I'm a palliative care doctor – the new assisted dying Bill puts the vulnerable at risk

Telegraph

6 hours ago

Prof Mark Taubert is a palliative medicine hospital consultant and clinical director at Velindre University NHS Trust. He is also a professor at Cardiff University School of Medicine and chair of the advance and future care planning group at NHS Wales.
As I watched the Terminally Ill Adults Bill on Friday, one moment struck me very hard. An amendment was being voted on by MPs. This amendment would ensure that someone 'substantially motivated' by feelings of being a burden, a mental disorder, a disability, financial considerations, lack of access to treatment, or suicidal ideation would not qualify for assisted dying. It was voted down. At this point, I knew the House of Commons would vote with a majority for this assisted dying legislation. Legislation I do not feel is good enough. And it was a slim victory, but passed it was.
The reality of my patients
Perhaps I should explain with some practical examples, regarding people whose details I have substantially changed to preserve anonymity. I have a patient who is his mid-40s. He has suffered from alcoholism and substance abuse for much of his adult life and is facing a custodial sentence. He has attempted suicide on four occasions, and he now has prostate cancer. In addition, he has Type 2 diabetes, and also a chronic lung condition which makes it harder for him to breath.
Another patient has stage 4 breast cancer and is 25 weeks pregnant; she is facing being evicted from her home, has an abusive partner and also a history of self-harm and anorexia nervosa. Offering these individuals assisted suicide (even amongst many other potential other options) does not feel like the right approach; in fact, it will very likely be misconstrued. Assisted dying may to some seem like a solution to all their challenges. A form of treatment, although many would contend that it is anything but. If we as clinicians start approaching it from such an angle, and mention this option as one amongst many 'treatment' options, will they just assume that 'doctor knows best', and go ahead?
Not all patients are strong independent people
Those working in politics in recent weeks seem to have been working under an assumption that patients have an advanced cancer in isolation from other conditions, that they are all strong, independent people, like those appearing in the advertisements by the pressure group Dignity in Dying. In Kim Leadbeater's proposed assisted dying legislation, the premise appears that the issue is simple – just give people the choice!
Much of the assisted dying debate we have heard focusses on patients with advanced cancer, with 'less than six months to live', who wish to die early. But clinicians like me have been frustrated at the lack of understanding about the complexity our patients face; for example, the ones I have just mentioned. They often live with multiple conditions and separate issues. Six months or less is, more often than not, guesswork.
In the real world outside of Westminster, which I see daily in hospitals, outpatient clinics and in the community, patients have multiple long term illnesses and other morbidities simultaneously. I regularly see patients who have a stage 4 cancer, but are also in a wheelchair; have had severe mental health issues including bipolar disorder and severe depression in the past; have attempted to take their own lives multiple times well before their cancer diagnosis; live in poverty; are facing homelessness and often feel devalued, due to a co-existing disability.
An additional diagnosis like prostate cancer or breast cancer may then become their 'key to access' the assisted suicide clinic; or may be used by a person controlling them as a way to gain access, and rid themselves of the individual.
What we have is a complex patchwork of patients with various, distinct needs, yet politicians are still debating this as though we can compartmentalise and separate these conditions neatly, quite separate from the patient. It's simply not the case.
Promises to make the Bill bulletproof and safe don't seem to have happened
Despite evidence from other areas of the world where assisted dying is legal, our political class – seemingly to honour a promise to a celebrity – blunder ahead with a pass-it-now-and-we'll-sort-out-difficulties-later attitude. Don't worry, the House of Lords can fix any of the flaws and then the Secretary of State can add on bits later, too.
It seems to me that at its second reading, back in November, similar promises were made to make the Bill bulletproof and safe by its third reading, but that does not appear to have happened. Clinicians like myself struggle to understand how amendments to this Bill, that might protect vulnerable groups – such as those with dementia or Down's Syndrome, or those suffering from eating disorders – have been rejected one by one. Establishing why someone wishes to take their own life, and asking whether an advanced cancer diagnosis really is the main trigger, and whether or not someone might change their mind, will be hard, even for the most experienced clinicians.
What exactly is going on? There is a blinkered mentality among some who do not wish to see the issues in anything but simple terms, with columnist and peer Lord Finkelstein being a prominent example, but you also wonder how much influence extremely well-funded pressure groups like Dignity in Dying have exerted in all of this. I would hazard a guess that Assisted Dying clinics of the future will have pink signage.
This Bill promises to make very difficult decisions much more straightforward and clear. But life is not straightforward and it is the vagueness of the Bill – with its huge number of unanswered questions – that concerns those at the coalface of the end of life like me. Without very significant changes and improvements from the House of Lords, we face the all too real prospect of the system provided for by this Bill failing our patients. The complex needs of many of the families I serve require a network of support, not, as the Bill allows, physicians bringing up the possibility of assisted dying to those who are already vulnerable and suicidal.