Assisted dying and coercion

[ArabellaScott]

This is live right now, so I'm not sure how well linking to it will work. Copy-pasting below, aswell.

https://www.bbc.co.uk/news/live/cy5k0qyled2t

'Rachel Clarke, a palliative care doctor, opts to answer a question about coercion and whether some MPs are right to feel concerned about this when considering the bill. (Earlier, MPs heard how medical and clinic staff are trained in safeguarding, though a retired GP acknowledged coercion was hard to spot.)
Clarke says she'd "strongly push back" on the suggestion coercion is something all medical staff are trained in spotting.
"I'm the kind of doctor who believes there is nothing to be gained by sugar-coating reality...about shortcomings, failings, areas where my profession the rest of the NHS are getting things wrong", she tells MPs.
"It is my clinical experience that not only are the majority of doctors not necessarily trained in spotting coercion explicitly, they're often not trained explicitly in having so-called advanced care planning conversations with patients around the topic of death and dying."'

One link in that post:

'Coercion is rare but it happens - and can be difficult to spot, retired GP tells MPspublished at 10:39
10:39
Labour's Sean Woodcock asks how frequently doctors have to deal with patient coercion - a key concern opposers of the bill have.
Responding, Dr Andrew Green reiterates a point made earlier by Chris Whitty - that all medical staff have safeguarding training.
He acknowledges that patients often make important decisions with the influence and help of family members, but he says this influence is usually helpful and comes from a position of love.
Green goes on to say there are moments where influence can become coercion and that it can be difficult to spot. "My experience is that it is rare," he says, recommending that MPs look at what has happened in other parts of the world, which have more experience in this area.'

I meant to add in the OP, the reason I post it here is because this is a key issue that is likely to have the most impact on women:

https://www.telegraph.co.uk/news/2024/11/25/assisted-dying-is-sexist-report-finds/

https://archive.ph/IbjF2

'The Other Half analysed data from 100 of these killings in the UK and found that “despite claims…‘mercy killings’ are not the wanted, ‘hastened’ deaths that need assisted dying” but instead “are overwhelmingly violent domestic homicides of women, by men: and show that our society is still poor at detecting and responding to domestic abuse”.

Of the 100 UK “mercy killings” over 25 years, the report found that 88 per cent of perpetrators were male, and 78 per cent of female victims were neither terminally ill nor willing to die but were often elderly, disabled or infirm.'

More from that thnk tank:

https://theotherhalf.uk/safeguarding-women-in-assisted-dying

Clarke says she'd "strongly push back" on the suggestion coercion is something all medical staff are trained in spotting.
I'd certainly echo that. You are lucky to see a doctor in person, let alone in situations where they can spot coercive relationships.

As an HCP, I'd agree with Dr C. There is a world of difference between yearly online safeguarding training (which may be supplemented by some in person case studies or attendance at safeguarding meetings) and the reality of being suspicious of the motives of 'caring' family members sitting in front of you (or on the phone, even harder). We're not trained to be suspicious or disbelieving. And she is right - some conversations around end of life or advance care planning are AWFUL - and the worst I witnessed as a student was by a consultant oncologist. Whilst I can believe coercion is rare, it will happen - though I have many further reservations about AD. One of the major ones is about internalised coercion, which I think will impact women (as generslly socialised into the more caring role) much more heavily.

A friend of mine went to her GP for help when she was in an abusive relationship. Physical abuse as well as coercive control. The (female) GP was clueless and suggested she had anxiety.

She had very little help from any official service, in fact, but luckily myself and other friends were able to help her leave her husband. That included one of our friends being the guarantor for a rental.

I dread to think what happens to women without anyone to turn to, especially considering coercive control often involves isolating people from family and friends. This is particularly concerning for older or disabled women.

Many DV victims become suicidal. Sometimes that's on their medical records, which means a domestic homicide could quite easily use a defence in court of 'mercy killing'. It's also not uncommon for abusive partners to encourage their victims to commit suicide. In the absence of sufficient help to leave or even understanding of coercive control, desperate women will I suspect turn to assisted dying.

It's scarcely naive to think 'that influence is usually helpful and from a position of love'.

I work in palliative care- we are seeing more and more unpleasant families along with family at the end of their rope who just can't cope anymore.

I understand the reasoning for assisted dying, I full appreciate some people really feeling it's an option they want BUT I just can't shake the feeling it would be heavily abused.

Currently we are fighting against a war on women, the volume of abuse, femiside, rolling back of women's rights should give people pause but it won't because the 'be kind' message is too strong.

In addition to possible family, or even HCP, coercion, and relevant to domestic abuse but equally for any older or disabled woman (or man) is societal coercion.

Lack of safe and affordable housing especially for older and disabled people. Disability benefit cuts. WFA issue, one of the lowest state pensions in the west, failing adult social care, under pressure NHS (and sometimes negligence). Insufficiently funded or provided palliative care.

I used to lean towards supporting legalising assisted dying. I would still support it. But not unless and until we have a society with a better safety net for the vulnerable, to ensure strong safeguards against coercion aka murder.

Of course some people will be coerced, that goes without saying. But it is not a reason to delay assisted dying. It's absolutely inevitable there will be some coercion, but it's the lesser of two evils.
We wouldn't consider banning abortions because someone might be coerced into one. Or making suicide illegal again because someone might be coerced into it. We expect that adults with capacity can make their own decisions. As is their right.
Already people are being coerced into staying alive when they don't want to because they worry about their relatives being prosecuted for helping them travel to Switzerland and others being coerced into committing suicide earlier than they really want for the same reason.
Plus, the law as it stands is disgustingly ableist. I could kill myself any time I choose because I am well enough to do it. If I was to become paralysed that right is removed from me.

Agree with all of that.

I would initially have been broadly supportive of the AD.

Not anymore. Too many eloquent, informed, and aware people have pointed out the very real dangers. It will lead to murders. Undoubtedly.

I'm sorry, this is a terrible argument.

'Of course some women will be murdered, but that doesn't mean we shouldn't do it'

What we need is far better palliative care and far better support and care in general.

From the report upthread:

' The UK is an leading outlier in taking action on domestic abuse: we have new recognition of coercive control (law in 2015), financial abuse (2014 and 2021), suicide as an outcome of domestic abuse (2024), and rejecting abuser’s claims that women consented to die (2021). But all this is very recent. '

Something heartening to read for once.

“It's absolutely inevitable there will be some coercion, but it's the lesser of two evils.”

You think some people who don’t want to die should be legally killed following bullying and coercion, so that some other people who do want to die but without committing suicide can have a medic end their life instead?

https://www.bbc.co.uk/news/articles/cge72eyzjl9o

'Dr Sarah Cox, of the Association of Palliative Medicine, which represents doctors providing end of life care and opposes changing the law, said: "Me and my colleagues have concerns."
She said accurately assessing how long someone has to live is "incredibly difficult", while identifying when someone was being coerced was not always possible, particularly when it was subtle.'

Thanks for the links @ArabellaScott.

I think coercion is an important topic and one which we should be really careful with in this debate. I understand why many people support assisted dying and think it often comes from a place of empathy and compassion. If we had a perfect world where we could ensure the choice was totally freely made, I would support it too. But we don’t have that perfect world and I fear far too many social pressures, particularly on women as PPs have outlined above, would result in people’s lives being ended when that isn’t actually what they would have wanted given totally free choice.

I’m pregnant at the moment and going back through the maternity services has made me very alive at the moment to the role medical professionals play in informing patients of risks and benefits and getting fully informed consent. Medical professionals are also capable of coercion unfortunately, and for example in maternity treatment that can result in women being coerced or pressured into accepting inductions or other interventions that they didn’t want.

Obviously, with assisted dying it’s a different thing, and I absolutely hope that no medical professionals would be coercing people into accepting assisted dying, but we do need to be confident that any professionals who may be involved in it are extremely well trained in giving detailed information about risks and benefits of any alternative treatments or care plans, they would need to be able to talk frankly about how an illness is likely to progress which I imagine must be very difficult to predict in some cases. I’m sure there are medical professionals who are already great at this, but the stakes are so high that we would need to be confident that all staff can do it to a really very high standard. But even if they can, the social, financial, societal and perhaps familial factors mean I don’t think many people would or could make a truly free choice.

I think the issues around subtle coercion are often a bigger issue for women than men. Socialisation of women, particularly around selflessness, is often apparent in elderly or vulnerable people. Not wishing to be a burden to their family, or eat into their children’s inheritance through needing carers in their final few months. Some of this of course will be self-imposed rather than the coercive behaviour of others.
I have serious concerns about AD, I understand for some people having the choice on how and when their life ends is what a compassionate society would wish. However I suspect the change in law will really not achieve what it’s supporters hope for, for every single person who opts for AD, there will be many individuals whose lives are cut short through coercion or not wishing to be a burden.

I agree with this. There may be some cases of attempted coercion, but has anybody got any idea of the likely number? Should the whole long-campaigned-for option of assisted dying be abandoned because there will be some bad actors? No legislation is perfect, but if it spares considerably more suffering than possibly slips through because of coercion, I find that an acceptable balance of consequences.

It's not the same as 'Of course some women will be murdered, but that doesn't mean we shouldn't do it', because women don't choose to be murdered, and it won't have been approved by two doctors and a High Court judge.

The decision whether someone is being coerced or not would not lie on the shoulders of just one person, and I'm sure that coercion will be on the radar of the doctors and judges - issues like coercion and mental capacity are being flagged and discussed in detail during the current process.

As somebody who has always supported assisted dying (although I can't claim to have devoted as many years of my life to supporting it as so many brave campaigners have) my increasing disabilities and health problems have only strengthened my belief that I have the right to say 'Enough'.

My dad went into hospital last month. He has cancer but it hasn't spread. The doctors tried a procedure on him to help him swallow but felt it hadn't worked, so they said there was nothing more they could do and we should find a hospice. But there were no places in the hospice. I am sure that my dad would have felt obliged to take AD if available. He was being made to feel such a drain on the hospital. He wasn't offered stomach feeding, it was just "that's it then". 6 weeks later he is still with us and swallowing again. The cancer nurse was so gloomy.....my sister has been completely on side with everything they said about him having days left. I am sure she would be pushing for AD and I wouldn't.

@MarieDeGournay the High Court wouldn’t have capacity to deal with AD cases - a retired judge gave evidence about that today. The court system is, and has been for a long time, chronically underfunded and overburdened so adding something like this to its remit is unrealistic. I fear that means the judge safeguard will be removed.

But even with the court safeguard, I can imagine many older people, particularly women but not exclusively who face seeing their life savings eaten up by care fees rather than passed to their children, making a decision to end their life and then insisting it was their free choice. Or not wanting to burden their family, and seeing the toll their illness has on their children or other relatives etc. If someone has capacity and gives evidence that it is their free choice, how hard would it be for a judge to rule that they didn’t actually?

I think truly free choice could only exist in a vacuum. And none of us lives in a vacuum.

I'm so sorry. I hope he is comfortable.

I’m sorry to hear that @Arran2024, that sounds so difficult for you all. 💐

In my experience of caring for an elderly family member, doctors are generally terrible at having conversations about advance directives and end of life care. I see no reason to think that this new law would suddenly spawn a cohort of doctors who would get it right.

I'm still aghast at the suggestion upthread, apparently in all seriousness, that many women having their lives prematurely ended by this legislation is just the price we have to pay for AD. Of course there are always 'winners' and 'losers' with new social policies but we are talking about people potentially being literally murdered for other people's convenience!

The imbalance in impact between the two sexes needs to be addressed before we, as a society, decide whether some people being coerced is acceptable collateral damage or not to having legal assisted dying.

I don't think it's reasonable to see what a skewed impact AD would have on women, and to just ignore that.

Don't they have to conduct equality impact assessments on new legislation (or is that wishful thinking)?

I'm pretty astounded by how glib people are about coercive control.

Don't they have to conduct equality impact assessments on new legislation (or is that wishful thinking)?

Supposedly. I can't remember the last time they bothered to assess any policy in terms of whether it would negatively affect women.

Indeed.

We know it exists and that is a real problem.

What is there to stop it existing in this cohort of the most vulnerable people in society, especially where other relatives stand to benefit?

It just boggles my mind that people can say oh no that won't happen.