Despite what campaigners say, legalising ‘assisted dying’ would have far-reaching impacts on our society, writes Professor Allan House.
Campaigners insist that ‘assisted dying’ and assisted suicide are not the same thing. There is a clear difference, they claim, between helping a terminally ill person die and helping someone who is not terminally ill die. They argue that ‘assisted dying’ merely ‘allows the terminally ill person to have a choice over the manner and timing of their imminent death. As an expert on suicide and the impact of severe physical illness on mental health, I reject their characterisation of this very serious issue.
The legal definition of suicide is a death arising from a deliberate (intentional) act, where the deceased intended the consequence would be death. The definition does not include any component of context. Even practice does not uphold a distinction based upon the idea of imminent death – Oregon’s latest annual report shows that one in ten of those who died by ingestion of medication prescribed under the state’s Death with Dignity programme used drugs obtained years before their death. ‘Assisted dying’ is another name for physician-assisted suicide.
I reject campaigners’ characterisation of this very serious issue
With this in mind, the recently published National Suicide Prevention Strategy for England is an interesting read. In its foreword, Maria Caulfield MP, Minister for Mental Health and Women’s Health, says the strategy “sets out ways that we can prevent suicides for everyone [my italics] over the next 5 years”, adding, “we also continue to look at what we can do for groups where we see higher suicide rates”. People with physical illnesses are listed as one such group, as they have double the suicide rate of the general population. It is therefore hard to conclude anything other than that ‘assisted dying’ is incompatible with England’s National Suicide Prevention Strategy. The same applies to other parts of the UK.
Legalising physician-assisted suicide carries direct and indirect risks. Direct risks affect those who might be recipients of a prescription from a willing doctor. Data on unassisted suicide associated with physical illness (for example from the ONS or National Confidential Inquiry) can give pointers to who these people may be. They are more likely to be socially isolated and unsupported, poor, and have a history of previous mental health problems or drug or alcohol problems. In other words – quite unlike the people used in case studies by supporters of assisted dying. The experience of countries like Canada tells us how likely this is, and that’s why supporters of assisted dying are so keen to shift focus to other countries with more recently passed legislation instead.
Legalising assisted suicide brings a radical shift
It has been suggested that one direct effect of introducing ‘assisted dying’ is that unassisted suicides will decline – either because ‘assisted dying’ is seen as a more acceptable substitute (a tacit acknowledgement of their fundamental lack of difference) or because both assisted and unassisted suicides might decline in response to a more relaxed approach to discussing options in end-of-life care. In fact a recent review shows that the reverse is true – if anything, unassisted suicides increase after the introduction of assisted suicide. This points to the other problem with legalised physician-assisted suicide: its underacknowledged, indirect risks.
Legalising assisted suicide brings a radical shift not just in clinical practice but in how we view severe disability, life-limiting illness, and end-of-life care. The shift happens when we stop saying we should prevent suicides for everyone and start saying we should prevent suicides for everyone except those whose suicide we think we should assist. At this stage we are making judgements about more than who might be eligible for a prescription of potentially fatal drugs. I think of this as the ‘Lives Not Worth Living Effect’, and I am unconvinced by the argument that you can avoid it by getting smart lawyers to draft carefully worded laws.
Assisted suicide will usher in profound cultural changes that cannot be mitigated by legislative measures. UK Politicians have said no to assisted suicide many times before. I’d urge those who will considering legislation in Scotland in the coming months to reject it again.
Allan House is a psychiatrist whose expertise lies in: the overlap between physical and mental health in people with severe physical illness; self-harm; and suicide