Assisted Dying Bill Scotland: Why fears about coercion of vulnerable people are misguided

In countries which allow it, there is no evidence that people are coerced into assisted dying

Coercion was on everyone’s minds in Holyrood’s dramatic debate on assisted dying earlier this month. Liam McArthur’s Assisted Dying Bill offers terminally ill, mentally competent Scots the option to end their own lives, allowing a dignified death when someone regards their own suffering as too great or their life no longer worth living.

Its multiple protections include strict eligibility requirements and the sign-off of two independent doctors. Opinion polls show that a large majority of Scots – across different demographics – support assisted dying.

While the Bill passed its first reading, it is by no means certain that it will become law. MSPs from both sides of the debate referenced worries about patients being pressured into a premature death. Colin Smyth MSP invoked “people’s deepest concerns… about patients potentially feeling like a burden or about the possibility of their being coerced”.

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Liam McArthur MSP with supporters of his Assisted Dying Bill outside the Scottish Parliament (Picture: Jeff J Mitchell) | Getty Images

Fear and speculation

MSPs are right to ask questions about the Bill’s protections against coercion, especially for vulnerable people. We can answer them by looking at the evidence. Examining data from countries that permit assisted dying – some with decades of experience – cuts through the fear and speculation that otherwise characterise these discussions.

One thing is clear: there is no evidence that people are coerced into assisted dying. Parliamentary committees in Holyrood and Westminster specifically sought such evidence. None was forthcoming.

Instead, Dr Ryan Spielvogel testified that “in the 25 years that aid in dying has been legal in jurisdictions in the United States, there has never been a single substantiated claim of coercion”, and Dr Alison Payne wrote “I have not yet seen evidence of coercion [in New Zealand] – more often the family are reluctant for it to happen”.

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Julian Gardner, chair of the Australian state of Victoria’s Voluntary Assisted Dying Review Board, said: “The only reports that we have had have been the reverse, in that people have experienced coercion – that might be too strong a word – or undue influence not to go ahead with ending their life, generally from relatives who have objections or from faith-based institutions.”

Even focusing specifically on vulnerable groups, such as disabled people, there is no sign of coercion. Indeed, there is less uptake of assisted dying in such groups – the opposite of what we’d expect if vulnerability were a factor.

Taking concerns seriously

This evidence will settle the matter for some. Others might worry that a risk of coercion persists. Bob Doris MSP argued that “coercion can be subtle and difficult to detect”, while Sue Webber MSP said “subtle pressure and coercion… are not always visible”. Absence of evidence isn’t always evidence of absence.

These concerns are speculative, but the potential risks should be taken seriously. How can they be addressed?

First, this is a problem medical professionals deal with all the time, right now. Competent adults can already refuse life-saving treatment, including through written, advance directives. They might be pressured by family members to end their lives early or, indeed, to request care they don’t really want. As Rona McKay MSP said, “it is part of doctors’ everyday practice to recognise coercion – for example, in abortion care or in cases of the withdrawal of treatment.”

The Bill’s safeguards build on existing good medical practice. Doctors must ensure that patients have capacity, check that their choices represent what they really want, and give them time, information, and support.

Greater protection

We should respond to risk not by disempowering people in the name of ‘protection’, but by empowering them to make decisions aligned with their values. The Bill does this and provides greater protections for assisted dying than any of the other ways in which people can already hasten their own deaths.

Second, the risk of feeling pressured into a premature death isn’t the only one that matters. As Karen Adam MSP asked, “is it not a form of coercion to force someone to endure pain that they do not want and to deny them peace when their death is already certain?”

Under the status quo, the risk of unnecessary suffering is 100 per cent. The Bill – a logical extension of our hard-won right to refuse curative treatment and opt for palliative care if we see fit – balances competing risks.

Third, the dangers that concern MSPs already exist, and this Bill reduces them. People with terminal illnesses already choose to end their lives – whether by refusing treatment, killing themselves without help, or going to Switzerland. If there is a problem with hidden coercion, it already happens.

As Liam McArthur said, “at present there are often no safeguards for many people who feel a burden, are subject to coercion or abuse, or feel unsupported”. The Bill gives legal clarity to doctors and family members, and strengthens protections with a new criminal offence of coercion.

An evidence-based approach helps resolve concerns around assisted dying. Worries that legalisation will damage palliative care have been refuted, including by the Health and Social Care Committee at Westminster.

Our own research on disability shows widespread support for legalisation among disabled people, and that assisted dying laws neither harm nor devalue disabled people’s lives.

The same approach can help MSPs determined to ensure that terminally ill people won’t be subject to coercion. There is no evidence that coercion occurs in countries where assisted dying is legal.

We should take seriously fears of coercion and aim for legislation that manages and minimises risks for all. With its evidence-based safeguards, this Bill will achieve that goal.

Professor Ben Colburn, of the University of Glasgow, is the author of Moral Blackmail and other studies on end-of-life ethics. Dr Joseph Millum, of the University of St Andrews, is the co-author, with David DeGrazia, of A Theory of Bioethics and a consultant to the World Health Organisation. They are members of the Philosophers Consortium on Assisted Dying in Scotland.