Live and Let Die? Margo McDonald's 'End of Life Choices' Bill

On the 8th Dec last year, Margo McDonald launched her ‘End of Life Choices’ consultation. This was a follow on from Jeremy Purvis’s ‘Dying with Dignity’ bill, which was an assisted suicide bill but was unsuccessful. On 8th March (next Sunday), the consultation period will come to an end and the bill will be circulated in Holyrood for a month to gather support. If it gets the support of eighteen MSPs or more, then it will pass, subject to a vote in Holyrood.

As someone who has been a carer for a dementia sufferer for ten years, and as a health campaigner, I want to contribute to this debate. My next couple of posts will be devoted to the proposed bill itself and the backdrop to it. The implications of this document are wide ranging, and I think it is important that people understand exactly what is likely to happen if this bill becomes law.

The ‘End of Life Choices’ consultation is a fairly free flowing document, informal in structure. It describes in detail the case of Diane Pretty, Daniel James and other high profile assisted suicide cases. Further on into the document, it starts to outline the details of what the bill would consist of.


Definition of ‘assisted dying’

The normal definition of assisted suicide or “assisted dying” as it is called in this bill, is where a physician supplies the medication and the means by which the person will end their life, but the patient has to administer the medication themselves. This is distinguished from euthanasia, where the physician can also administer the medication to the patient. This is a fine, but an important difference between the two, because with assisted dying it is clearer that the patient actually gave consent. Assisted dying has been favoured as a middle ground for this issue; in Oregon, patients can take their medication home and in around half of these cases, the patient has chosen not to go ahead.

However, in this bill, assisted dying has been defined as follows;

‘ A medical practitioner administers a lethal dose of medication to terminate a patient’s life, or supplies the means, and assists the patient to self administer.’

This means that this bill is not an assisted dying bill, but it is actually a euthanasia bill under this definition. Therefore, in considering the possible consequences of this bill, we should be looking at the example of Holland, which it most closely resembles. Examples such as the Northern Territories in Australia and Oregon in America should be discounted.

Who can apply for this?

The bill states that it applies to ‘capable adults who are residents of Scotland,’ ie those who are over 16 and sound of mind. The circumstances under which they can apply for this are if they are terminally ill, suffering from a degenerative condition or if they become unexpectedly incapacitated. However, it then goes on to say,

‘Patients who are not terminally ill, suffering from a degenerative condition or unexpectedly incapacitated, but who find their life to be intolerable may request assistance to end it..’

This is a very wide ranging definition and it is not clear who it is referring to. This might be someone who is medically ill. Then again, it might be someone who is not medically ill, in which case the role of the doctor towards the person requesting assistance is unclear. The word ‘patient’ has been put in inverted commas all through the document. Does this mean that someone who requests this does not need to be ill to do so?


Who can perform this?

The bill states that an ‘assisting physician’ should be the person to carry out the request. What is normally understood by this, is that it will be a doctor. However, at the back of the draft, ‘attending physician’ is defined as follows;

..ordinarily, the GP or physician who has primary responsibility for care and treatment of the patient, but may be another suitably qualified health professional.

This does not define what a 'suitably qualified health professional' is. This might be a doctor; then again it might refer to a nurse, a nurse practitioner, a health worker or even a pharmacist. It is simply not clear what this means.


Documentation

The condition for allowing a request for assisted suicide, is that the patient makes two verbal requests, 15 days apart. These requests are documented in the attending physician’s notes. Apart from this, no written evidence or corroboration is required from a witness. The request can be carried out by one doctor on the patient, without a third party intervening at any point. Post mortem, he is required to request that a review committee verify that the specified criteria and safeguards had been observed, but it is difficult to see how they could do this, if the only documentation comes from the physician who carried out the request. In cases where the patient’s mental capacity is in doubt, there needs to be a ‘consulting health professional’ to give a second opinion, but in all other cases, one physician is sufficient.

Because the definition of ‘assisting physician’ is so vague, it is unclear as to who is actually going to be responsible for keeping the documentation. If, for example, a nurse practitioner carried this out, would they be responsible for the documentation or the doctor that the patient was registered to?

Further Considerations

People who are mentally incapacited are excluded from this bill at present. It is worth noting however, that the ‘rule of thumb’ test for someone’s capacity esp in the case of dementia, is whether they can sign their name. There are many people with dementia who can sign their name, but have no idea what they are signing and this could be abused.

Under the Adults with Incapacity Act, if a person has not previously arranged a power of welfare attorney with a relative, welfare attorney goes by default to the nurses and doctors responsible for their care at that time. This could result in a conflict of interest especially in a hospital setting, if the bill’s definitions widened. There is a possibility that this could happen, because under European law, omitting the mentally incapacitated from a service could be classed as discrimination. As I speak, the Dutch are drafting legislation to include people with mild dementia under their euthanasia laws.

I understand that this is currently a consultation document and not a legal document at present. However, I am surprised at the lack of detail, at the re-definitions of terms like ‘physician’ and ‘assisted suicide’ which are going to lead to a great amount of confusion and the wide range of the bill. If this ever gets to committee stage, it will have to be completely re-written or ditched altogether; there are too many holes in it. Whether you are for or against euthanasia, this is not fit for purpose.

Raising the Stakes- Getting a Deal on Refinancing

It's the words that make the lawyers groan, and the private sector rub their hands.

Voluntary code. It's that grey middle ground when a government knows that it should make a definite law about something, but doesn't, because it is afraid of the consequences. So it puts down what someone should do, thus taking the side of the angels, but makes sure that the government does not have to act if big business walks all over the code with tackety boots. It's a wimp's charter.

So it happened with the re-financing of PFI deals. Just to explain exactly what re-financing is, it works like this;

In a PFI contract, you have a consortia, or a number of players. The banks are the lenders. The contractors building the project are the borrowers. And the public bodies are the payers in the form of a rent paid to the contractor who owns the building. Are you still with me?

The public body doesn't have a direct relationship with the lender. They pay the rent that the borrower charges, and the borrower uses this money to pay the loan that the bank gave them. At the start of a project, the risk is higher, so the bank charges a higher rate of interest on the loan. When the project is completed, there is a lower risk, so the borrower can negotiate for a lower rate of interest. This is known as re-financing of the loan. Now when the borrower does this, they have a choice. They can go on charging the payer the original rent, or they can pass on part of the saving to the payer. Guess what route the borrowers took? Yep, they kept all that lovely money to themselves. And why did this happen? The Treasury had 'negotiated a voluntary code' that they should pass on 30% of refinancing profits to the payer, but they didn't. It was voluntary. It was assumed they would do the honorable thing, but hey, they never claimed that they were gentlemen. And rack up some more profits by charging outrageous costs on maintenance contracts, like £400 for changing a light switch and you've got yourself a nice cash cow, backed up by a sound investor that ain't ever going to go bust, because the government can't allow NHS trusts and local councils to go bust.And there was very little the Treasury could do about it, because there was no law against it, you couldn't change a commercial contract and they had little or no leverage with the banks; the banks had control of the Treasury. Until now, that is.

Over the past few months, the government has been nationalising our high street banks, by becoming the majority share holder. This is particularly significant in Scotland, where Westminster has taken a 70% majority stake in the Royal Bank of Scotland. RBS is one of the biggest players in PFI in Britain and so the government has effectively taken control of all the contracts that RBS owns. Jamie Hepburn, an SNP MSP has realised this and wrote to the Treasury asking if they could not get the public a better deal on PFI. The Treasury neatly dodged the question by saying that it couldn't re-negotiate PFI contracts and it would be detrimental to the banks interests and ultimately to the public purse to do so.

Now this is just codswallop. Think about it for a minute. The government owns a 70% stake in RBS which makes it both lender, shareholder and payer. Any money the government makes as a shareholder, is going to be lost at the other end as NHS trusts and local authorities struggle with payments. But if it leans on the likes of Laing, Serco and Balfour Beattie to be more generous on its re-financing profits, then it will mean that NHS trusts and local authorities can share in the profits and the government will get more bang for its buck. It is all public money, but it means that more of it will stay in public hands, instead of being poured down a black hole of rack renting on the part of the private sector. The government won't get a better opportunity to sort PFI out. It should take it.

Jamie, you're right about this.Find yourself a friendly MP down in Westminster and keep pressing. It could save us and the government an awful lot of money.