Terminally Ill Adults (End of Life) Bill

Written evidence submitted by Marion Shoard , Writer and Campaigner on Older People’s Issues (TIAB372)

I am concerned about the limitations of the current mooted safeguards in the Terminally Ill Adults (End of Life) Bill.

Financial Incentives for Coercion

About 154,000 older and disabled people living in care homes in England and Wales pay their own fees (averaging £4,600 for a residential and £5,600 for a nursing home per month) and in doing so are gradually wiping out their heirs’ inheritances. More than 46,000 are likely to meet the mental capacity requirement for physician-assisted suicide proposed in the Bill. Many residents, with conditions such as Parkinson’s disease, heart and lung disease are likely to meet the medical requirement for terminally-ill too. There would thus be a huge financial incentive for the heirs of these people to persuade their ‘loved one’ to sign the form.

While researching my books A Survival Guide to Later Life (2004) and How to Handle Later Life (2017), I came across many cases of callous treatment of older people by their nearest and supposedly dearest. I am sure that plenty of them, perhaps encouraged by their partners or spouses, would be prepared to pressure, bully or coerce a reluctant relative into ending their life.

A grandparent or great-grandparent, living an often quite socially-isolated life in a care home, left with few of their possessions, perhaps without easy access to a phone, let alone a computer and perhaps clinging to a sense of identity through family, might be persuaded to feel guilty about continuing to live what looks like a pointless life at the expense of heirs with financial needs. Hints could be dropped about school fees, new cars and first-time buyer deposits. The ‘voluntary’ option of a useful death could be made to seem the best thing for all concerned. Deals could be done, without anybody quite admitting that they exist.

How is any doctor, judge or witness to the signing seeking to prevent coercion under the current mooted safeguards in the Terminally Ill Adults (End of Life) Bill to detect and deal with this? How much time would they have? How many older people would be killed who actually much preferred – given the alternative – to stay alive?

Coercion might take place in other ways and for other reasons too. It is important for committee members to be aware of the special circumstances of the care-home environment.

The Position of Care Home Managers

Now some older people who go into care homes retain their former GP. But many others switch to the GP with which the home is associated, who visits the home once or twice a week to see any patients who need attention. The manager of the home often plays a key role in residents’ access to GPs. While in theory a resident is free to arrange a GP appointment independently, in practice it is my impression that more frequently the home’s manager initiates contact with the GP practice on behalf of the resident, whether that resident is going to see their long-time GP or members of the GP practice with whom the home has an arrangement. It is not beyond the bounds of possibility that a manager might mention to a GP when he or she arrives on the premises that, when seeing a particular resident they might bring up the subject of assisted dying, as the doctor is perfectly free to do under section 4(2). Of course, such a conversation might be beneficial – the resident might genuinely wish to die and have not heard of the new legislation. On the other hand, the owner and/or manager of the home might have been influenced by someone with a pecuniary interest in the resident’s death. Should not the doctor be forbidden from initiating a conversation about assisted suicide unless the resident themselves has first expressed a strong and convincing wish to die – ‘I wish I were dead!’

Or the owner or manager might have motives of their own. Many owners and managers of care homes will be only too anxious to keep their residents alive for as long as possible, partly because they genuinely care about their well-being, partly perhaps for financial reasons, partly perhaps because they are relatively easy residents to care for. But some owners and managers may not regret the departure of particular residents – they may be troublesome, often complaining about some aspect of the home, they may be challenging to care for, while the manager may calculate they could get more money for the resident’s room if it were occupied by someone else.

The position of the doctors

Presumably the coordinating doctor and the independent doctor would each talk to the person seeking an assisted death one-to-one, in private. How is the High Court to be sure that those doctors have followed a code of practice and have been conscientious in ascertaining that the person seeking physician-assisted suicide has a clear, settled and informed wish to end their own life and that there has not been any coercion? Will these conversations be tape-recorded? As things stand, the High Court will be utterly reliant on the word and signature of the doctor. In a situation in which a misunderstanding or omission or even some form of coercion on the part of the doctor would result in death, should not some provision be made for the presence of an independent, trained third party?

Section 30(6) omits to provide any punishment for a doctor who fails to have regard to the relevant provision of a code of practice, saying it does not render them liable to any criminal or civil proceeding but may be taken into account in any proceedings. In view of the grave potential implications of a doctor failing to abide by a code, this sanction seems to me inadequate. Abiding or not by this code is a matter of life or death.

Clearly, it is very important that anyone making a first declaration for assisted suicide is aware that they can change their mind right up to the moment that they take the poison or are offered some other means of ending their life. Again, how is an outsider to know that the doctors have explained this to the person and that the person has understood fully what they are saying? Some people seeking assisted suicide might have hearing impairment for which the doctor has not made adequate allowance; some might not be able fully to understand what a doctor with an unfamiliar accent is telling them. How dreadful for them later to regret signing the form and die without realizing that they could have reversed their original decision.

All doctors might behave in an absolutely exemplary fashion, but of course safeguards are devised to provide a safety net in the case of any with ill-intent – in the worse-case scenario, doctors amenable to influence from outside and/or doctors who take pleasure in watching someone die, as apparently did Dr Harold Shipman.

I have already explained that there is a danger in the coordinating doctor, who will ultimately administer the poison, being free to initiate a conversation about assisted suicide with a patient. He or she might be influenced consciously or not by a care-home manager, who again might have been influenced by a prospective heir. But also, the coordinating doctor might be someone who has little regard for the well-being of his patients’ or indeed have psychopathic tendencies.

I think there is also a danger in the freedom within which the coordinating doctor can choose the independent doctor. He or she is forbidden under section 16 from seeking an independent doctor who is part of their same medical practice or clinical team, but that does not prevent them selecting a doctor who they know and of whose attitude to assisted suicide they may well be aware. Should not the independent doctor be selected by someone outside the situation in question?

The Reputation of the care home

I worry about how assisted suicide may impact on the reputation of care homes. Will care homes be expected to reveal to prospective residents and their families the number of assisted deaths in any year? This could work unfairly against a care home – residents might have independently and legitimately decided to seek physician-assisted suicide even though they received good care in the care home, and as a result a home might attract suspicion and an undeserved poor reputation.

But would a home be obliged to tell prospective residents or anybody else of physician-assisted deaths amongst its residents, if asked? Would it be expected to reveal this information in the data it issues to the Care Quality Commission or the Care Inspectorate Wales, and would the Commission or Inspectorate in turn be expected or required to include such information in any publicly-available report on the home?

February 2025