Tony Delamothe on the assisted dying debate at the Maudsley

Tony DelamotheFinally made it to a Maudsley debate (28 April 2010), after years of noting their carefully worded topics and starry lineups. This one was no exception. Household names were debating the motion that: “This house believes that doctors should be allowed to assist some people with suicide.”

It was the first public discussion I’d been to since the Director of Public Prosecution clarified the circumstances under which people would be prosecuted for assisting others to commit suicide. Effectively denying a role for doctors, he listed among the public interest factors favouring prosecution:

“the suspect was acting in his or her capacity as a medical doctor… and the victim was in his or her care”

The first speaker, for the motion, was Baroness Warnock, staunch defender of personal liberty in the House of  Lords and elsewhere. She said that given the DPP’s latest advice, doctors who assisted their patients to commit suicide would very likely be prosecuted or disciplined.  So being in favour of the motion meant being in favour of a change of law.

She wanted to assure the audience that no one would be helped to die unless they had made this clear, and she acknowledged that palliative care can help people to die comfortably.

But if someone wanted to be helped to die doctors needed to take this into account. In nursing homes she had noticed a conspicuous lack of acknowledgment that we were all going to die. People who asked to die did not regard the request as unreasonable or immoral, and doctors who refused the request were putting their principles above the patient’s.. It’s “diminishing” to have your wishes brushed aside. Doctors didn’t have the right to override others’ opinions, she said.

Baroness Ilora Finlay, professor of palliative medicine at Cardiff University, spoke against the motion. She seemed happy with the DPP’s new advice, which combined “a stern face with a not unkind heart.” She doubted that we could trust patients’ expressed desire to die – they could be discreetly manipulated by others or could act voluntarily out of a wish to spare others. Their wish to die could fluctuate. In her view, legalising assisted suicide was incompatible with patient safety.

She cited approvingly the Royal College of Physicians’ submission to the DPP that “Clinicians’ duties of care entail active pursuit of alternative solutions to assisted suicide, not its facilitation.” Referring back to the wording of the motion, she said doctors didn’t have to be involved with assisted suicide: “anyone can be trained to kill.”

Professor Raymond Tallis, the second speaker in favour of the motion, had previously chaired various committees on the topic for the Royal College of Physicians. Initially he’d been against assisted dying, but looking into the evidence made him change his mind. Originally, he thought good palliative care would make assisted dying unnecessary – but he found that not to be so. He was originally concerned that assisted dying would inhibit the expansion of palliative care, but could find no evidence for that internationally.

Wouldn’t trust between doctors and patients be eroded? He found that the Netherlands had some of the most liberal euthanasia legislation in the world, yet Dutch doctors had emerged as the most trusted in a European survey of attitudes to doctors. He decided that this was not surprising:  knowing that your doctor would not be abandoning you at the time of greatest need would be more likely to foster than undermine trust.  Against the slippery slope argument he pointed out that deaths from assisted dying had fallen, not risen in Oregon, over the past decade (from 0.8% to 0.4% of deaths). Oregon has laws on assisted dying closest to what British campaigners want.

And regarding the concern that the most vulnerable in a society would avail themselves most of the option: in Oregon it was the middle class, long used to defending their autonomy, who were overrepresented among those who’d chosen assisted suicide.

The last speaker in the debate was Professor Rachel Jenkins, head of mental health policy at the Maudsley and architect of the Royal College of Psychiatrists’ position statement against assisted suicide. She approached the topic via considerations of suicidality and capacity.

Surveys had shown that most people with suicidal ideation had a psychiatric disorder, with only 0.6% of suicidal attempts occurring without such disorder. Once treated for their psychiatric disorder, 98% of people who had wanted to commit suicide no longer wanted to do so. On the basis of these figures, she thought there’s no evidence to support Koestler’s notion of “rational suicide.” Mental capacity can be affected by depression (as well as physical illness), and doctors are notoriously bad at detecting this.

She seemed to be arguing that findings from the general population could be unproblematically extrapolated to the terminally ill. In this formulation, their desire for suicide was likely to result from psychiatric disorder and so would disappear after proper treatment of the psychiatric disorder. Good palliative care was therefore the answer.

In the Q&A session after the formal debate, it was pointed out that the latest Joffe bill had carried two safeguards relevant to the discussion: patients requesting assisted suicide would receive a psychiatric assessment of their mental state, and there would be a “cooling off” period to ensure that theirs was a sustained wish.

The Joffe bill had been defeated in the House of Lords, and although the motion debated at the Maudsley wasn’t defeated, it was a close run thing. After the debate, there were 43 votes both for and against the motion, with 3 abstentions. (Before the vote the figures were 47 for the motion, 32 against, with 5 abstentions.)

Tony Delamothe is deputy editor, BMJ.

Listen to the debate at:

Read Clare Dyer’s news story on the debate: