William Lee: A question of proportionality?

William Lee On Wednesday 25th February Baroness Warnock spoke at the Maudsley Philosophy Group. Her topic was, ‘Assisted Dying: Should the law be changed?’. The Maudsley is a psychiatric hospital in south London which adjoins and collaborates with the Institute of Psychiatry. Baroness Warnock, now in her eighties, is an extraordinarily accomplished person. She is a philosopher who was also a headmistress for a period, she has written many influential and popular texts, and she has chaired several government committees of inquiry which resulted in the Warnock Reports of 1978 and 1984 on the subjects of special educational needs and human fertilisation and embryology. These provided the framework for government activity in these areas.

Baroness Warnock started by describing being elderly and knowing that death is likely to be relatively near. She expressed frustration that no-one talks about it and no-one seems interested in controlling it. This is not something that she finds acceptable. She cited the many surveys of public opinion (summarised here) showing strong support for assisted dying in some form, but she was not optimistic for a change in the law any time soon: Four groups of opposition were identified: doctors, lawyers, religious groups, and disability rights groups. She did not refer again to disability rights groups.

Doctors were described as universally opposed: The idea that the taking of life is not what doctors do, and it is wrong to expect them to change their ways, was rejected with the suggestion that doctors should get over their squeamishness. There was no mention that the Hippocratic Oath specifically forbids assisted dying, and that the legal situation in Germany is that one person assisting in the suicide of another is legal, but it is forbidden for doctors to do this. The idea that physician assisted dying may undermine trust between patients and doctors was dismissed out of hand: The Baroness felt that the current lack of that capability undermines this trust. This view ignores the repeated finding that doctors are the most trusted of professionals. Further, she claimed that doctors currently do administer illegal lethal doses of drugs to their families and friends when the need arises. This claim was made three times during the talk. I can find nothing about it on the web, and I have never heard of a case of it in ten years as a doctor.

Lawyers were disposed of by saying that it was difficult to argue with a group who have control of the way laws are written, and who claim that no effective and safe bill to allow assisted dying with appropriate safeguards can be drafted. Religious groups’ views were condensed into “sanctity of life” arguments, the mediaeval concept of vitalism was equated with this, and the untenable (in her view) supernatural claims of vitalism were dismissed, and with it any religious opposition to assisted dying.

A junior psychiatrist asked, assuming that the human mind can make a capacitous decision about its own destruction, and given an imperfect test for this capacity, whether Warnock would find it acceptable if for every ten people killed by assisted suicide, one was wrongly killed, and therefore sacrificed for the supposed good of the others. Warnock replied, but to her the sacrifice was keeping people alive wrongly rather than killing them wrongly, and she suggested that it was acceptable for 9 people to be killed wrongly if it meant one person being killed correctly. Another psychiatrist, in response to Warnock’s claim that there was no rational obstacle to appropriate legislation with appropriate safeguards being created, said that when it comes to assisted dying, psychiatry is not good enough to determine the capacitous from the non-capacitous with sufficient accuracy.

Assisted dying can be viewed as intrinsically bad (or good), in which case there is little progress to be made in discussion. It can also be viewed as right or wrong, based on the likely consequences. Assuming that the intention of the various proposed, legislative changes is to allow only the “right” suicides to happen, then it presupposes that there is such a thing as a ‘right’ suicide. Given that there is, then the challenge is to distinguish these ones, which would require assistance, from others, which would need prevention, as suicide is a major public health problem. All tests have errors, and these are quite easy to model, so for a given testing method and circumstance we can calculate how many people requesting assisted suicide will pay the price of being ‘wrongly’ assisted to die for each person correctly assisted. How many to you think is appropriate?

There is a problem with this though: We do not have a gold standard against which to judge our test, so even if we had a good test, we’d have no way of knowing that we had it. Perhaps Baroness Warnock’s recent book has the answer?

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