Terminally Ill Adults (End of Life) Bill

Written evidence submitted by Steven Bow, FFPH, Consultant in Public Health (TIAB185)

 

1. I am a Consultant in Public Health, a Fellow of the Faculty of Public Health, and Chair of the Faculty of Public Health Ethics Committee and the Public Health Ethics Special Interest Group.

2. In my professional capacity, I am the Chair of the Berkshire Suicide Prevention Group, and the Suicide Prevention lead for West Berkshire Council. As such, I approach suicide as a public health issue, which I strive to utilise my professional skills and expertise to address.

3. This is supported by a huge amount of work at the national and local level. For example, NICE has Quality Standards for Suicide Prevention, which covers ways to reduce suicide and help people bereaved or affected by suicide; successive governments have published National Suicide Prevention Strategies, and in Berkshire we have a pan-Berkshire Suicide Prevention Strategy owned by 6 local authorities, the local NHS organisations, and other partner agencies.

4. In West Berkshire we see around 10 suicides per year. These are small numbers compared to the total annual deaths, but in some demographic groups constitutes one of the top causes of death. Each suicide represents morbidity and mortality pertaining to the individual in question, but the overall impact may be felt widely in family, colleagues and communities for decades.

5. Suicide prevention takes the view that every suicide is a tragedy, and no suicide is inevitable - every suicide is preventable (National Suicide Prevention Strategy). In recognition of this, the overarching aim of suicide prevention is to get the number of suicides per year down to zero.

6. "Assisted dying" in the Bill permits someone with a wish to end their own life to be provided with assistance to do so (Clause 1) – i.e. to die by suicide. This falls within the scope of the current suicide prevention efforts, which aim to discourage and prevent individuals from ending their own lives, and it is difficult to see how it can be enacted in a way compatible with these efforts.  

7. The Bill would create a medical system that facilitates and advertises suicide as a service, which would have implications on suicide prevention activities including the following:

8. It is difficult to see how local and national suicide prevention strategies could effectively distinguish between suicides that the state seeks to prevent (i.e. those not carried out within the provisions of the Bill) and those which the state would create and fund medical pathways to facilitate, given that it would not be known before the fact which path a suicidal individual may ultimately choose. Would the aims of these strategies shift from ameliorating the challenges that make individuals suicidal, to helping individuals access a medically-facilitated suicide? For example, the NICE Quality Standards for Suicide Prevention include Standard 2 "Reducing access to the methods of suicide". Given that this Bill aims to legally oblige the provision of assistance to this specific method of suicide, this and other similar recommendations would need to be, at least, partially reversed.

9. It is not clear how the risk of contagion and suicide clusters of medically-facilitated suicides would be managed. Currently, each suicide notification receives a concerted multi-agency response to prevent contagion and take action to prevent future similar or related suicides. There seems to be no provision for partner agencies to be notified about suicides that take place under this Bill, which would make it difficult to respond and support families and communities affected, or to learn lessons or address underlying issues that could prevent future suicides.

10. It is not clear that Bill makes sufficient provision to ensure that medically assisted suicides would be reliably recorded and investigated, in order to allow local and national public health authorities to accurately monitor and assess population health outcomes, such as through suicide audits and local arrangements such as Realtime Suicide Surveillance Systems. It is important to gain substantial details about the background and circumstances of a suicide, to identify what action could have been taken to prevent them – and future suicides. Currently, suicide audits depend heavily on information provided by Coroners, and it appears that Clause 29 excludes the requirement for suicides assisted under the Bill to be reported to the coroner. This would inhibit our ability to understand the risk factors that lead to suicide in general, and for legally-assisted suicides in particular, and therefore inhibit the ability to work to address these risk factors to prevent people feeling the need to end their own lives.

11. Suicide prevention training is provided by many local authorities for frontline staff and volunteers – including healthcare staff including GPs and hospital doctors, to help them to identify suicidal individuals and intervene to persuade them not to take their own life. Clause 23 of the Bill provides "protection for healthcare professionals" in the limited sense that they would not be obliged to participate in assisting a patient to take their own life in the manner described in the Bill. However, this protection does not appear extend to those healthcare professionals who may, in line with their training, actively attempt to discourage or prevent someone from doing so. It is not clear whether such intervention to attempt to prevent or discourage patients from taking their own lives through this route – or indeed unspecified intent - would be legal if the Bill were enacted.

12. The NHS and local authorities also often fund support groups and services for those who are Bereaved by Suicide since being bereaved by another’s suicide is a major risk factor for an individual’s own suicide. It is not clear this could realistically continue if the same organisations were also funding medically-facilitated suicides, or at least there would be an obvious tension between the two.

13. It is also not clear that the best interests of family, friends and acquaintances of the individuals assisted to suicide through the Bill are considered in the medical or judicial assessments of cases, or whether they have any recourse to appeal. This seems a major oversight, since the consequences of suicide redound not only on the individual in question, but on their social network, and the harms on the latter, as already stated, can often include further suicides.

14. Public health messaging on suicide prevention (e.g. World Suicide Prevention Day) articulates that every suicide is tragic and preventable and seeks to empower individuals to intervene to redirect individuals away from suicidal intent and actions. This simple and powerful message will be effectively contradicted by the pathway established by the Bill, and so its enactment would have significant implications for local, national and international suicide prevention media campaigns.

19 January 2025