If we are honest with ourselves, as Parliamentarians the depth of our knowledge on issues is often shaped by the public square – from our mail bags, from those who come to see us, from our research or from simply trying to do the right thing.
I too have taken much time to listen to constituents on all sides of this debate, and am truly grateful for their sharing of very personal experiences. Some patients or carers, some medical practitioners, most predicting the future choices they could make if in an advanced stage of a disease process, but very few, if any, having read the Bill.
However I believe that on an issue so momentous as the one before the House today it requires a real depth and understanding, and a strong evidence-base from those who are experts and have read the Bill.
Not only have I worked with patients in acute medicine, often in the later stages of their disease processes for 20 years in the NHS, I have taken time to engage with those who oversee end of life care. It is the time that I spent with palliative care specialists whose raison d'être is to manage the dying process that has been the most enlightening, and why on a technical and cultural level I believe this Bill is deeply flawed.
First as one who has campaigned for our NHS against a background of austerity, I oppose this Bill as rationing of drug therapies and social care provision is driving people to make difficult choices. Without the obligation to provide palliative care, as is currently the case, assisted suicide could rapidly become a cheaper alternative to more expensive interventions. This in itself causes me to strive for equality and excellence in end of life care and against assisted suicide.
In the time I have, however, I want to focus back on the core concerns raised by the ‘experts’.
The Bill forces senior clinician’s to ‘play God’ in determining the life expectancy of a patient. The volumes of papers concerning the probability of life expectancy is significant, and the body of evidence concludes that it is impossible to determine. This comes as a shock to so many of us, but the catalogue of errors in predicting life expectancy is there for all to reflect on. Ali Megrahi, the Libyan bomber would be one such case living 2 years and 9 months more. Jeanette Hall who opted for assisted suicide in Oregon, but did not medicate is still alive after 14 years. A new treatment, a transplant, or simply some remission – all can extend and improve the quality of life. However the unanimity with which those who work in palliative care couldn’t be clearer – you can sometimes predict hours and days but when it comes to weeks it becomes more challenging – 6 months; impossible. We must heed to their experience.
Where comorbidities are present, which is frequently the case, the future is even more challenging to read. Simply there are too many variables as to how the disease process progresses and how people respond to different therapeutic interventions.
We must now focus on research and services to further improve the quality of care at the end of life and the new NICE ‘Care of the dying adult’ guidelines will be a first step in this. I recommend that Members of this House first reads them before voting today.
A second weakness with this bill is the process for assessing a patient’s capacity. All clinicians will relate that it takes time to come to know and understand their patients. Even with this time, it is not always possible to know the pressures of home. When evidence shows that those requesting assisted suicide are most likely to due to not wanting to be a burden on family or society or finances, understanding context becomes vital.
Accompanying a diagnosis, there is often layers of reactive situational depression, clinical depression, and lack of absorption of information. With these variables and no stipulation on the level, depth and quality of information provided, how can safeguards prevail? A clinician has a duty to assess a patient’s capacity, but recognises that this can take time and with interventions from a range of clinicians.
The Bill refers to patient notes being the core assessment tool. Notes in themselves are no more than a log of events. They can never be all encompassing and therefore for the attending or independent doctor to assess a patient on the basis of notes and a single examination at one point in time will provide no complete understanding of the individual or safeguards. The judiciary, so called, safeguards merely examine if the right boxes have been ticked as the judiciary has no medical competencies.
This is why clinicians who have studied this Bill are virtually unanimously in their opposition, as they know that to have to make such vital decisions out with their competencies and scope of practice questions their registration. But most will also add that it will fundamentally change the patient-clinician relationship of trust.
A further concern has been expressed about the administration of the lethal drug. Whether taken orally and the risk that an individual may vomit or partially absorb the medication, or confronted with a syringe drive that malfunctions, the role of the assisting doctor is then brought to the fore. Do they then actively terminate the life themselves and thus moving into a new messy debate around homicide, do they revert to emergency health interventions, or do they simply manage someone until their natural death.
Finally I want to talk about death itself. Death is not a moment, but a process. As a nation we do not discuss, value or understand the process well, and I believe that this Bill must be a call for us to advance real discussion over death. Throughout my clinical practice, I have had the privileged to witness the intensity of relationships formed through the dying and bereavement process. The two are intertwined and a necessity, no matter how sad, it can be so enriching with the right care and support provided, as the most vulnerable is cradled by those who do really care. Dying changes us and those around us. It is the beginning of our healing.
I implore all those who have doubts over this Bill today, to step back, pause and instead of allowing it to progress, vote against and fight for excellence in life.