Assisted Dying

[mdgv2]

How do!

So this is something hitting the headlines in the UK, and something quite close to my heart.

In short? It seems attitudes toward voluntary euthanasia in the UK are changing. An inherently tricky and often taboo subject is being talked about openly, and typically without much hysteria. That is heartening to me, because I am in favour of it. Not only do I have any intention of being the Last Man Standing, but my Mum suffered a fairly drawn out death when she developed upper stomach cancer, and ultimately starved to death.

My stance is supportive in sheer principal. Just because we can extend life using modern medicine, it shouldn’t be done against the wishes of the patient. If someone is given a confirmed terminal diagnosis, I’m against them being forced to keep going just because they can.

But? I appreciate and acknowledge there’s far more to it here. Sadly humanity remains awful, and so any associated legislation will need to be strict, and tight. So no trying to bump Granny off to get your inheritance a few years early, or trying to get shot of disabled relatives because you’re a cunt and can’t be arsed.

Exactly what that legislation should involve? Wrong man to ask. But one suggestion I’ve long offered is to not allow the processing of inheritance until the prognosis is up. Example here would be I’m given five years to live. Medical histories show people with this condition are usually fine for a year, then go downhill fast, spending the second year suffering increasing debilitation, and the third year onward a vegetable. Under any Euthanasia law, I should be allowed to call time at any point during that five year prognosis. But? In terms of any potential inheritance, nobody gets anything until the five years are up.

Way too simplified to be that straight forward, but it would at least remove some motivation for a beneficiary of my will to try to persuade me to pop off early to avoid the crowds.

Then there are moral objections, whether secular or religious. Because yes. If I really wanted to prevent future suffering I could throw myself under a bus or off a cliff or what have you, but that involves other people having to clear up the resulting mess - especially if I was selfish enough to involve an unwitting party such as a bus driver in my quest to Buy The Farm, where I’d be doing psychological damage. And the thought of a place where people go to die voluntarily may seem entirely alien - and those voices deserve to be at least heard, as rational minds on that side would likely have “yes, but what about this situation” input to help any legislation enshrine the same protections I’d want as a proponent of euthanasia.

But how do you view it? Is it something you’d want to be enshrined in a person’s living will before they get a terminal diagnosis? For instance, Mum was always clear with us that she wouldn’t want to be kept alive by machines just because machines could do so, not if it significantly impacted the resulting quality of life.

[Haighus]

I've linked to a great video on this by a cardiologist in the UK.

Full disclosure: I am a doctor working in cancer care. My job is working with people with palliative diagnoses, and is all about extending their life and/or relieving their suffering. I am also working in research and will be presenting a study looking at quality of life in a cancer cohort in the near future.

So end-of-life care and patient quality of life are important to me and I have experience in them.

With that said, I fully support the right of individuals with the mental capacity to do so to choose to end their own lives. However, I also recognise the potential for abuse in a system set up to facilitate this,so I think, pragmatically, that the permitted circumstances need to be narrower and more restrictive than I think is morally acceptable, in order to minimise abuse. For example, I think it should be limited to individuals with terminal diagnoses intially, with no guarantee of expanding beyond that if adequate safeguards cannot be enacted.

I do want to point out that in the UK, the healthcare system doesn't force people to keep going if they have made decisions otherwise (when they have the capacity to do so) and people have the right to refuse life-extending treatment. This decision can be made in advance if the individual anticipates or is concerned about losing capacity at a later date. However, clinicians cannot prematurely end a person's life even with their consent, with the niche exception of the principle of double effect*, although that hasn't been legally tested for decades.

I have encountered a number of situations where people experience an end-of-life situation that is extremely unpleasant to both them and their family. Situations such as pain that cannot be controlled even with very specialist medications, refractory breathlessness where the underlying cause is not reversible, advanced dementia where the patient becomes extremely anxious and agitated, untreatable bowel obstructions, and worst of all is terminal agitation. The family of every patient I've ever cared for with terminal agitation has asked if we can end their suffering, and we cannot. It is difficult to manage with medications once it gets going properly (patients often end up on ludicrous doses of sedatives that would outright kill most people if you gave it to them), and sometimes we run out of options before the patient settles down. The final option is very rarely used because it tends to precipitate death shortly afterwards. It is a very, very difficult and distressing condition for everyone involved that is thankfully rare.

In these situations, ending the life of the individual a few days early is undoubtedly the most compassionate option, and should be an option available to the patient (if they have capacity) or the clinician (if the patient does not).

*A treatment can be given with the knowledge it will shorten the patient's life, if the intention is to achieve a different clinical effect deemed necessary in managing the patient. For example, giving large doses of sedatives to patients undergoing terminal agitation with the aim of reducing their obviously-distressing agitation with the knowledge this is likely to hasten the death of the individual.

[herzlos]

It seems needlessly cruel to drag out a life when all that's left is suffering and a slow decline, though you'd still need some measures in place to avoid abuse but I don't know how much of an issue that'd really be?

So I guess at a minimum you'd need to get a panel including some doctors to agree that (a) it's what the person genuinely wants and (b) that any improvement in circumstances are unlikely.

Maybe treating it as an expansion of a "Do Not Resuscitate" order where a patient can produce something like a will with conditions for end-of-life care.

It's something I've spent a lot of time thinking about because my kids will likely need care for their entire lives, so I wouldn't want to divert from their care if I'm unable to provide it anymore. Being temporarily out of action for a while is fine, but if I needed permanent full time care in such a capacity that I can't express my wishes I don't think I'd want to continue. Rotting in a care home just doesn't sound like a fun way to spend my last years.

[Peregrine]

Aside from the issue of "pull the plug to get the inheritance early" there's also the problem of the system deciding that encouraging suicide is cheaper than proper treatment. We've seen some cases already (IIRC in Canada) where a person with PTSD, depression, etc, was given information on assisted suicide as a suggestion despite no reasonable belief that their condition was terminal, pretty obviously because the person was struggling financially. And we've seen some cases where the system shrugs and accepts a suicide request from someone with chronic but stable mental health issues because they hadn't improved yet and didn't believe they would. Ending one's own life should be an option when the choice is between a painless end or a brief additional period of suffering before dying but we really need to be aware of and avoid the temptation to use it as a tool for eugenics and purging the disabled or undesirable.

[Haighus]

Disclaimer: UK perspective based in UK law and practice. Other jurisdictions may and do vary.

It should definitely be something that can be included as part of an advanced directive, which is already available to people to express that they do not wish to receive specified treatments if certain conditions are met and they have lost capacity (an advanced directive can always be overruled by the individual if they have capacity). I do think it should probably require two senior doctors to assess the patient has capacity to make the decision and authorise such an advanced directive, and also at the other end when assessing if the conditions have been met and assisted dying is now appropriate in line with the directive. There also need to be safeguards to detect and investigate potential abuse and coercion.

That said, you can make an advanced directive now to decline life-extending treatment if you were to enter an irreversible state with loss of capacity, like advanced dementia. If this is something important to you for the reasons you specified, I'd suggest you look into setting one up.

Do not resuscitate decisions are a bit different, although they can be included in an advanced directive. CPR is a specific intervention that is simply not appropriate in many circumstances (such as advanced, irreversible disease), and therefore shouldn't be available to everyone in the same way antibiotics or a blood transfusion are not appropriate in many circumstances and shouldn't be available on demand. Offering CPR is a medical decision, and people have a right to refuse it but not demand it if it isn't appropriate. Of course they also have a right to request a second opinion on any such decision if they feel it is erroneous (and would be appropriate in their case), and there has definitely been some bad and/or negligent practice around resuscitation decisions (especially regarding communication and individuals with mental disabilities).

[Haighus]

May 9, 2024 4:54:23 GMT -5 Peregrine said:

Aside from the issue of "pull the plug to get the inheritance early" there's also the problem of the system deciding that encouraging suicide is cheaper than proper treatment. We've seen some cases already (IIRC in Canada) where a person with PTSD, depression, etc, was given information on assisted suicide as a suggestion despite no reasonable belief that their condition was terminal, pretty obviously because the person was struggling financially. And we've seen some cases where the system shrugs and accepts a suicide request from someone with chronic but stable mental health issues because they hadn't improved yet and didn't believe they would. Ending one's own life should be an option when the choice is between a painless end or a brief additional period of suffering before dying but we really need to be aware of and avoid the temptation to use it as a tool for eugenics and purging the disabled or undesirable.

Agreed, although I can see the ethical minefield when it comes to capacitous adults and autonomy. Theoretically, any adult with the capacity to do so should be able to choose to end their own life. In practice this is so open to abuse, and not just abuse by other individuals but also systems of oppression as you allude to, that I don't think a society could ethically offer such open access to assisted dying until it is basically a utopia.

But for the terminally-ill is generally a different story.

Of course, having good access to high-quality universal health and social care alleviates the majority of the "cost-utility" concerns over assisted dying, as it means an individual actually has choice rather than seeing death as the least worst option.

[Haighus]

To summarise my post above:
If your healthcare system is already largely unethical, you cannot expect it to handle assisted dying in an ethical way overall, and there are lower-hanging fruit to address first.

However, if a system has low levels of health inequality, I think it is an ethical and moral option to offer to some individuals, with availability increasing inversely to inequality.

[mdgv2]

I guess the counter argument to Peregrine’s post (and I categorically am not arguing that myself) is someone who is still of able body and mind faces relatively few barriers to ending their life.

Which I think is a weak argument, when there’s at least one conviction on the books for encouraging someone to take their own life - en.wikipedia.org/wiki/Death_of_Conrad_Roy#:~:text=On%20February%206%2C%202019%2C%20the,prison%20sentence%20would%20be%20enforced.

That’s just what turned up from a widely worded, cursory Google. And I’m not entirely sure it’s the example I was originally thinking of.

We also have the Sheer Hell Of Internet Echo Chambers influencing people. Because some of them are outright dangerous, like Bulimia and Anorexia encouragement groups.

So overall, for me? Peregrine’s point absolutely stands. And it’s not an angle I’d thought from before.

I guess it’s possibly less of a concern for someone confirmed to be living with a life limiting, incurable disease or disability. But even then, there has to be Necessary Red Safety Nets applied to all instances. Yes living will “I’ve made it well known this would be my intent since waaaaay before the underlying situation arose” type arrangements could bypass some of sad Red Safety Nets - but never all of them.

[Peregrine]

For context, here is one of the Canadian cases: www.ctvnews.ca/politics/paralympian-trying-to-get-wheelchair-ramp-says-veterans-affairs-employee-offered-her-assisted-dying-1.6179325 A disabled person with no interest in ending their own life was seeking help with physical accommodations for their disability, the government initiated the topic of suicide and offered it as a solution. I don't see any possible interpretation of this incident other than eugenics, someone who saw "suicide" as a way of getting rid of an undesirable disabled person.

www.cbc.ca/news/politics/veterans-maid-rcmp-investigation-1.6663885 is about veterans and claims it was a single rogue employee going against standards but the fact that it was possible for that to happen should be a major red flag.

[carlo87]

May 9, 2024 4:54:23 GMT -5 Peregrine said:

Aside from the issue of "pull the plug to get the inheritance early" there's also the problem of the system deciding that encouraging suicide is cheaper than proper treatment. We've seen some cases already (IIRC in Canada) where a person with PTSD, depression, etc, was given information on assisted suicide as a suggestion despite no reasonable belief that their condition was terminal, pretty obviously because the person was struggling financially. And we've seen some cases where the system shrugs and accepts a suicide request from someone with chronic but stable mental health issues because they hadn't improved yet and didn't believe they would. Ending one's own life should be an option when the choice is between a painless end or a brief additional period of suffering before dying but we really need to be aware of and avoid the temptation to use it as a tool for eugenics and purging the disabled or undesirable.

  I remember ready about those cases a while back.  Now, I'm okay with assisted suicide if, and only if, the disease is terminal, the person is of sound mind, and they have reached a certain point of life-crappiness.  Even then, I think there need not be an express line to death. There better be some screenings, time to think, more screenings, and come counseling. 

  Correct me if I'm wrong, but wasn't Canada also toying with the idea of making assisted suicide available people with depression? I'm pretty sure they were wanting to open it up to minors as well. Frankly, okaying a sad 15 year-old to off themselves is a no-go for me. 

  I also think it needs to be treated like Blockbuster treated porn in the 1990's. It's in the "special" room behind the curtain. Everyone knows it's there, but no one brings it up. The clerk doesn't allow the kiddies in there, and the manager will get super pissed if the counter guy starts talking about what happens in them to random customers.  

[Haighus]

Canada has definitely been the nation that has had the biggest scandals with this. They clearly need more oversight to prevent abuse within their system.

Having said that, Canada has had literal eugenics programs in the past, so maybe it is not so suprising.

I don't think Canada doing a poor job should stop other countries introducing assisted dying though, the experiences of Canada should be used as a learning experience. It isn't like clinicians don't already have an immense capacity for abuse, so there are significant systems of oversight in most developed health services already.

The US should probably provide universal health coverage and clamp down on rogue clinicians before they go near this though. Some of the stuff US healthcare... practitioners* get away with is mind boggling to me.


*For want of a better term. Well, scammers works too.

[easye]

Everyone should probably read the book Being Mortal by Atwal Gawande.

That is all.