Legal Action

Is “Mercy Killing” ever the right thing to do?

The BBC, and a number of newspapers, (see the Ayrshire Post), report the story of Ian Gordon who smothered his wife of 46 years with a pillow as “a final act of love” to relieve her pain and suffering. Did he do the right thing?

The judge’s explanation in sentencing, though interesting, doesn’t really help. The judge may well be doing his job to the best of his ability, implementing the law within the bounds he is permitted. But cases like this are complex and, (MDMD believe), indicate a failing in the law itself, rather than its application. The original charge of murder which Mr Gordon faced was reduced to culpable homicide, on the basis of diminished responsibility, at an earlier hearing.

The court heard that Mr Gordon’s wife did not want to be treated for her health problems because she was afraid of hospitals. Her family report her suffering excruciating pain immediately prior to her death. This is the first complexity – the possibility for treatment and pain relief, and even professional diagnosis was apparently refused. This was Mrs Gordon’s right, but it makes the situation harder for everyone else when it causes desperate actions, however well intentioned.

Did she actually ask to be killed? And if she did, was it her own, well considered and persistent wish, made when she had sufficient mental capacity? No verbal or written request is recorded, though apparently the couple had a “death pact” between themselves. There were, of course, no independent professional witnesses to this.

Had all alternative options been explored? For example, could increasing levels of pain relief have been given at her home, possibly including terminal sedation? To what extent might these have provided a good death, or at least a better death, for this unfortunate lady?

Mrs Gordon’s daughter explained that her mother had a history of suffering from anxiety and depression. To what extent did this exacerbate the situation? Was it resistant to all possible treatments?

In cases like this, without the possibility of legal medically assisted dying, these questions cannot be satisfactorily answered. In the most important sense, it is too late to ask after the person concerned – and primary witness – has been killed, or has taken their own life. It is only when a formal legal process for assisted dying is available,and someone has requested this, that proper investigations can be made before the death, and the secrecy and anguish of well-meaning but possibly misdirected illegal actions can be avoided.

MDMD Coordinator, Phil Cheatle, says, “I have been in a similar, very difficult situation to Mr Gordon, so I have every sympathy with him and his actions. On balance, I decided to refuse my mother’s requests to help end her life when I had a similar opportunity, but perhaps my mother’s suffering was not as great as Mrs Gordon’s. However, seeing my mother in pain, and her personality slowly disintegrating due to dementia, was dreadful, both for her and for those who knew the person she had been. We need a change in the law to prevent tragedies like this – whichever decision people like Mr Gordon, or me, take.”

What sort of assisted dying legislation would have avoided the Gordon’s tragedy and others like them? Fundamentally a law which respects a dying person’s well informed and well considered wishes, and which gives them some control over the timing of their death. However, for the protection of vulnerable people and the wider society, such a law needs to place strong requirements on the person seeking assistance to die. For someone to take advantage of such a law, they would have to agree to many examinations and consultations with multiple trained professionals. At the very least these professionals would need to ensure:

  • that the requestor was incurably and unacceptably suffering from a condition that was highly unlikely to improve;
  • that the requestor considered an assisted death to be the best option available for them, having carefully considered all other available options, and the likely future quality of life they could expect;
  • that the requestor had sufficient mental capacity to take a life-ending decision;
  • that the requestor’s decision was consistent over a period of time;
  • that the requestor had instigated the request themselves and had not been coerced into their decision.

It is not clear whether Mrs Gordon would have agreed to the process, or would have met conditions like these, had the option been available. This makes this case particularly difficult. It surely cannot be correct for others, (in particular those who are emotionally involved, and not medically qualified), to make a life ending choice on behalf of another, however well-intentioned and compassionate their motives. The only exception is in the situation of doctors making a best-interests decision to stop further treatment in cases they deem hopeless, or following a patient’s advance decision to refuse treatment. Our sympathy with the actions of Mr Gordon is precisely because there didn’t appear to be better alternatives available to him and his wife. With better alternatives, his actions would have been unacceptable.

An appropriate law would make the situation much clearer to those who wanted to do their best to help their loved ones to have a good death. If someone like Mrs Gordon had sought professional help – knowing that help to die would be available when needed… If she had put on record, many years before hand, her desire for the option of an assisted death if she ever reached a point in later life where she deemed it necessary… Then there would be no excuse for people to take drastic, illegal and dangerous action themselves, and as a result society, (and in particular, vulnerable people), would be safer.

Mr Gordon told his daughter “I don’t have a single regret.” His whole family and many character referees, appear to back his decision to kill his wife out of compassion. A law that makes people feel they have to take the law into their own hands to “do the right thing”, due to lack of appropriate legal choices, is fundamentally a bad law and needs to be changed. This failure of the current law to provide a more compassionate option, is made worse, in this case, by compounding the tragedy of the violent death of a much loved wife and mother, with another tragedy of a jail sentence imposed on a caring husband, driven to break the law due to lack of an acceptable alternative.

The case is not an isolated incident. For example, earlier this year a man who attempted to kill his wife to end her suffering was given a suspended manslaughter sentence. How many more cases of successful or attempted mercy killings, assisted suicides, and people taking their own life do we have to endure before we get more compassionate laws – throughout the UK? How many more tragic events like these go undetected, or under reported?

Update 19th March 2018:

Scottish Legal News reports that the custodial sentence of Ian Gordon has been quashed on appeal – leaving Mr Gordon with an admonition. The full ruling is here. It appears that the appeal court decided that the original  sentence was inappropriate as insufficient weight had been given to psychiatric reports on Mr Gordon which indicate that he “was suffering an abnormality of mind” which rendered him “unable by reason of mental disorder to appreciate the nature or wrongfulness of any conduct”. Good news for Mr Gordon and his family, but it further emphasises the need for a change in the law to avoid these dreadful, unsafe situations in the first place. We need to allow the option for a medically assisted death under carefully controlled circumstances, in order to remove the need for desperate actions by apparently compassionate, well-meaning, people who are “suffering an abnormality of mind” which leaves them “unable … to appreciate the nature or wrongfulness of any conduct”. Where are the safeguards in that? Where is the careful, objective, consideration from impartial experts – before the (possibly vulnerable) person has died?

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Court Ruling no longer needed before life-support is withdrawn from patients with severe illnesses

In a landmark ruling a judge has ruled that in future, in decisions concerning the withdrawal of life-support, including artificial feeding and hydration, a judge’s consent is no longer required in cases where medical opinion and relative’s wishes agree that the cessation is in the patient’s best interests.  The story is reported widely, including by the BBC and the Guardian.

MDMD cautiously welcomes this ruling. Medical professionals are generally the best qualified to make such decisions. Good professional conduct would ensure they take the views of relatives into consideration.

However, making a life preserving or a life ending decision for someone unable to make the choice for themselves, in their best interests, is a huge responsibility which is very difficult for both doctors and for relatives. In the vast majority of cases, both are likely to play safe, quite probably prolonging life for much longer that the patient might want.

But what if medics and relatives do not agree? These situations are not covered by this particular ruling. The end of life process can be even more drawn out and even more difficult, involving the courts. The tragic case of Paul Briggs illustrates this.

Far better for every one of us to make our wishes known clearly in advance, to cover possible future situations in which we have lost our mental capacity and are suffering from an incurable condition which means that our future quality of life will never return to a level we would find acceptable. This can be done today by making an Advance Decision to Refuse Treatment (ADRT). Not only is it a legal requirement for medics to follow a person’s wishes expressed in a valid ADRT, but the document gives certainty to both doctors and relatives, that by following what the person has stated, they are doing what the patient wants – surely a huge relief for both groups.

An ADRT can include a refusal of artificial life-support, in situations the person chooses. This can therefore be used to hasten their death, avoiding delay or possible involvement of the courts. Too few people are aware that this is a right we already have, without any recourse to the recent legal ruling.

MDMD urges everyone, regardless or age or health, to make an ADRT to specify their treatment wishes, should they be unable to make a decision at the time. Once complete, copies should be given to your GP and relatives. The ADRT should be reviewed and updated periodically. ADRTs can be completed at no cost, and free personal advice is available if needed. For more information see our page on end of life planning.

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New Legal Challenge on Assisted Dying

Today a new legal case to challenge the law on assisted dying is seeking financial backing. Please can you help!

The law firm Bindmans are representing ‘Omid’ who was diagnosed with the incurable illness, Multiple System Atrophy (MSA), in 2014. He is now largely confined to bed, has to wear a catheter bag and needs help with all personal care. He has difficulty speaking, and has lost much control in his arms and hands – making him unable to attempt suicide unaided. (A previous attempt failed.)

Omid is not terminally ill, in the sense of having a life expectancy of 6 months or less. For MDMD this is an important distinction as we do not believe the 6 month criterion can be anything more than a first step in our campaign. MDMD encourage supporters to help fund this action by Omid. We note that another legal case being brought by Noel Conway is limited to helping those with a life expectancy of six months or less – something doctors say they cannot accurately predict. Omid’s case is much more representative of MDMD’s objectives.

The Bindmans legal team are experienced as they also worked on the cases of Tony Nicklinson and Debbie Purdy. The last case ended in 2014 . In that case Lord Neuberger said “There seems to me to be significantly more justification in assisting people to die if they have the prospect of living for many years a life that they regarded as valueless, miserable and often painful, than if they have only a few months left to live“. (Lord Neuberger is President of the Supreme Court, the final court of appeal in the UK for civil cases, and for criminal cases from England, Wales and Northern Ireland.) MDMD strongly agree with his opinion that assisted dying should not be restricted on a life expectancy basis.

The BBC reported the outcome of the 2014 case saying:

The Supreme Court … right-to-die judgement boils down to a single phrase directed at Parliament: Sort it out, or we will.

“It argues that MPs have ducked the issue for too long – and it is time they, as our democratically-elected representatives, find the political backbone to amend the law on assisted suicide.

In 2015 the House of Commons failed to do so. We await with interest the outcome of this case. The issue will not go away until people like Omid are allowed a peaceful, medically assisted death if that is their persistent, well-considered wish. Why should people be forced to continue a life suffering against their will, (often having to pay for their own care), and be denied access to the drugs which can give them the good death they crave?

If social and medical care is serious about being “patient-centred” they need to be legally able to give people like Omid the end of life help they so desperately want. For example, NICE, the National Institute for Clinical Excellence, state in their guidelines to improve care for people at the end of life:

“… put the dying person at the heart of decisions about their care, so that they can be supported in their final days in accordance with their wishes.”

Omid’s wishes can not be put at the heart of decisions about his care, with the law as it is at present. MDMD wishes him every success in his legal challenge to allow what to him is a good death.

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Book Review: Rational Suicide in the Elderly

Rational Suicide in the Elderly: Clinical, Ethical, and Sociocultural Aspects

by Robert E. McCue (Editor), Meera Balasubramaniam (Editor)

Springer 2017 (8th Oct 2016)

An entire book devoted to the better understanding of Rational Suicide in the Elderly was essential reading for MDMD (Our name was formerly SOARS: Society for Old Age Rational Suicide). We were pleased to see that SOARS gets mentioned on the first page of the introduction and the SOARS website is extensively quoted in Chapter 6 – an indication of the influence of our campaign.

The book is a collection of 15 papers written mostly by psychiatric academics working in the USA who discuss the notion of rational suicide in the elderly and what they see as the best practices for treating patients exhibiting a rational wish to die. The psychiatric viewpoint is broadened a little with contributions from those in departments of psychology, philosophy and oncology. Two of the 18 contributors come from the UK and two from New Zealand. Surprisingly and unfortunately there are no contributions from medical professionals in the Netherlands, Belgium or Switzerland, where much practical knowledge and understanding of rational suicide is developing as those countries have the most far reaching assisted dying legislation in the world.

Many of the authors carefully question the notion of “rational suicide in the elderly”. How old is elderly? What is a “rational” decision? Can suicide ever be rational? But the book’s prevailing view is that, despite the ethical and philosophical considerations, there do exist people who are suffering from an incurable medical complaint, which renders their life no longer worth living in their opinion, who are not terminally ill, nor mentally ill, are not suffering from a curable depression, but have a desire to hasten their death. This is perhaps best demonstrated in a quote from the book’s final paragraph (in a chapter that carefully unpicks and rejects a lot of the standard justifications for “rational suicide”): “It seems to me obvious that it is sometimes better – kinder, more decent, dignified, compassionate – to bring an end to human suffering than to let it continue.”

Many of the issues considered by the authors in developing an understanding of “rational suicide in the elderly” are the same as those raised by SOARS supporters in the discussions that led to the organisation both changing its name from SOARS to MDMD, and broadening its objectives beyond “Old Age”. (And prior to that, in our consultation on the “When is a Life Complete?” document.)

Given that people exist who rationally believe suicide is their “best” option, the book attempts to give guidance to psychiatrists who encounter such people as “patients”. It is here that the book seems to get into several difficulties.

It is implied that the issue of rational suicide in the elderly is only about those who end up as psychiatric “patients”. The presumption is that a true rational suicide would successfully have done the job him or her self, without ending up in the psychiatrist’s consulting room. The fact that they have instead become a patient leads to the possibility that they may be seeking “help” to overcome their suicidal thoughts. Although this may be true in some cases, there are much wider issues, most notably the case of people who “successfully” choose rational suicide without any counselling.  Is it the correct attitude for psychiatry, or the wider medical profession to take – to accept people rationally ending their life, without professional counselling; alone; without assistance; and often in tragic circumstances? MDMD think not, we would like to see two forms of help available to all potential rational suicides: first, independent counselling to ensure that they are making the correct decision for them, at the right time; and second, legal medical assistance to die within agreed safeguards. It is only in the knowledge that medical assistance to die is a possible outcome, that people will intentionally seek medical help with their rational suicide decision. Without that possibility, the rational person, wishing to hasten their own death, would avoid discussing their plans with their doctors for fear of either being “treated” until they gave up their desire to end their life, or worse, being physically prevented from doing so, possibly including enforced hospitalisation, as a form of “safety planning”. A third risk for those in the UK considering going to Switzerland for medical help to die, is that a full discussion with their doctor may result in the doctor refusing access to medical records needed by the Swiss organisations who help foreigners. In these areas, the doctor patient relationship appears to be broken.

There is an irony here. Only with the option of legalised medically assisted suicide will potential rational suicides wish to consult their doctor. But once they do, it is likely that their suicide can be delayed and in some cases prevented, while ensuring that more people have the “good death” they should be entitled to. Much better a peaceful medically assisted suicide at a carefully considered “right” time, than a traumatic, lonely unassisted suicide, done too early while the person still can. The book does not consider these benefits of assisted suicide and therefore misses many of the issues that need to be discussed in a full coverage of rational suicide.

One important observation it does make is that the reasons given by people seeking rational suicide who are not considered “terminally ill”, as their life expectation exceeds six months, are identical to those who are terminally ill and receive assisted suicide in US states where it is legal. This usefully highlights why the 6 month criterion is so inappropriate.

Once a potential rational suicide is accepted as a “patient”, psychiatrists are in a very awkward position. On the one hand it can be very difficult for a medical professional to accept that an assisted death or worse, an unassisted suicide, is actually the best option for the patient. There is a tendency to see this outcome as a failure. This attitude is something that MDMD thinks needs to be overcome as society better understands the true nature of rational suicide as being the best outcome for some patients. A more pressing concern, especially in the USA where the book is focused, is on possible legal repercussions from relatives of a suicide who might claim that a psychiatrist involved had been negligent. An entire chapter is devoted to “Rational Suicide and the Law”, and several other chapters stress the importance of “risk assessment”, “safety planning” and “preventing impulsive behaviour”. For both these reasons it seems clear that professionals helping those who wish to actively hasten their death need some form of emotional and legal protection to do this difficult work effectively.

The main approaches suggested for working with people seeking a rational suicide are various talking therapies such as “Motivational Interviewing” to help the person understand the motivations behind the desire to end their lives and to expose and build on any uncertainties and desire for change the patient may have. Authors recommend applying these techniques non-judgementally, with respect for the patient’s views. While these approaches may be successful in preventing suicides, they run the risk of undermining a patient’s choice, possibly making them feel guilty in wanting a hastened death. It seems essential to ensure that the person has properly considered all options, including that they may be able to adapt to changed capabilities, but where should this dialogue stop? At what point should the psychiatrist stop challenging the patient and simply accept their view, even if they disagree with the patient’s conclusion? Many of the authors appear to have an attitude that suicide should be prevented if at all possible. The realisation that a hastened death may actually be the best option for some patients sits uncomfortably with what they are legally and ethically bound to do. A re-evaluation of these legal and ethical limitations seems necessary, but the book does not explore this.

Several authors refer to spiritual or religious belief as helping people come to terms with their dependency and changed circumstances. A full chapter is devoted to Christian objections to suicide. This may be appropriate for a USA audience, but in the UK only 59% of the population consider themselves to be Christian, with 25% of the population claiming no religion – a proportion that has grown by 10% over the preceding 10 years, growing in all age categories. (ONS report based on 2011 census data.) The reducing significance of religion is hinted at in a chapter about the attitudes of the “baby boomer” generation which concludes: “… a significant minority will consider suicide to be an intelligent and rational act in the face on an irreversible worsening in the quality of life.”

The penultimate chapter suggests that one or two doses of psychedelic drugs such as psilocybin might be an effective “treatment” for those who have lost meaning in life, possibly to the degree that suicide could be prevented. While this may suit some people, and may indeed reduce suicidal ideation, we must question the extent to which rational suicide is an illness to be treated with drugs that alter the person’s personality, as opposed to respecting the person and their personality as they are, and accepting rational suicide as it purports to be – a rational evaluation of one’s likely future quality of life leading to a decision that the person would be better off dead.

While several authors acknowledge that in some cases a hastened death would be best for the patient, the practical advice is all about attempting to alleviate symptoms, especially in cases where the patient can be helped to find some new reason for living. An important issue that is not tackled is how to help someone decide that their death should be hastened – or rather to corroborate the decision that the person has already reached. Of course, without the necessary law, the decision is irrelevant as the psychiatrist cannot assist. But advice from the psychiatric community is necessary in order to draft appropriate, safe and workable laws. A good law would enable more appropriate action in cases where, after full consideration with professional help, the patient is convinced that a hastened death is in their best interests.

Although the book has the serious limitations noted above, it is a step in the right direction. Many difficult issues are carefully analysed in commendable depth. Psychiatry (and the law) has a long way to go before it can be said to fully support the real needs of people whose quality of life is permanently, unacceptably low, to the point that they consider hastening their death. But at least the issue of rational suicide for people with intolerable quality of life, due to incurable medical conditions, is now firmly placed on the psychiatrist’s couch.

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PRESS RELEASE: MDMD Response to Noel Conway’s legal challenge on Assisted Dying

Today MDMD issued the following press release:

My Death, My Decision is pleased that, with support from Dignity in Dying, (DiD), Noel Conway, who is most unfortunately terminally ill with motor neurone disease, has begun judicial review proceedings, claiming that the failure of Parliament to amend the present Suicide Act, to permit him to have a medically-assisted rational suicide, unlawfully interferes with his rights.

While welcoming Mr Conway’s appeal, MDMD regards his attempt to change the law only as a “first step”.  By focusing on someone who is terminally ill, we are forgetting that very many other individuals (especially the elderly) may also be suffering severely, and for much longer periods than six months, from various medical conditions. These people may also hope, for the possibility of a legalized medically-assisted rational suicide.  Whenever our Parliament considers legalizing “assisted dying” again, it must then consider changing the law to include all competent, incurably suffering adults – as is fortunately possible today in Belgium, Luxembourg, The Netherlands and Switzerland.

The six-month criterion proposed by DiD is a particular problem for those suffering from early stage dementia. By the time a sufferer is within six months of dying they will have lost their mental capacity to choose an assisted death, should that be available. By then they are likely to have experienced extensive suffering and loss of dignity. Dementia is now the single largest cause of death in England and Wales. [Office of National Statistics:  Deaths registered in England and Wales (Series DR): 2015]

MDMD also wants to comment on part of the extensive statement by Mr. Conway which appears on the DiD website, www.dignityindying.org.uk/news/noel-conway-seeks-change-law .  In this, he notes that, regarding the possibility of going to DIGNITAS in Switzerland, “I do not wish to die in a faceless clinic, away from home and without my loved ones around me”.  Since MDMD was founded in 2009, at least nine of its supporters have travelled to Switzerland to end their lives there. Most of them have gone to DIGNITAS.  Our patron, Dr. Michael Irwin, has personally witnessed five such assisted suicides.  While we strongly agree with the need for assisted dying without travelling abroad, it is a great distortion of the truth to describe DIGNITAS – To live with dignity – To die with dignity, near Zurich, as “faceless”. In fact, The Guardian, on November 18, 2009, noted that it “is sunny, clean and neutral, not unlike a holiday rental apartment”.  Furthermore, everyone can see photos on the DIGNITAS-website. The word “clinic” is inappropriate as there is no medical staff or equipment present (although an individual is interviewed by a Swiss physician, independent of DIGNITAS, upon their arrival in Zurich, who writes the necessary prescription).  Furthermore, family members and friends are encouraged by DIGNITAS to be present when someone dies, and this happens with almost all assisted dying cases.

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