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William Lee on “A Short Stay In Switzerland”

27 Jan, 09 | by BMJ

William Lee Last night the BBC aired “A Short Stay in Switzerland”, a one-off drama based on the true story of a terminally ill doctor who killed herself in Zurich with the help of Dignitas, an organisation specialising in assisting suicide (read obituary). Assisting a person to commit suicide is illegal in the UK, though there have been several attempts to change the law in recent years.

Dr Anne Turner was diagnosed with progressive supranuclear palsy (PSP), a rare, terrible and incurable brain disease, after her husband had died from a similar long illness. A superb performance from Julie Walters reveals some of the emotions that the real Dr Turner might have had as she made her choice to die. She saw it as a choice between a good death and a bad death. It seemed so reasonable. It seemed so inevitable. It seemed so unreasonable that we do not have Dignitas clinics here is the UK. At the end was a short scene of her son’s wedding in which his mother’s ring is used and a grandchild is seen. Life went on.

What appears to lie at the heart of this story is a question of mental capacity. Did Dr Turner have the mental capacity to decide whether she should live or die? Capacity to make a decision is commonly tested using the framework of Understand-Retain-Balance-Communicate, and this is now incorporated into British law. She was certainly represented as a person who was able to do these things – and we witnessed her communicate her decision clearly at several points. So it’s simple: She had the capacity to decide the issue and it’s not illegal, so what’s the problem?

A judgement over mental capacity is specific to a particular decision, and a person can have the capacity for one decision but not for another. The greater the consequences of a decision, the more certain of the possession of mental capacity the assessor must be. How much capacity must a person have to sanction their own destruction? Is the human mind capable of making such a decision? The question of the natural limits of human understanding has received philosophical attention already: Locke addressed the issue of whether a person could voluntarily sell themselves into slavery in 1690. He concluded that they could not: No-one has that degree of mental capacity. Today the world agrees with him. Might the domain of decisions that no human has the capacity to make include the choosing of death over life?

In any case, mental capacity is not at the heart of this story. It’s a story of value. It’s a story of how much one life is valued in comparison to another. Watch the programme and imagine Dr Turner saying all the same things, but earlier in her illness. What if she had decided the time had come to go to Zurich the day she was diagnosed? Would it all seem so inevitable then? Could it be that the point in her illness at which it becomes easier for you to understand her decision is the point at which her life stops being valued by you? A related programme was broadcast on Sky Real Lives on 10th December last year called “Right to Die?“. Several people approached Dignitas to end their lives, and not all of them were thought to be suitable. Some of them are turned away. There is no suggestion that their mental capacity is impaired, it’s just that the assessors judged that their lives were worth living, and that the other people’s lives were not.

William Lee is a clinical lecturer and MRC training fellow in general hospital psychiatry at the Institute of Psychiatry, London SE5 9RJ

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  • http://www.semeioticabiofisica.it Sergio Stagnaro

    Such as problem is really to complex, and thus difficult to solve by a comment. Among individuals who in someway approach Dignitas to end of their lives, some , but not all, show mental capacity impaired! In any case, let’s broadcast on Sky Real Lives “Right to Die”, followed also by another broadcast about “Right to Live”. I mean, broadcasting a programme on Primary Prevention of most common and severe disorders, like diabetes and cancer, based on inherited constitution-dependent real risk (Ask Google.com).

  • CAROLE SOLOMONS

    i saw this film and felt that the portayal of Anne Turner was excellent. Much was made of the fact that she was medical and fully understood the likey outcome and that she had witnessed her husband’s terriable death so her choice was fully informed. I beleive that it is possible to be more afraid of choking/disability/humiliation than death itself. However I am still very uncomfortable with the idea that it is our choice to end life and think end of life care should be improved to the extent that people need not be afraid of being left in physical or emotional distress. Yes the choice may be what sort of death but not necessarily when.

  • Amina Aitsi-Selmi

    Interesting commentary Will. Could it be applied to other non-clinical domains such as prostitution? Is one woman’s life worth more than selling her body but not another? The latter should therefore have ‘the right to choose’ whilst the former would be in ‘an awful situation beyond her control’.

  • Liz Hennel

    I too watched the programme, and was profoundly moved by it.
    I am not sure, however, that I agree with your summation that it boils down to what is a life worth. That Dignitas makes a judgment about who is suitable for their assistance is only sensible – and sensitive, but I am not so sure that it is a decision about what that life is worth, per se. I suggest it is about what the process of death is worth. How it will be experienced by the patient and their family. What is suffering – and what that suffering does to those who are intimately involved with it. The slow, steady, drip by drip erosion of the capacity to be independent and interactive, to determine how, when and by whom you are cared for is terrible to contemplate when you know that your body is going to die by degrees.
    I believe it is time that this country had an honest debate about assisted dying – without recourse to religious or other pseudo-moralistic posturing. And lets not patronise chronically and terminally ill people by suggesting no-one in their right mind would opt for this course of action. there is plenty of evidence to the contrary.

  • Alice Watson

    William Leigh dislikes the thought of somebody “choosing death”. That is very negative: “rejecting life” is the better phrase. There are some things which it is wise to reject, and Anne Turner’s life had given her no choice but rejection.

  • Simon Kenwright

    Many thanks to William Lee for his interesting comments but why highlight this particular decision? Patients may make far more significant decisions as regards overall length and perceived quality of life when , for example ,when refusing potentially life-saving surgery. Is the suggestion that if the human mind lacks capacity to make such a decision , then treatment could be compulsory? That would seem a retrograde step to a level of paternalism in medicine which I had hoped was long gone.It also has a wide range of implications for our Society which puts much emphasis on the right to choose (however poorly that “right” might be understood. Rational individuals may wish to shorten their lives or plan their deaths when imminent for a wide variety of reasons. As doctors we have to work towards providing a caring environment where they feel they can discuss these and other options. Difficulties arise when the patient is not prepared to discuss these reasons – or when the doctor is judgemental in ruling out a line of action that might be appropriate for that patient.Perhaps it is the doctors who pre-judge who lack the “capacity” to be involved in these decisions? The present approach to mental capacity is not ideal and we have yet to see just how it works in practice.We need to avoid it just becoming a battle over who is in “control”. Just how far doctors should be involved in assisting death for those who make an apparently informed decision and are dying in distress despite all other options will remain a separate and emotive issue. DOI Member of Dignity in Dying.

  • Lloyd

    We can do a sum: total happiness minus total misery. If the result is positive, live, if not, die.

    Of course there are complications. When a person is tremendously upset, such as when in grief, the total might be negative at that moment, but the sum in this question is total happiness to be experienced _in the life to come_ minus total misery in the life to come. Of course, to know these figures, we would have to be prescient. If a patient is rational, and consults learned doctors who can confidently give a dire prognosis, then the misery half of the equation can be estimated well enough I’d have thought for assisted suicide to be contemplated.

    Perhaps the biggest complication comes from the different interests of the state and the individual. If an individual is no longer of any use to the state, and wants to die, then it seems unreasonable for the state to forbid them death. Who would benefit from their enforced life? If an individual wants to die, but the state values them (perhaps for their knowledge) even then does the state have the right to enforce life? Remember here that enforced life = enforced misery if the sum has been done correctly.

    Personally, I do not wish to live in a state that has the right of life and death over me. I want the state to mind its own business. Yes, the state perhaps should protect the feeble from those who might exploit them (“Granny, we think you ought to die now so that we can inherit before our kids go to university…”), but I wish to be master of my own fate.

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