Disclaimer: The opinions expressed in this blog are entirely our own and not necessarily those of our employer or any other occupational therapist.

Thursday, 10 July 2008

Occupational Therapy and Assisted Dying

image by AHook

As an occupational therapist who has worked in a palliative care environment for around 10 years I have always believed that individuals who have capacity should be able to choose when and how they die based on the view that can’t be easy to admit that life is so bad you want to die; but it must be even harder to know that you can’t kill yourself and have to ask for help but be refused.

I was really interested therefore to hear Baroness Finlay speak against the now rejected Assisted Dying Bill at the COT conference in Harrogate recently. I expected her to present a number of emotive case studies describing people who wanted to die but who are now glad to be alive and I expected her to say that good palliative care negates the need for assisted dying. I also expected her to refer to medical ethics and to suggest that some patients would want to die for fear of feeling burdensome. She presented all of these convincing arguments and more besides, however it was her description of the implications of assisted suicide for occupational therapists that stopped me in my tracks.

The Assisted Dying Bill suggests that in order to meet the criteria for assisted suicide a person must have a terminal illness and consider them self to have intolerable suffering. They must also have the capacity to make this judgement and to request the right to die, but capacity cannot be taken at face value. The responsibility for determining mental capacity lies with health care professionals and Baroness Finlay suggests that this may include occupational therapists.

Could I or anyone else really assess the quality of a person’s life and then judge whether or not it constituted intolerable suffering? Is this even possible? If I concurred with the patients view does this mean they have capacity and can be allowed to die? What if they have a better day tomorrow? What if I am wrong?

It is with some regret that I have to conclude that although I still believe in a person’s right to choose when and how to die, I honestly don’t think I could help them do it. Until these issues and more are resolved, I do not believe the Bill should be passed.


Sarah Stewart said...

Many years ago when I was a nurse, I looked after terminally ill people and when I came to give them their diamorphine, I knew that that does could be the one to actually 'kill' them. It never stopped me giving it to them though.

Anonymous said...

I've always worried a little that someone could ask to die, but actually have a treatable depression at that time - and if their depression was treated adequately, they may feel quite differently.
I also wonder whether it would lead to the eventual erosion of the belief that human life is precious. On the other hand, if I could no longer communicate, respond or appreciate the world around me, then I think I'd like the opportunity to die peacefully rather than gasp by gasp.

Anonymous said...

This is an issue that provokes quite extreme responses! I've discussed it recently with quite a few people some who are palliative care workers, some not.
Generally peoples responses seem to be influenced by their professional knowledge, religion, personal experience, what they feel they would want for themselves, their definition of suffering and the stage at which someone asked to die.
I'm thinking that if those views are typical, and agreement is so hard to reach even hypothetically, how would this ever work in practice?

school loan said...
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Kevin Reel said...

Many years after this was originally posted, I have just discovered it.
In the last years I have been very involved in debates and discussions of assisted dying - in the UK and more recently in Canada.
As an occupational therapist who now works full time as a practising healthcare ethicist, I agree that the spectre of being part of capacity assessments that would potentially be one critical link in a causal chain that might lead to a person's death is....well....unsettling to say the least.
That said, in health care we regularly assess capacity - as per the law, and ethics, and standards of practice.
The assessment of intolerable suffering is a very subjective one...which is less the task of any clinician and more the work of the client.
Assessing the capability of a person to understand and appreciate the decision at hand, the options, the outcomes, etc....that is a clinician's duty...and has been for years.
We regularly remove freedoms from individuals based on those assessments - freedom of movement, freedom to refuse or to choose treatments.
Where people are making choices in favour of an arranged death as the best solution to their intolerable suffering, can we really say 'sorry, that is too unsettling to ponder' and shy away from exploring any concerns about capacity? Capacity ought to be presumed, unless there is good reason to doubt it. Our discomfort with a choice is not necessarily good enough reason. And to deny access to an arranged death to all people because we may have difficulty with some capacity assessments is an unethical fettering of choice. Where capacity is truly in doubt, the individual would not be eligible for an assisted death.
Unsettling clinical and professional responsibilities or involvements need to be reflected upon very closely, consciously and deliberatively...recalling that there remains a client who needs our support and a often needs decision made. Practitioners do have the right to make a conscientious refusal to participate.
In Canada we are preparing for legal requests for death. Our Supreme Court found a blanket denial of such services was unconstitutional and a violation of Charter right.
As part of this preparation, we surveyed OTs and Student OTs across Canada for their opinions.
While they were unsettled, most respondents felt it was important to be able to talk with clients about it, and many identified clear roles for OTs in the process of responding to inquiries and fulfilling requests for legally arranged death.
Some select interim results are available here:
Reading the affidavits of those who might wish to make legal requests for death when possible, I was further moved by the need for very reflective examination of what it means to be client-centred practitioners.
More thoughts on the topic can be found in the September 2015 issue of OT Now:
The idea of assisted dying should never sit comfortably in our minds or hearts...it should always be approached with a circumspect attitude, lamenting the inability to assuage the suffering of a small number of people who request it. But we must also respect the judgement of the person who lives with the effects of their suffering every minute of every day...often as they wait for it to get worse, as they approach death.....or as they wait for years if their condition is static.
The right of conscientious refusal to participate is afforded practitioners in all jurisdictions where this is legal. Nevertheless, the immense 'yuck factor' it carries must be addressed by each of us....so we are prepared to respond to any client that wishes to discuss the idea.
In Canada it is soon to be a client's right. In the UK, time will tell...but many feel it is just a matter of time.
We need to begin preparing ourselves for the fact that a few capable clients will identify this as their preferred plan.

Kevin Reel said...

the URL above [http://www.caot.ca/conference/2015/presentations/t26.pdf] has been changed to:
September 2015 issue of OT Now [http://www.caot.ca/otnow/sept15/otnow_9_15.pdf] is now available to CAOT members only, or through library subscriptions.