Before We Give Them Our Permission to Die …

Have We Done Enough That They Might Live?

The UK’s Royal College of Psychiatrists (RC Psych) has taken an unusual position on an Assisted Dying Bill before parliament. Unlike many in the US and Canada, the RC Psych has chosen to be cautiously neutral while disagreeing with politicians and advocates that this is the ultimate expression of empathy.

When people are miserable, particularly with a taxpayer-funded health care system, their treatment will always cost a good deal more than getting them to volunteer to die. It is a morbid incentive, but we’ve seen it in Canada, a nation that is responsible for much of the misery that creates the conditions it then suggests are grounds for medically assisted dying. And while we don’t have many examples similar to that in the US (80% of Oregon’s assisted suicides just happen to be on government health insurance), it is the slippery slope that leads me to oppose it, especially here in New Hampshire.

You can’t trust the government not to use it to solve the problems it creates or to create problems as an excuse to lean on it. The UK isn’t suggesting that likelihood (no government or elected body ever truly does), but it is considering medically assisted dying, and the Royal College of Psychologists has concerns.

Photo by Ahmed Adly on Unsplash

The RC Psych statement is worth reading because it hints at a thoughtfulness I find lacking in most conversations on state-managed medically assisted dying.

1. Terminal illness is a risk factor for suicide: Should the Bill become law in England and Wales, it needs to set out clearly how and at what point a clinician would be deemed to have discharged their duty of care to those who are at risk of self-harm or suicide under existing legislation and codes of practice.

2. There should be a requirement for a holistic assessment of unmet need: Treatable needs such as intolerable pain, financial hardship and inadequate care or housing can make a person want to die. Yet the Bill makes no provision to assess unmet needs at any stage, nor consult others involved in the person’s care or life.

3. Assisted dying/assisted suicide (AD/AS) is not a treatment: AD/AS does not aim to improve a person’s health and its intended consequence is death. The Bill does not specify whether AD/AS is considered a treatment option and this ambiguity has major implications in law in England and Wales. Should this Bill proceed, it should be explicit that AD/AS is not a treatment option.

4. The Mental Capacity Act does not provide a framework for assessing decisions about ending one’s own life: The Mental Capacity Act was created to safeguard and support people who do not have the capacity to make decisions about their care or treatment or matters like finances. Should the Bill become law in England and Wales, implications for both the Mental Capacity Act and Mental Health Act need to be considered. How would clinicians assess the new kind of capacity to decide to end one’s life that is framed in the Bill? How would clinicians protect and empower people with terminal illness to decide whether or not to end their own life, while at the same time detain those who are at risk of suicide so that they can be urgently treated?

5. It is not clear what a psychiatrist’s role on a multidisciplinary panel would be: If this Bill proceeds in England and Wales, any role a psychiatrist plays in an AD/AS process should be consistent with the core duties of the profession, including determining whether a person’s wish to die can be remedied or treated.

6. There are not enough consultant psychiatrists to do what the Bill asks: As things currently stand, mental health services simply do not have the resource required to meet a new range of demands.

7. Professionals must be able to conscientiously object to involvement in any part of the process: We are pleased to see that the Bill no longer requires medical professionals who do not wish to be involved to refer a person to another clinician, but they are still required to signpost patients to information on AD/AS. For some psychiatrists who wish to conscientiously object, this would constitute being involved in the AD/AS process.

8. Robust professional standards and oversight would need to be in place: Any professional involved in assessments for AD/AS would need to be adequately experienced, trained, and independently overseen.

9. Physical effects of a mental disorder shouldn’t make a person eligible for assisted dying/assisted suicide: If the Bill proceeds in England and Wales, it must exclude the physical effects of mental disorder, such as anorexia or dementia, as the basis for eligibility for AD/AS.

The notion that psychiatrists and medical professionals’ first obligation is to life should not seem unique. First, do no harm means what it means. Professional ethics should at least suggest that this is less than a last resort, and as such, RC Psyche rightly states that wanting to die is a symptom that, if not first fully considered and treated, fails the patient who contemplates “assisted” suicide.

“It’s integral to a psychiatrist’s role to consider how people’s unmet needs affect their desire to live. The Bill, as proposed, does not honour this role, or require other clinicians involved in the process to consider whether someone’s decision to die might change with better support.

Canada’s race toward failure in this regard brings the slippery slope into focus. Their ethicists, therapists, and the entire care system appear eager to hurry people to their graves. Medically Assisted Dying looks more like the eugenicist’s dream. Set about manipulating economic and social circumstances to see who falls through the cracks, then advise them to consider death as a way to relieve their state-sponsored misery with a nod to how much they’ll save their fellow citizens in tax dollars and oh, by the way, would you like to donate your organs – God Save the Queen.

These perverse incentives are increasingly less conspiracy theory and more fact, on display, in the northernmost part of North America. A trend that, in nations where suicide is permitted if not encouraged, is claiming the lives of young, productive people or those with ailments that are troublesome if not treated, but manageable when they are.

The RC Psych position is a clear voice amidst the noise. There is – especially in a system like that in the UK – a legal and ethical obligation to address the unmet needs that are likely responsible for the suicidal ideation. If the proposed legislation fails to require this in no uncertain terms, then we still have work to do.

I’m not advocating government-mismanaged assisted dying, even in this context; this simply strikes me as a breath of fresh air on another subject where proponents of “assisted suicide law” are using false empathy to claim moral authority at someone else’s expense (in this case, a life).

There is so much that the government should not be involved in; this is just more of that. It is an opportunity to leverage political and financial relationships with Big Pharma, the Medical Industrial Complex, Big Insurance, and proponents of the welfare state—and let us not ignore the social imagineers ideologically descended from the early 20th-century eugenicists.

Are death taxes another motivation? Who could say? But treatment is always going to cost more than suicide, so the question isn’t how much we might save, but what value do we place on human life and doing what we can to improve its quality, especially when that quality declines as a result of other government interventions? And let’s be honest. If people want to kill themselves, there are plenty of painless ways to do it with or without anyone’s permission. And maybe the best solution is a long list of things other than death, which has to include the government not doing things that make people want to kill themselves.

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