There are two areas where we should look for such safeguards – in the conduct of the individual contact between a health professional and somebody who wants to die, and in organisational oversight of any system put in place to manage such contacts.

First though we need to start with a challenge to the over-simplified dichotomy often applied to thinking about safeguards and vulnerability in this situation. When suicide is viewed as a personal choice it is assumed that there are only two scenarios – a mentally competent, fully informed individual acting on their own volition, or somebody lacking mental capacity or severely mentally ill or coerced in some way. What isn’t accounted for is the situation where the individual’s range of options is constrained – because they are socially constrained by for example lack of emotional or social support or by practical considerations like financial circumstances, or personally constrained by for example a personal sense of lack of agency that may have arisen from life experiences. It also doesn’t account for ambivalence, often hidden because it is buried under a (surface) over-certainty.

In thinking about who is vulnerable in the present context, we need to start by recognizing that what is being proposed in the name of assisted dying is physician-assisted suicide. What we know from the data on unassisted suicide in the presence of physical illness can therefore give pointers. Unassisted suicide is associated with feeling of hopelessness or worthlessness; is more common in those living alone and often lacking emotional and social support; in those with a history of depression (40-50%), self-harm (60+%) and problems with alcohol (40-50%).

Imagine a situation where a 45 year old woman diagnosed with multiple sclerosis 10 years ago goes to see a doctor. She has had two relapses since diagnosis. She lives independently and uses a wheelchair for trips outside the house. She has decided that she wants to end her life and she asks for the doctor’s help to do that.

What would we normally expect to be the response of a doctor faced with somebody like this with suicidal thoughts? That is, what would safeguards in the initial contact look like? Good medical care would entail a detailed and probably repeated contact with the woman to discuss the reasons for her thinking, to explore her personal circumstances and previous history of physical or mental health problems, and to meet with close others such as a partner or next of kin.

It is likely that the woman’s general practitioner would know about her personal and health background and they should be contacted. Under normal circumstances a contact like this would lead to referral to a psychiatrist especially if the doctor immediately consulted did not have expertise in responding to suicidal thoughts and plans in somebody with severe physical illness.

In fact none of this is required in MacArthur’s or Falconer’s Bill. There is no mandated requirement to explore anything about the woman’s background beyond confirming that she does indeed have multiple sclerosis as she describes and there is no requirement to consult her general practitioner (although they must inform them in the case of McArthur’s Bill that the person wishes to die by assisted suicide) or a neurologist who might be managing her case or to speak to a next of kin or close other. The first any member of family may know is when they are informed of the woman’s death. The doctor involved is required to involve a second doctor who need undertake no more extensive assessments than the first. The two may consult a psychiatrist if they are uncertain about the woman’s mental capacity to make the decision she has, but they are under no obligation to accept the psychiatrist’s opinion. Neither doctor is required to make detailed notes of their contact with the woman as you would expect from any other medical involvement in a life-threatening situation.”

The necessary expertise of the two doctors involved is unspecified in the Bills and there is no mandated requirement for supervision.  The steps they can take to assist the woman’s suicide are similarly unclear. For example, the nature of the assistance they can provide in administration of a fatal drug dose is not specified. A doctor or delegated other health professional must stay with the woman until she dies but there is no note of what further intervention they can make if death is attended by unacceptable complications or long delay after administration of the potentially fatal medication.

In relation to organisational oversight of a programme of physician-assisted suicide the details are similarly sparse. Imagine what you might expect from oversight of some other health system of such life and death importance – for example a paediatric cardiac surgery unit or an intensive care unit. In both Bills there is a requirement to produce an annual report but it is not suggested that it will contain any information about problems such as rates of adverse events or prolonged time until death. There is no mechanism for obtaining formal feedback from surviving family or close others and there is no formal complaints procedure. The annual report will do little more than provide basic details about the numbers of people whose suicide has been facilitated, with almost nothing said about their personal or social circumstances or health problems aside from the one listed as “terminal”. In Scotland there is even a requirement to issue a false death certificate giving the immediate cause of death not as the fatal drug administration but as the underlying disease that served as the rationale for assisting suicide.

Many campaigners for assisted suicide cite the Oregon Death with Dignity Act as a model. The claim is that Oregon’s legislation works effectively and safely and is one to use as a template. There is no central management of the Oregon system and any licenced physician whether a Doctor of Medicine or a Doctor of Osteopathic Medicine can participate. Last year only 1% of licenced doctors in the state in fact did so – one doctor alone signed 76 prescriptions, 14% of all those filled in the state that year. The truth is that nobody knows how well the Oregon system works because the data are not available. For example in 2023 in a quarter of all cases where a lethal prescription was issued the annual report noted that it was not known whether the prescribed medication had been taken – even in those cases where the recipient of the prescription was known to have died. Untoward incidents are not fully recorded because in 3/4 of cases no physician is present at the time of death. In the minority where information is provided, side effects of the medication are common and delayed time to death after ingestion is not rare – it can take up to five days. In about one in 10 cases death results from use of a prescription issued outside the year in which the individual died and it is now acknowledged in Oregon that despite what the law says assisted suicide is available to people whose death is not imminent and can include people with conditions such as diabetes.

Most people picture slippery slopes going downwards…