AcuteMedicine - South London

The Mental Capacity Act is the right place to start in terms of determining if a patient can make this decision. It's been tried and tested. It's used every day. Doctors are confident using it and it strikes the right balance - protecting both them and their patients. 4/7

This week the assisted dying Bill committee heard from SIX pro-assisted dying Australians about how well it’s all going there. The former Attorney General of Victoria disagrees. If the aim is safety, surely he must be invited to give evidence? blogs.bmj.com/spcare/2025/01…

99 Problems (With The Terminally Ill Adults (End of Life) Bill): —Who qualifies? 1. People feeling like a burden. Under the bill, any terminally ill person who requests suicide only because they feel like a burden – on loved ones or the NHS – will be given lethal drugs. 2. People on waiting lists. If you can’t get a wheelchair or a cancer treatment any time soon, and that is your sole reason to want to die, you will be given lethal drugs . 3. People who are homeless, indebted or otherwise in crisis. Again, any of these would count as a complete valid reason in itself. 4. “Terminally ill” here doesn’t mean dying.  The courts have held the same words used in benefits legislation means “it wouldn’t be surprising if you died within 6 months”: for many long-term conditions, you might not even be that unwell and satisfy this. According to experts, “six months” is an extremely vague category (Financial Times, Nov 27). This is not just for people in their last days – it could be for tens of thousands who are not. 5. Disabled people (who would often, at least at times, fall within the criteria). Disability Rights UK: “At a time when social care is chronically underfunded, accessible housing is scarce, and many Disabled people are unable to afford food, energy, or other essentials, this legislation … risks pressuring Disabled people into decisions driven by fear, desperation, or lack of options rather than genuine choice.” 6. Anorexia. Scores of patients suffering from anorexia and other eating disorders have died from assisted suicide in countries where this is legal – including where the law is very similar to the Leadbeater bill. The chair and vice-chair of the Royal College of Psychiatrists’ eating disorders faculty say the text of the Leadbeater bill “fails the public safety test.” 7. The Bill means you can make yourself qualify as terminally ill by refusing treatment: this could matter a lot for those with long term but manageable conditions, like diabetes. 8. People with suicidal ideation. Prof Sir Louis Appleby, who leads the National Suicide Prevention Strategy for England, opposes the bill: “Once the principle behind suicide prevention has been set aside, once any part of the ground has been ceded – not only to allow suicide but to assist it – we have lost something we may not get back.” —Coercion risks 9. Domestic abuse. Last year there were 2.3m victims of domestic abuse.  They will be vulnerable to this new cliff-edge. 10. Abusive carers. The whistleblowers charity Compassion in Care, which tracks the scale of abuse in the care system, ask: “What message does this proposed law send to those who are already playing God with people’s lives? 11. Wills and gifts. As the private wealth lawyer Tamasin Perkins writes, coercion is “depressingly common” in this area.  Vulnerable people are regularly preyed on by relatives and opportunistic acquaintances. 12. Pension incentives. Currently your pension pot is taxed much more heavily if you die at 75 or over. Creates a big motive for an early exit. 13. Invisibility of coercion to victims. “Victims describe this as a ‘drip, drip’ effect, and it goes unnoticed … It is also hard for victims themselves to realise they are being coerced until they have got free.” (Jess Asato MP) 14. Invisibility of coercion to outsiders. Coercion “can be very difficult to spot”, says Tamasin Perkins  – even for lawyers who deal with these cases all the time, know the details and meet the family. Mental health worker Andrew Page says coercion “is reasonably common despite the safeguards stemming from Section 76 of the Serious Crime Act, and the idea that two doctors and a High Court judge are best-placed to identify it seems, at best, wildly optimistic.” 15. Difficulty of proving coercion even if detected. Only 3.7% of recorded crimes of controlling or coercive behaviour result in a charge; more than half of cases are dropped due to evidential problems. 16. Indirect coercion. “The bill does not address…more subtle forms of coercion” (Royal College of Psychiatrists). 17. No mandatory coroner’s inquiry (as there currently is for all suicides). Former Chief Coroner Thomas Teague says this makes the bill unsafe as it knocks out a crucial safeguard. Leading barrister Karon Monaghan calls this omission “frankly inexplicable”. 18. No guidance on what “pressure” means: plenty of manipulation, or even open persuasion or encouragement, will fall outside that. The Bill makes clear that it is a reasonable thing for someone who is terminally ill to want to die: in that context, even openly encouraging a relative to ask to die might not be perceived as pressure, as long as you do it carefully. —How not to legislate 19. Slapdash approach. Liberty, which opposes the bill, says: “Good laws do not follow a ‘details later’ approach. For an issue as serious as assisted dying … Every single part of this Bill has to be the ‘gold standard’ – silver is simply not good enough.” 20. Lack of transparency. Kim Leadbeater has visibly associated herself with Dignity in Dying - so what exactly is their involvement? And where precisely does all their money come from, including the stuff recently highlighted by the Daily Record? 21. Lack of time to discuss bill. The 18-day gap between publication and second reading meant MPs were getting key details wrong during the debate – which lasted all of five hours. The PMB process also limits parliamentary time. 22. Lack of accountability. The PMB process means that key questions are dodged. “The PMB’s co-sponsors say ‘That’s a detail for the Government to decide,’ while ministers hide behind ‘neutrality’.” (Richard Dunstan). 23. Lack of freedom for Labour MPs. Reports of a “soft whipping operation”, and Starmer’s very public advocacy, have made this an unusually pressurised “conscience vote”. —Trust the process? 24. Familiarity with patients. Doctors are not required to know the patient at all. 25. First mention. Doctors can bring up assisted suicide even if the patient has never thought of it. 26. Signing by proxy. This can even be done by “a person who is of good standing” but doesn’t know the patient. “I am worried that this could create issues for vulnerable groups” (Florence Eshalomi MP). 27. Conscientious objection. Doctors must refer. Judges, it seems, cannot opt out. 28. Doctor-shopping. If one doctor rejects an application, you can find another. 29. Secrecy from family. No obligation to inform loved ones, who might be able to help or spot a problem. And the first you might hear of your parent, sibling or child dying by suicide, approved by the state, might be when you are told to pick up the body. 30. Secrecy from those with expert and first-hand knowledge. Doctors and judges not obliged to check with the patient’s GP or with social workers, community nurses, mental health workers etc. 31. No palliative care duty. No legal duty to offer palliative care to a patient requesting assisted suicide – let alone top-quality palliative care. 32. Cuts off possible alternatives. “Patients ask me all the time: ‘Please, can you kill me?’ … The question I always ask is, ‘What would have to change in your life for you to not want to die right now?’ There is always an answer, and I can nearly always improve that thing.” (Palliative care consultant Natasha Wiggins) It would now be far easier for people to simply insist on death. 33. The consent safeguard. Royal College of Psychiatrists surveyed members: “Almost two thirds (65%) of respondents were not confident that consent can act as a safeguard against people making unfree choices.” 34. Mental illness. Doctors cannot reject the application merely because the patient is, say, badly depressed – only if they seem to lack capacity by the Mental Capacity Act’s definition (9 (3) (b)). 35. Groups of doctors. In Victoria last year, “the ten doctors with the highest VAD case load co-ordinated or consulted on 55 per cent of all VAD cases” (Former State Attorney General Robert Clark). Even worse, if a few doctors want to be as “compassionate” as possible, and are prepared to be generous with “six-month” diagnoses, nothing stops them from approving each other’s applications in the thousands. 36. Capacity threshold. Baroness Hale once called the MCA threshold used here (cl 3) “not a demanding one.” A suicidal patient could be plainly influenced by a personality disorder and, as long as this was only one factor in desiring suicide, the application could not be stopped. (cf King’s College Hospital NHS Foundation Trust v C) 37. Capacity requirement. No requirement to seek expert psychiatric assessment if in doubt. The Mental Capacity Act tells you to assume capacity if not shown to be lacking. 38. Limited cancellation process. If the patient says to a doctor who is *not* the co-ordinating doctor or from their GP practice, “I don’t want to die anymore,” that doctor has no obligation even to inform anyone. 39. No power in the bill for the court to appoint an investigator. “Without some such infrastructure … it is not obvious how the court could meaningfully carry out its proposed inquisitorial function.” (Sir David Bodey, former High Court judge) 40. Lack of written evidence. Bill doesn’t say judges have power to check financial records, wills, police records of family, etc. 41. Lack of oral evidence. No requirement for judges to hear from anyone except the doctor. Not even the patient. 42. Doctors don’t need to face questions. No requirement for judges to ask doctors anything. 43. No requirement to speak under oath. 44. Third-party applications to the court. Bill doesn’t say these are even allowed. 45. Balance of probabilities. If a judge thinks coercion is possible, but 1% less likely than no coercion, he must grant the application. 46. No right of appeal if application granted, even if evidence of coercion comes to light. (See latest analysis from Sir James Munby, former president of the Family Division.) 47. Judicial officer could be a (very) junior figure. Leadbeater’s phrase “High Court judge” is not in the bill: by law the function could be carried out by a district judge, even a registrar. —Context is all: 48. Lack of alternatives. Palliative care is not “where it needs to be to give people a real choice” (Wes Streeting). 49. Care costs. “Residential care for a whole year (52 weeks) costs on average £60,320 and nursing home care costs on average £73,320 a year”. This creates strong incentives for suicide – and for pressure. 50. NHS record on Do Not Resuscitate. CQC investigation found 508 DNR notices handed out without agreement from patient or family. NHS processes can sometimes encourage a swift pathway to death. 51. Poor care. Care whistleblowers’ charity Compassion in Care say: “We are struck by the naivety that presumes such life and death decisions would be made by unbiased, qualified people in accordance with the wishes of the individual. This is not the reality, vulnerable people are dying for the want of care every single day.” 52. Box-ticking. Dame Caroline Swift, the lead lawyer on the Harold Shipman inquiry, predicts that assisted suicide safeguards will become box-ticking in the same way as they did with cremation certificates in Shipman’s time. 53. Drug complications. Complications occur with assisted-suicide drugs and can be serious: “The pervasive belief that these, or any, noxious drugs are guaranteed to provide for a peaceful and painless death must be dispelled; modern medicine cannot yet achieve this.” (Journal of Law and the Biosciences) 54. Where will the money come from (for DHSC and MoJ)? Health and justice budgets are already under strain. 55. Where will the money come from (for families)? Lawyer Alexa Payet, who specialises in helping with Dignitas, says the legal fees could be “tens of thousands” per family. 56. NHS crisis. According to a statement signed by more than 3,400 doctors, nurses, and healthcare professionals: “The NHS is broken, with health and social care in disarray… The thought of assisted suicide being introduced and managed safely at such a time is remarkably out of touch with the gravity of the current mental health crisis and pressures on staff.” 57. Courts unable to cope. This will need an estimated 34,000 hours of judicial time. “It could basically blow up the family courts” (Government source quoted in the Spectator). —Unintended consequences 58. Clinical negligence. A participating doctor can’t be sued for negligence. 59. New minefield for clinicians. Can a doctor be disciplined or sued for refusing to sign a declaration, if patient believes this is unjust? Can families complain/sue if a doctor signs a form in too cavalier a fashion? What if one doctor makes a complaint against another doctor? 60. Won’t stop bad deaths. Palliative care consultant Natasha Wiggins: “For the very, very small percentage where they do have a catastrophic experience, that is wholly unpredictable. If a patient suddenly goes into bowel obstruction or, very rarely, vomiting faeces, I can say, having seen thousands of people die, that I’ve seen that happen once. It’s completely unpredictable. So the bill as it stands is either going to completely miss those people, because it’s unpredictable, or, what’s more likely, you’re going to have a lot of people dying earlier than they would have done … out of fear of something happening that would never happen to them.” 61. Frightens people unnecessarily. “I fear that lurid stories of faecal vomiting or suffocating in bodily secretions may have set back, by decades, attempts to better acquaint the public with what dying ordinarily looks like” (Palliative care consultant Rachel Clarke). 62. Perverse incentives in NHS. Assisted suicide may cut some waiting lists and care costs. That leads to structural incentives: at the very least, not to invest money and people in areas which will be “solved” if more people take up assisted suicide. 63. Impact on palliative care. Comprehensive recent review from Prof David A Jones finds “clear indications in several jurisdictions of palliative and end-of-life care deteriorating in quality and provision following the introduction of AD/AS… palliative care is not improving as quickly in jurisdictions with AD/AS as it is in jurisdictions without AD/AS.” 64. Damage to the caring professions’ ethos. “The caring professions would lose something irreplaceable – their position as exclusively caregivers” (Gordon Brown). 65. Damage to doctor-patient relationship. “Making myself or other members of my profession agents of assisted suicide would break the bond of trust.” (Andrew Stedman, intensive care consultant) 66. Damage to trust in healthcare system. “Elderly people admitted to hospital have always faced age discrimination to such a degree that many older people fear to go to hospital because they fear for their lives” (Compassion in Care). That fear will be hugely increased. 67. Doctors leaving the profession. GP and Labour councillor Shabina Qayyum: “The variants of the Hippocratic Oath descend upon us all at graduation, reinforcing the tenets of life being a sacred entity to be honoured and protected. The Bill in its current form causes an element of sacrilege to the pledges of that Oath. Would the Oath be altered? Would the Good Medical Practice guidance of the General Medical Council be changed [?] … If the Bill in its current form were to become law, I would need to reconsider continuing to practice medicine.” 68. Safeguarding redefined. Those working in mental health services and welfare would have to rethink when and whether to discourage suicide; as Kim Leadbeater has said, in some cases discouragement could be “coercion”. 69. Doubters and whistleblowers marginalized. In Victoria, says the state’s former Attorney General, “The government and the central health bureaucracy have pushed all public hospitals that may have terminally ill patients to make VAD readily available to the point where … many practitioners working in public hospitals now feel unable to raise concerns lest they suffer adverse professional or career consequences.” 70. Courts discredited. Sir James Munby warns that the scheme is likely to involve “a secret process destructive of the integrity of the scheme and corrosive of the judicial function”. 71. Suicide rate rises. Prof David Paton has found “strong evidence that legalisation of assisted suicide leads to a significant increase in the total (assisted and unassisted suicides) suicide rate”. 72. Undermines NICE and other regulators. They would have to give approval to drugs which are untested for this purpose, and haven’t been approved by any drug regulator anywhere in the world. “I think it puts us back 100 years to when there was no regulation, basically people could do pretty well what they wanted” (Palliative care consultant Claud Regnard). —How slippery? 73. Slippery slope (court safeguard). A co-sponsor of the bill, Jake Richards MP, says the court safeguard should perhaps be removed in the vast majority of cases. 74. Slippery slope (media pressure). The bill covers less than half of those who go to Switzerland (Brewer, Hopwood and Winyard 2024). When Brits are still going to Dignitas, this will create the same pressure as today around unequal access, the law “clearly not working”, etc. 75. Slippery slope (numbers). Where assisted suicide is introduced, the number of people opting for it goes up and up, so far with no end in sight. 76. Slippery slope (criteria): Bill co-sponsor Sian Berry has already suggested that the criteria could be expanded. The campaign group My Death My Decision and prominent figures like AC Grayling explicitly argue for this. 77. Slippery slope (legal): Alex Ruck Keene KC and others say this could open us to an ECtHR judgment requiring parliament to expand the law to a Belgium-style one. 78. Slippery slope (normalisation): “The result of allowing assisted suicide is bound to be its progressive normalisation as an available exit route. This poses significant risks for the old and ill” (Lord Sumption, who supports assisted suicide). 79. Slippery slope (hyper-normalisation). Matthew Parris, who supports the bill, believes and hopes we will come to see that “useless lives” ought to end. 80. Slippery slope (euthanasia). What is the difference, people start to ask, between the doctor raising the mixture to the patient’s lips and actually giving it the final tilt? It becomes hard to avoid the euthanasia which the bill’s supporters say they don’t want. —The long term: 81. Impact on family dynamics. Leadbeater says it is “coercion” when families “try to stop” relatives requesting suicide. This new social norm will have major consequences for how we understand our responsibilities towards others. 82. Trauma for families. Suicide bereavement is notoriously severe. 83. Ripple effect. A major survey found that friends of those who died by suicide, and those who come into contact with suicide through their work, also experience “serious psychological and physical health problems, including suicidal behaviour, and perceived these had occurred as a consequence of being exposed to suicide.” 84. Deepening inequality. “Health inequalities are wide and persistent. We know that black and minority ethnic disabled people have far worse health outcomes than the national average … we should be helping people to live comfortable, pain-free lives on their own terms before we think about making it easier for them to die.” (Florence Eshalomi MP) 85. Consequences for the marginalised. A study of Ontario in the BMJ SP Care Journal found that assisted suicide “may exploit systemic neglect, particularly at the intersections of gender, poverty, and isolation, and may better be described as structural coercion to die—essentially the opposite of autonomy.” 86. Market forces. David Smith MP notes that when private companies offer the service, they may be “either driven by a market incentive or ideological conviction to increasingly provide AD”. 87. Austerity. Even if Starmer’s government protects NHS and courts budgets, it’s very possible that a near-future government will not, thus ripping up the safeguard structure, such as it is. 88. Worst-case scenarios (privatization). Very easy to imagine this becoming part of a privatized service with the same injustices as, for instance, the care system. 89. Worst-case scenarios (public sector scandals). Why shouldn’t assisted suicide repeat the same problems seen with the infected blood scandal, the Post Office scandal, Hillsborough, the Liverpool Care Pathway, etc? 90. Worst-case scenarios (malevolent doctors). If there is another Dr Shipman in the system, this would make them harder to find. 91. Worst-case scenarios (bad relatives). Court of Protection barrister Barbara Rich writes: “Morally unscrupulous, greedy people to whom every week’s care costs for a parent seem like an attrition of their inheritance don’t rationally trade off the risk of conviction for coercion against opportunism.” 92. Extra-legality. It’s common for assisted suicide to become an unscrutinised area where nobody looks too closely. In Belgium, of more than 50,000 cases only half have actually been officially reported, and only one has ever led to a court case. 93. Political fallout. Public opinion is extremely mobile – support falls steeply when people are told counter-arguments, and 70 per cent fear disabled people could face pressure to end their lives. If those fears are proved right, public trust in government (and in Labour) will hit a new low. 94. Threat to democracy and the rule of law. Liberty note that the law gives huge powers to the Health Secretary to define the process. “This raises huge rule of law concerns as it will inevitably lead to the law being applied inconsistently or policy changing without democratic oversight.” 95. Possible increase in bad deaths. Since the main remedy for bad deaths is palliative care, and this will demoralise the profession and divert funding away from it, assisted suicide may well increase the number of tortured and – for loved ones – traumatising deathbed experiences. 96. Funding diverted from hospices. The Telegraph reports that Hospice UK adopted neutral stance on the bill to get “a seat at the table” in funding discussions. There is only so much money to go around. 97. Hospices closing. Hospices cannot impose non-participation on staff members (whereas in eg California hospices can). So for those who wish to opt out of assisted suicide entirely, the only option may be to close down. 98. No sunset clause. California has one, so that the legislation has to be actively renewed. Here there is no realistic exit route if it turns out to be a disaster. 99. Sunrise clause. The bill must come into full effect two years after it is passed – it cannot be delayed even if the implementation looks like being chaotic.

“We absolutely will not invite the Royal College of Psychiatrists. All 14 of us are voting against it” [18 hours of negative publicity later] “Sorry, we actually love the Royal College and definitely want to invite them!” Is this scrutiny, or stage management?

Thanks Naz. I will always work collaboratively & listen to colleagues. The Bill Committee will hear from nearly 50 witnesses with a range of views & a huge amount of expertise. (Important to remember this will never be enough for people who are fundamentally opposed to the Bill)

We have plans in place to manage extra demand – we use critical incidents to manage and monitor pressures, we have more beds than we did last year and we have new ways of working which ensure people can get cared for at home.

Starmer: “Today I welcome a new agreement…with the private sector” to deliver more beds and treatment to reduce waiting lists. He says better care should Trump ideology

Nobody does a State banquet like 🇬🇧

Today, I give praise to @RCPhysicians senior leadership & key contributors. Over the last 12 months RCP hit rock bottom. A catastrophic EGM, leaders departing, the future looked bleak. Led by @Mumtaz_Patel_1, RCP underwent an independent King’s fund review. Published it unredacted, warts n all - no excuses given. The PA oversight group was formed, calmly & diligently it has done what it needed to do. Led by @HilaryWMedic & @BDChadwick, the docs published today are helpful & appear to have been accepted well so far. Council have also made our stance clear to NHSE & GMC. I am very grateful to fellow fellows who raised the issues originally & called an EGM. I must thank other colleagues who have continued to raise these issues within RCP. @parthaskar prominently, also many others in the background too. To overcome such inertia is impressive, RCP is now increasingly reflecting the views of its members & fellows, protecting trainees, PAs, and ultimately our patients. The work isn’t perfect, nor is it done - but today is a good day.

In 2023, @gmcuk awarded a four-year £2.8 million contract for private medical insurance (£700k per year) 💰 The tender documents show the actual spend on private medical insurance in 2022-23 was £642k for 1066 staff This is equivalent to 3690 x FY1 fees or 2006 x PA fees

I've asked a colleague who teaches stats in the University to run constituency deprivation scores and assisted suicide votes through some independent statistical analysis. The results are quite interesting. Here, for example, are how Labour MPs split on assisted suicide: