Back in the UK to catch up on the news. I’m very pleased the Law Lords have decided to ask the CPS to clarify their position on when they will prosecute a person who assists a suicide. It doesn’t move us very much further forward on the issue of whether a terminally ill individual in the UK can ask for help in dying if they feel their time has come. Many of you-Bedd Gelert, Alfdred, B, Senex, raised points I didn’t have time to address in my last blog on this issue and I would like to comment now. There were moving and well- reasoned articles in the press by Matthew Parris and Bryan Appleyard this week raising some similar points. If one ignores the religious arguments against assisted suicide for the moment (I can’t argue with a religious notion, it runs a parallel course to rationality), then we are left with two seriously concerning arguments against which are subject to analysis from properly collected data gathering: first ‘The Slippery Slope’ that somehow if we allow some individuals to request help to die that there will be a subtle shift towards encouraging people to die and before you know it all kinds of people will be popped off. And the second argument is that old and or sick people will be coerced by avaricious relatives into seeking death. As a psychiatrist working with older people I’ve probably seen more than my fair share of ghastly grasping families wanting their grannies out of the way and for me that is one argument we need to examine closely.
Let’s address the slippery slope first. If the slippery slope were a real danger we would have seen such a move by now in Oregon where they have had over 11 years of experience with their act. It is a far better act than many other countries have although it doesn’t have as many safeguards as I would like to see. The numbers of people choosing an assisted death has not risen in a statisically significant manner since the inception of the legislation, allowing for the Act to become known and used. Blogger B mentions the figures have gone up, but to be honest we are talking about a rise since the inception of the Act from a no more than a fragment of 1% to a slightly larger fraction of 1%, tiny.
The Oregon Department of Human Services’ (DHS)11th annual report giving this past year’s statistics are largely in keeping with the data collected over the past 10 years. 88 people received prescriptions in 2008, and 60 people died under the terms of the Act. The typical participant was 72, college educated, and suffering from cancer. Over the years, participants have listed quality-of-life issues as their main reasons for using the Act, and this year was no different. The top concerns included an inability to participate in activities that made life enjoyable, loss of autonomy and loss of dignity.
There were some categories in which the statistics made a more noticeable shift. In 2008, 98% of patients were enrolled in hospice care, which is a significant increase from previous years when hospice enrollment was at 86%. In addition, in 2008 more patients had private health insurance (88%) than in previous years (63%). In other words out of about 8OOO or so annual cancer deaths in Oregon, only a minute proportion, less than 1% chose this route. There is no evidence of it spreading to other groups. That is not to say that there haven’t been some anxieties; one well known case of an older person considered in retrospect to be of questionable mental competence was the subject of much discussion. I find this reassuring rather than worrying but does highlight the need for further safeguards on mental competence.
Now the second area, how to detect coercion. Clinically it’s easy, it usually stares you in the face the minute you meet the relatives, that there are significant financial gains for X if his/her Mum or Dad is in care home/ NHS ward/ home with them. But coercion is very rare where the individual themselves are fully mentally competent; it is those who are not mentally in tact who are so vulnerable to persuasion or coercion, but as they would have been been ruled out of the option of an assisted death on mental competence grounds this is unlikely to be a problem. Courts are used to making a judgement about whether an individual has been coerced or subject to ‘undue influence’ in making a will; it is not difficult to spot it and I can see no reason why we cannot readily build in safeguards to avoid it.
Matthew Parris in the Times this past Friday raised another point, that he did not want to have the State involved in his death in any way, not in sanctioning it nor in preventing it. I have some sympathy with that. The problem is that the State via the NHS already interferes a good deal, determines where you can die, denies you the right to make a private arrangement with your own friendly doctor, insists that only the fit able bodied and those with private access to drugs can have a good death at their own hands. All others, unless struck down suddenly must die with whatever dignity is afforded them by their illness and the lottery of services available in their area. Death is not as easy as it used to be; doctors are less likely to slip you you a quiet solace barbiturate than 30 years ago. We could get safeguards in legislation right here in the UK which would enhance rather than diminish human dignity at the end of life.
“I can’t argue with a religious notion, it runs a parallel course to rationality”
If you take out the idea that there is a God involved in our lives, who decides when and where we will die, then an unproductive life has no further use. How long before we do go down that slippery slope? It didn’t take WWII Germany very long.
Oregon is surrounded by states and come under a federal government that are not sympathetic to assisted suicide, so is kept in check. I’ve heard others argue about EU countries already going down the slippery slope, as I mentioned before.
I’m sorry that you feel that “a religious notion … runs a parallel course to rationality“. In an increasingly topsy turvy world, current events make little sense. However the Bible’s view of where we have come from, where we are going and why, explains, with rationality, what is going on and what is happening. Nothing else makes any sense, but I feel sure that we will disagree on this.
I don’t see how this ruling helps. If the CPS defines the guidance tightly then they are removing their own discretion parliament wished them to exercise on the application/meaning of the law. If they define it too loosely it cannot clarify matters greatly. Either way the guidance will just present something else to judicially review the next time there is a dispute.
Despite having listened to the odd ‘moral maze’ on this point, I’m by no means as familiar as I should be with some of the subtle arguments here.
I guess the difficulty is that obviously grasping offspring are easy to spot. What may be more difficult is where the ‘care home’ fees are eating not just into the inheritance, but would wipe out the surplus left after selling the house and inheritance tax and might leave a hardworking family with children to raise with ‘financial worry’.
I am by no means justifying their wanting to remove that worry – and most of us have to struggle one way or another with financial choices. But such feelings may be transmitted non-verbally to the older person.
The other point is that even where there is a huge amount of money available, the older person may simply want to be cared for at home, but the surviving relative and their children may be exhausted by the caring responsibility and possibly bringing up very young children as well.
But I do commend you for addressing these very difficult issues. To coin the jargon, politicians put these in the ‘too difficult box’ and leave them there because they know there is no electoral advantage in tackling them when there are more expedient things to worry about.
Croft, I think you may be right. The guidance will almost certainly be drawn vague but it is a small and I think possibly an important step in the right direction; history will clarify!
Alfred, your faith guides how you feel about these issues and I can only respect your views but you can’t leap to predicting Nazi outcomes on such a flimsy basis. Besides, many Nazis had faith in God. Catholicism and the far right have been cosy bedfellows at times…belief and behaviour seem surprisingly disconnected in community mores.
Bedd Gelert, I recognise the scenarios you paint very well, as you can imagine, they are the bread and butter of old age psychiatry. There are huge dilemmas for families worrying about the care of older people who are becoming frail and old people are overtly coerced, heavens I’ve done a fair bit of coercing of my own in my professional life. These are unavoidable I think. I do think however that doctors would start behaving differently and asking different questions of terminally ill people if we had legislation in place. But your other point, that we must have the courage to have the discussion, not to try to politicise or oversimplify the questions and not to rule out any options solely because traditionally they have been unthinkable or because the ‘safeguard’ element seems very difficult to tackle. .
I don’t “leap to predicting Nazi outcomes on such a flimsy basis.” However, I do see that as a warning that we should not ignore. Tale away the foundation, and anyone’s ideas are as good as those of any one else, whether they are the ideas of Hitler, Sadam or whoever.
“…belief and behaviour seem surprisingly disconnected in community mores.” Yes, how sad that is, which is why in the Reformation, the reformers tried to get back to the idea that God’s Word was far more reliable than any fashionable sage, or religious leader.
As much as I have tried, I do not believe there is one or more Gods. This makes living much easier for me since a good proportion of my faith deliberations revolved around the issue of life and death.
Thus, this issue is not about death but how I live. In general, I am buzzing with ideas, love life, learning new stuff, writing, creating, whatever. In general, I would rather die than lose the essence of ‘me’.
Some days ago, I thought I was dying and called an ambulance. By the time it arrived I had recovered but at the moment, when I truly believed I was dying, I desperately wanted to stay alive.
This was an irrational thought, one of survival. It was about the very personal manner of death, as a moment in my life, and it later terrified me that I will not be able to make this decision.
Please, get this legislation passed.