ACTION ON ELDER ABUSE (AEA)

ASSISTED DYING BILL

BRIEFING NOTE JULY 2014
Introduction:

Action on Elder Abuse (AEA) focuses upon challenging and preventing the
abuse of older people, whether in the community or institutions. The charity
has been in existence for 21 years.
AEA has no objection to the principle of assisted dying (physician assisted
suicide). This is a moral debate that is not in itself abusive. However, it is the
process, and the associated safeguards, that dictate whether or not the reality
becomes abusive, and it is this that we have addressed in the Bill proposed
by Lord Falconer.
As it stands, we believe that the current Assisted Dying Bill lacks any
meaningful safeguards to protect the interests of people who will be in
the most vulnerable of situations, and we recommend that it should be
opposed in its current form.

The key issues for AEA relate to:

(a)
(b)
(c)
(d)

how individuals may self elect for assisted dying;

how external pressures, including coercion or feelings of family
obligation, may influence a decision to hasten death and what
weight is given to such pressures;
who is nominated to validate that a decision is taken voluntarily, on
an informed basis and without coercion or duress; and
how that validation is undertaken.

This is exclusively about ensuring that people are not coerced, either overtly
or covertly, into self-electing to commit suicide with assistance, that they
understand the implications and options, and have had the opportunity to
consider their decision in an environment that ensures it is genuinely free of
coercion or duress.
Starting Point:
We recognise that the Assisted Dying Bill is focused upon adults who are
terminally ill, and as a consequence of that terminal illness, are reasonably
expected to die within six months. Consequently, as it is drafted, it would not
apply to people simply as a consequence of age or disability.
But this raises a question about the approach adopted and what the Bill is
seeking to address. It is not linked to advance decisions associated with other
factors (e.g. some people might strongly wish to trigger assisted suicide if they
feared a loss of capacity through dementia at some future date). Nor is it

linked to levels of pain or suffering, but seems to focus exclusively on the

likelihood of dying within a short timeframe.
This is not to imply or suggest that other circumstances should be included.
But it raises the question as to whether a diagnosis/prognosis of a terminal
illness, with likely death within six months, is sufficient criterion by itself for
assisted suicide particularly when such prognosis can only be subjectively
established.
Validation of the decision
The witness:
The Bill indicates that the person should sign a declaration in the presence of
a witness who is not a relative or involved in their care/treatment.
What is the purpose of the witness, is it simply to confirm that it really was the
person who signed the declaration? If so, what is the point, as that will
become apparent at the next stage of the declaration?
To be effective, a witness would need to be independent (i.e. not the next
door neighbor or friend who is due to inherit in the Will), able to confirm that
there was no coercion or duress applied and that the decision was free and
genuine. That would be a huge responsibility, with major questions around
how it could be performed effectively. It is akin to the role of an Independent
Mental Capacity Advocate in levels of complexity.
As defined, the witness role seems superfluous to the process and would not
provide any safeguard. It is effectively of no value.
The Medical Practitioners:
The Bill indicates that the medical practitioner from whom the person has
requested assistance, and another medical practitioner independent of the
family and the original practitioner, should countersign the declaration. These
practitioners are to confirm that the person is terminally ill; has the capacity to
make the decision; and voluntarily wishes to end their life on an informed
basis and without coercion or duress.
The prerequisites for undertaking this role are that the doctor holds a
qualification or has experience in respect of the diagnosis and management of
terminal illness.
The Secretary of State may issue a code of practice on assessing whether the
person has capacity to make such a decision; and on recognising and taking
account of the effects of depression or other psychological disorders that may
impair a persons decision-making.
This approach toward validation is exclusively a medical model i.e. it only
considers if someone has mental capacity, or whether they are affected by

cognitive issues that may influence decision-making. However, the

practitioners are not required to be trained in assessing capacity, just the
management of terminal illness, so it is unclear as to how this would be
effectively undertaken in the context of the Mental Capacity Act 2005?
The Bill makes reference to - but does not address coercion, undue
influence or duress, which are major factors in elder abuse, and these issues
do not appear to be considered within the parameters of the Bill. It is unclear
as to how the persons decision would be validated to ensure that it is
genuinely free of coercion or duress? By who? Over what time period?
There are currently major concerns around the potential misuse of Do Not
Attempt Resuscitation notices by medical practitioners in hospitals, and
ageist approaches that are discriminatory in terms of denying treatment based
on age. The spectre of Dr Shipman still haunts the profession. The linking of
this assisted suicide process to a profession that is aimed at healing the sick
is a dangerous one in terms of the messages it sends to people who are frail
or sick; it challenges the basis of the trust that must be integral to the
relationship between the physician and the patient.
Are medical practitioners the best people to undertake this role, or is this
something that should be undertaken by specialists?
To be comfortable with a proposal for assisted suicide, the safeguards need
to be clearly defined in advance, be meaningful and proportionate, and
address a range of factors additional to those affecting mental heath or
capacity. It is about getting to know ad understand the person, their
circumstances, and the external and internal pressures on them. All of this
takes time to do effectively.
The Assisted Dying Bill falls short of meeting these goals in its entirety.
Timeframes:
Medicines will be delivered after a period of not less than 14 days, unless the
doctors agree that a persons death is reasonably expected to occur within
one month in which case this timeframe is reduced to six days.
We understand the reasons why timeframes are short within this proposal.
However
a) this would be insufficient to allow anyone to adequately establish that
coercion or undue influence was not occurring;
b) it would be difficult if not impossible to establish that the decision was a
genuinely informed one, that all suitable alternatives had been
explained, and that it was consequently an informed choice.
The timeframes increase the need for the earlier processes to be robust, that
there is an identified method and process for establishing the actual

circumstances affecting the decision, and for adequate investigation to ensure

the decision is genuinely free of coercion etc.
As it stands, we believe that the current Assisted Dying Bill lacks any
meaningful safeguards to protect the interests of people who will be in
the most vulnerable of situations, and we recommend that it should be
opposed in its current form.