“Death is a social event with a medical component, not a medical event with a social component”

“Remember that death is a social event with a medical component, not a medical event with a social component. The larger part of dying happens outside of the institution and professional care.”

In a discussion yesterday with two very experienced palliative care social workers about the assisted dying legislation currently before Parliament, one of them brought up this quote by Professor Alan Kellehear, a medical and public health sociologist, and a co-author of the Lancet Commission on the Value of Death, which is required reading for all of my students at King’s College London on the Law at the End of Life course I teach.

The quote resonated with me in two ways (I hasten to add, not necessarily in ways that Professor Kellehear would have intended).

The first is the need for Parliamentarians to be clear that legalisation and implementation of assisted dying / assisted suicide in the way proposed in Kim Leadbeater’s Bill will change the balance, so death in the circumstances prescribed by the legislation would no longer be a social event with medical consequences, but rather a medical event with social consequences.  That is, in itself, neither a good thing nor a bad thing,[1] but it is undoubtedly a thing upon which people might wish to reflect.

The second is that the focus on medicine and medical professionals in the debates around assisted dying is leaving out a profession who might be thought to have a vital part to play, namely social workers.[2]  Medicine undoubtedly holds the cards in terms of diagnosing that a person has a terminal illness and as to the prognosis for that illness (although it is notoriously difficult to assess prognosis with any accuracy).  But medical professionals might be thought less well-equipped than social workers to interrogate the wider social circumstances in which a person may come to make a decision to seek assistance to end their life.  And if, as Kim Leadbeater’s Bill frames it, the capacity question is whether the person has capacity to decide to end their life, it is not obvious that a medical professional will be any better placed than a social worker to answer what is in reality an existential question (for more on how capacity questions are framed in different legislative frameworks around the world, and the consequences, see the slides from Professor Gareth Owen’s presentation here).

By way of analogy, social workers have historically played a crucial – indeed determinative – part in the process for admission under the Mental Health Act 1983, as they still form the vast majority of those who serve as Approved Mental Health Professionals (and those other professions who are now eligible to serve are equally recruited for their wider perspectives).  Their role is to consider, based upon the medical recommendations, whether an application for admission for assessment and treatment under the Mental Health Act 1983 is “appropriate.”  An insight into what that means, and the wider perspectives that might require, including into the person’s social situation, can be found in this discussion I held with two Approved Mental Health Professionals here.

For people wanting to think more about this, I recommend reading the statement by the Association of Palliative Care Social Workers, and their proposal for a role of Approved Palliative Care Professional should assisted dying / assisted suicide be implemented.

[1] Although some might consider it places medical professionals in a very challenging position where, as the legislation currently appears to be drafted, it requires them to be present at the self-administration of the medication (following potentially extensive steps on their part to assist the person to be able to do so), but then does not allow them to intervene to as to “up the dose” should complications ensure.

[2] I am conscious in saying this that there are others who may well have very important roles to play, not least nurses.