Ignoring the Psychiatrists
What the assisted dying vote tells us about attitudes to mental illness
At some point during Friday’s House of Commons debate on assisted dying, one MP shared the rationale behind his support for the bill. “If I get to that point in my life, I want that choice available to me,” Kevin McKenna, MP for Sittingbourne and Sheppey, announced. “The choice… needs to be there” he argued, because “this is about each of us at the end of life”. “This is about individuals” he suggested, urging his fellow MPs to “think about themselves as well”.
Other speeches in favour of the bill continued in this fashion. Supportive MPs appealed to personal choice, control and agency at the end of life. They imagined individuals like themselves, expressing autonomous wishes to relieve pain and suffering, currently stymied by regressive legislation.
Outside of Parliament, experts warned of a different story. One day before the debate, the Royal College of Psychiatrists released a strongly-worded statement, warning that the legislation “risked preventable deaths of people with treatable mental illness”. The statement spoke of people quite unlike McKenna and his colleagues, warning of the bill’s impact on people with intellectual disabilities, and those experiencing social isolation or clinical depression. The concern was that the legislation might see suicidal people with treatable mental illnesses be “given the means to end their life”, when “with time, care, and access to proper treatment, they might have chosen differently”.
At the heart of the disagreement was confusion about what mental capacity involves – the framework the bill uses to assess people’s eligibility for an assisted death. Mental capacity assesses four criteria; a person’s ability to understand, remember and weigh up relevant information, and to communicate their decision. If (and only if) one of these criteria is not met, a patient is determined to lack capacity. Simply noticing that a patient has symptoms of a mental illness, or recognising that a patient’s decision is unwise, are not alone grounds to influence this assessment. If you can understand, retain, weigh and communicate your decision, you are judged to have capacity.
This differs from how psychiatrists assess decision-making related to mental illness and suicide. The Mental Health Act requires clinicians to specifically assess for symptoms of a mental disorder, and to explore the consequences of them on a patient’s safety, including the risk of suicide or self-harm. Put simply the two concepts assess different things - someone can have a treatable mental disorder which is making them suicidal and still be deemed to have capacity. This is why the Mental Health Act is still in use over forty years after its introduction - it provides a more thorough, sensitive and specific test to check if a psychiatric disorder is affecting a patient’s decision-making.
If the legislation is implemented in the form approved by MPs last week, it could lead to some perplexing situations. As a psychiatrist, I could find myself caring for a depressed, suicidal patient who has been sectioned to a psychiatric hospital with the explicit purpose of preventing them from taking their own life. Yet, if this patient were to have a concurrent terminal illness, they might at the same time be eligible for a government-sanctioned assisted death[i]. The same person could be presenting with the same symptoms, diagnoses and wishes to end their life, and yet at the same time be eligible for suicide prevention (an admission to psychiatric hospital) on the one hand, and suicide facilitation (an assisted death) on the other.
It’s unlikely that such a patient would ever reach my psychiatric hospital, however. Amendments that would have required mandatory psychiatric assessments were proposed but not voted on, such that candidates for assisted dying will only need to undergo the laxer mental capacity assessment. Despite 15% of terminally ill adults experiencing a depressive disorder at the end of life, clinicians will not routinely consider the possibility that a mental disorder might be influencing a patients’ wish to undergo an assisted death. As Dr Lade Smith, the president of the Royal College of Psychiatrists, told BBC Newsnight last month, the Mental Capacity Act “is not designed… and hasn’t got the safeguards or the support” to assess eligibility for assisted dying in the way the bill proposes.
One might ask how we’ve ended up here. How did MPs approve the biggest amendment to suicide law in modern history, against the explicit advice of the country’s experts on suicidality – the Royal College of Psychiatrists? And why did MPs design legislation based on its likely effects on middle-class, mentally healthy, able-bodied individuals like themselves, while at the same time ignoring its probable impact on society’s most voiceless populations?
In many ways, this is to be expected. As Professor Allan House, a psychiatrist and academic expert on suicide, wrote, “extreme individualism typically prioritises the wishes of privileged individuals over community or societal needs, and especially over protection of the most vulnerable”.
It is true that there are real and difficult tensions here. The bill’s proponents were met with an unenviable task of cobbling together workable legislation with little government support or civil service time, while burdened by the understandably desperate expectations of the campaigners they worked closely with. (In contrast to recent votes of conscience - such as same-sex marriage legislation – this issue was left to a Private Member’s Bill rather than introduced as government legislation, despite Keir Starmer making pledges on it during the general election campaign).
However, even in the context of a Private Member’s Bill, there is a sense that these concerns weren’t treated with adequate consideration. The bill’s scrutiny committee initially voted against inviting Royal College of Psychiatrists to give evidence at all, only reversing their decision after public outcry. Throughout the entire process, interventions from psychiatrists, mental health charities and advocates were ignored, warnings not heeded, and proposed amendments not tabled. And this disregard of psychiatric expertise spanned beyond politics. The Chief Medical Officer Chris Whitty (an infectious disease doctor, who is unlikely to have much clinical experience working with mentally ill patients), felt confident to give his opinion that the Mental Capacity Act was sufficient for this legislation, contrary to the advice of psychiatric experts. (Whitty later admitted he’d made errors when speaking on this matter).
For all the fanfare about mental health awareness and parity of esteem, it seems we continue to privilege some health considerations above others. We’ve struggled to accept mental illness and suicidality as salient medical problems deserving of rigorous examination, clinical expertise and medical representation, assuming that intuition and folk wisdom will suffice.
Would Whitty have felt comfortable pontificating on a clinical opinion related to another clinical discipline outside his expertise? It seems unlikely; he usually speaks cautiously on topics he doesn’t have direct experience of. Would MPs have readily declined the opportunity to hear from medical experts in another clinical discipline? History suggests not. The Abortion Act, also a Private Member’s Bill, was preceded by extensive consultation and a medical advisory committee, chaired by the president of the Royal College of Obstetricians and Gynaecologists.
Yet on this bill – pertaining to legislation on suicide - psychiatrists have struggled to have their concerns heard. The age-old story of neglected health conditions was repeated; legislation was written on the basis of MPs imagining what they themselves might want at the end of their life, overlooking the distant, side-lined and stigmatised realities of mental illness.
“Ultimately, a good death is something that we all want for ourselves, and for those we love and care for” concluded one MP in support of the bill. The problem – as any psychiatrist sees almost every day of their working lives – is that not everybody is equally loved or cared for. Some are voiceless, some are despairing, and some cannot make decisions in the way that we imagine ourselves making decisions. If we are to make laws fit for society – and not just fit for certain kinds of individuals – we need to put these realities at the centre of our public debate. Doing so might temper our fantasies of individual autonomy, choice and control with the actuality of human psychology and its vulnerabilities.
In recent years, much has been said about raising mental health awareness and de-stigmatising psychiatric illnesses. Yet when the country’s professional body of psychiatrists warned of preventable deaths, legislators did nothing. Perhaps we should ask ourselves how much has really changed in society’s attitudes towards the mentally ill.
In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email jo@samaritans.org or jo@samaritans.ie. Other international helplines can be found at befrienders.org
Image by Dignity in Dying, CC BY 2.0
[i] Such a patient, for instance, might be sectioned under the Mental Health Act, but meet eligibility for assisted dying under the Mental Capacity Act.
The wealthy already had the option of travelling overseas for 'assisted dying'. This bill, and the initiatives for GP's to sign up their patients for 'do not resuscitate' orders, need to be considered in the context of the drastic welfare cuts being pushed through by Labour.
Great post. As a former NHS mental health support worker, and a mental health patient, I agree that the lack of psychiatric input into the assisted dying debate belies the attitudes to mental health patients and provision. No matter your views on assisted dying, this ‘oversight’ is important and highly relevant. Thanks for writing.