretion, which means that people who give minor assistance for compassionate reasons -- such as accompanying a relative abroad to a suicide facility such as Dignitas -- are not prosecuted.

Few criminal laws are broken so rarely, although such prosecutorial discretion is not uncommon.

Is the law cruel? Any of us can refuse life-sustaining treatment or have it withdrawn, including, if we have signed an advance directive, once we have lost the capacity to take such a decision. We remain entitled to good quality end of life care, including palliative medicine to ease pain, and other distressing symptoms.

The Assisted Dying (No. 2) Bill and Lord Falconer’s Assisted Dying Bill on which it is based is not about committing suicide. It is about the state licensing doctors to supply lethal drugs to people to assist them to commit suicide -- physician-assisted suicide.

Two doctors would determine diagnosis and whether someone was expected to live less than six months. They would assess whether someone had the capacity to make such a momentous decision using the definition in the Mental Capacity Act  -- which assumes capacity unless there is evidence to the contrary.

They would also be required to certify that the person had a settled wish to commit suicide and that there was no coercion. While the first couple of criteria seem straightforward, as the Royal College of Physicians (RCP) has made clear, predicting death in terms of months rather than hours or days is extremely difficult -- “the margin of error can extend into years”.

The RCP, along with the BMA and other Royal Colleges, does not support a change in the law.

How are doctors supposed to assess whether someone has a settled wish or is subject to undue influence? Are doctors qualified to make those judgements, which stray from the medical into family dynamics and other social influences? The Bill is silent.

After pressure from those with concerns about public safety, more recent versions of the Assisted Dying Bill give a role to the High Court. But it is little more than a rubber stamp. The Court would conduct no independent investigation.

This is a world away from the sort of independent, considered, evidence-based scrutiny that it gives to issues of similar gravity now  -- cases like the separation of conjoined twins where one will die, or switching off life support machines.

We know what the criteria for assistance with suicide are. We do not know what checks and balances would be in place to ensure that someone met those criteria. In effect, Parliament is being asked to legalise physician-assisted suicide without anyone, apparently, understanding what safeguards, if any, are planned.

Supporters of physician-assisted suicide cite Oregon’s law as a system that works without being abused. However, there is little in the way of detailed monitoring or analysis of what is actually going on in Oregon.

There is no regulatory body responsible for checking the quality of doctors’ decisions or whether there is abuse. We simply do not know whether the one in three doctors there prepared to carry out assessments are conducting serious enquiries or just ticking boxes.

Official reports do reveal a steady rise in the death rate from assisted suicide. Independent research analysing a selection of case notes found that lethal drugs have been prescribed for people who had undiagnosed clinical depression.

In Washington State, where there is a similar law, almost two in three of those “choosing” assisted suicide say that, “being a burden” is one of their reasons.

This is why legalising, “assisted dying” and grounding it within clinical practice, with the social approval that entails, can be seen not just as assisting but encouraging suicide too.

Those who campaign in favour of a change in the law no doubt do so for compassionate reasons. If you stopped most people in the street and said, “people are suffering; something must be done”, chances are most would agree.

But our laws should not be decided solely on emotion or public opinion. A look at the evidence does not show that this kind of legalised assistance with suicide is either necessary or safe.

Agnes Fletcher is Director of Living and Dying Well

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