Physician assisted suicide and the economic impossibility of safeguarding For best results and links to related articles and to read my other work, find this post on Substack: https://shirabatya.substack.com/p/death-affirmative-care. ------------------ Last Friday, the UK Parliament voted by a narrow margin to legalise physician-assisted suicide. Since then, there has been much discussion of the possibility that the House of Lords could tighten up safeguarding for this bill, which has been criticised widely for lacking sufficient safeguards for people who are mentally ill, anorexic, diabetic, or simply socially isolated and therefore easily suggestible by doctors who, according to this law, will be allowed to raise the topic of suicide with patients who have not raised the issue first themselves. In fact, Parliament explicitly rejected an amendment to prevent doctors from suggesting to patients that they may wish to end their lives, voting only to protect children from such suggestions. Similarly, although Parliament approved an amendment that prevented patients from being deemed terminal due to voluntary stopping of eating and drinking (VSED), this does not apply to anorexics, whose refusal of food is due to a mental health condition and therefore is arguably involuntary. The erosion of safeguarding is not a matter of if, but of when. It is not a bug but a feature. A number of people who have concerns about the bill are hopeful that with the correct amendments in the House of Lords, it will be made fit for purpose and add the safeguards that are currently lacking. Although safeguards are obviously to be welcomed, I believe that such people are failing to recognise a more fundamental problem with this proposal, which comes down to economics. In the end, whatever safeguards are officially agreed, as long as this matter is framed in terms of a “right to die”, over time, practical constraints will lead to an erosion of safeguards as has occurred in places such as Australia and Canada. The erosion of safeguarding is not a matter of if, but of when. It is not a bug but a feature. For those who are in favour of physician-assisted suicide, the discussion about this legislation has been framed in terms of patient choice and the “right to die”. How dare I restrict the choice of somebody else who has freely consented to ending their life? It's their life, not mine. Their body. Their choice. For those of us who have followed the child gender transition debacle of recent years, this conversation is oddly familiar. It is no coincidence that people such as Kathleen Stock and Fred Sargeant who are critical of physician-assisted gender transition, have also been concerned about physician-assisted suicide. In gender critical circles, we know to be careful when people talk about bodily autonomy and choice; we know that the issues of safeguarding or gatekeeping or autonomy are never as simple as people might think. How will the NHS deal with this backlog of people demanding to die, particularly if the service is framed in terms of people having a right to die? Already in recent days, health secretary Wes Streeting has raised concerns about the cost of implementing physician-assisted suicide, possibly topping £15,000 per patient. A whole new service needs to be set up in the NHS to provide this procedure. Personnel need to be trained to assess requests from patients and to determine which patients should be allowed to die, and which should be told “no, not you”. This will also divert resources away from other treatments, possibly away from the important palliative care, provision of which is known already to be inadequate. Adequate palliative care is crucial if patients are to have a real choice between ending their lives and having a dignified death free of excessive pain. Whether or not the House of Lords strengthens safeguards, we know that implementing this legislation will be difficult and costly. The greater the safeguards that may be added, the greater this cost, as savings are generated only after sick people actually do die. We have already seen that practical constraints (economics) have led to changes in the safeguarding process. A shortage of available high court judges forced the bill’s proponents to remove the safeguard that such a person would need to approve applications, in favour of a more practical panel without a person of such high legal qualifications. We must ask: What will happen in a few years’ time, when there is a backlog of say hundreds or thousands of patients who have requested assisted suicide? What will we do when the safeguards necessary to make sure that their suicide has not occurred under duress or due to inappropriate factors such as mental illness — when these safeguards lead to unacceptable delays because systems are overwhelmed. How will the NHS deal with this backlog of people demanding to die, particularly if the service is framed in terms of people having a right to die? Imagine a few years hence, if careful safeguarding and gatekeeping is in place, if the process has not devolved into the informed consent model in which a patient’s “right to die” is simply affirmed and they are pushed down the pipeline towards death. Someone will be frustrated by the delays from “excessive gatekeeping” that interferes with their “right to die” and they will sue complaining that they are being coerced into remaining alive. If strong safeguards are kept in place, this lawsuit will happen (again, not a matter of if but of when). More likely, organisations such as Humanists UK will push for a reduction in safeguards to avoid such delays. Those of us who have been following the issue of gender-affirmative care in medicine cannot help seeing the obvious parallel: the similarity to another story in which gatekeeping was eroded due to the reality of practical constraints or economics. Years ago, when Dutch doctors initially decided to begin to transition a small number of gender non-conforming children in order, theoretically, to provide them better cosmetic outcomes as fully transitioned adults, there were significant safeguards in place. Let's leave aside the question about whether, in principle, we think that one should ever block the puberty of a child and medically transform a young person to look like the opposite sex. Leave aside that question for the moment and simply consider the matter of safeguarding. Leave aside for the moment the very valid criticisms of the Dutch protocol, which I know was severely flawed research. Nonetheless they did have safeguards in place. If you have followed the New York Times podcast, The Protocol, you will recall that one had to undergo several months or years of therapy. There was screening for all sorts of mental health problems that disqualified patients from puberty blockers or medical transition. Thus the “gender-affirmative” care model began to view gatekeeping as a pejorative, something we should not do as we had a duty to affirm patients… So what happened when American and British doctors saw what was happening in Holland and decided to bring these procedures back to their own countries to replicate them so that patients in their own countries could have access to this new apparently ground-breaking treatment protocol? Quickly, in both the UK and the US is, the number of children seeking “gender-affirmative care” far exceeded what clinics they could cope with following the Dutch model, because along with the patients they expected to see (those who had been gender nonconforming from a young age, mostly boys), there came a multitude of distressed adolescents (mostly girls) with no prior history of gender dysphoria. Thousands of patients built up on waiting lists, or in the case of the United States, patients sought treatment at hospitals hundreds of miles from their homes, and so they could not reasonably be expected to show up for months and months of appointments and therapy sessions (See NYT The Protocol, episode 3). As a result, as explained in the NYT podcast, the process was changed. It was streamlined to get through the waiting lists. Months of therapy often turned into a single assessment. And thus we ended up with problems that far exceeded those from the Dutch protocol. Again, I am not saying that the Dutch protocol was itself a good process or defending that research, which is deeply flawed. But certainly, what happened in the USA and UK etc. was far, far worse. It became a free-for-all. You will change the product to fit constraints just like any vendor of any product in a market economy. Therefore, if it is impractical, expensive or onerous, safeguarding gets cast aside. Johanna Olson Kennedy explains on the Protocol (again episode 3) that she realised it actually made no sense to engage in these sorts of safeguarding / gatekeeping procedures in order to decide which patients should be getting gender-affirmative care and which should not. Gatekeeping did not work because, of course, doctors could not easily tell which patients should and should not be transitioned, and patients would simply change what they told doctors in order to get past gatekeepers, thus hiding other mental health problems. Again, this is a matter of economics, of practical constraints and incentives (people may not be honest with doctors if that does not get them what they want). Olson Kennedy therefore decided that patients who wanted to transition should be allowed to transition, should be affirmed. Thus the “gender-affirmative” care model began to view gatekeeping as a pejorative, something we should not do as we had a duty to affirm patients and believe them when they claimed a gender identity. Transition was no longer a treatment which would be provided or not based on medical judgment by a trained professional. Rather, transition became purely the exercise of what was framed as “trans rights.” You could say that this was
