What compassion really means…

I believe a wider and more open debate on The Terminally Ill Adults (End of Life) Bill is very much needed. I propose we use some of the conceptual tools at our disposal to analyse pressure and coercion, which were discussed by Professor Carla Willig and Dr Rachel Stocker in the Psychologist Jan/Feb 2025.

The Royal College of Psychiatrists (RCPych) surveyed its members and submitted detailed evidence to Parliament. Specifically, only 31 per cent of respondents were confident 'that consent can act as a safeguard against people making unfree choices'. The RCPsych concluded that there are 'Unanswered questions about the reliability of assessments of capacity to end one's own life and the adequacy of consent as a safeguard against coercion in this context should be carefully considered by the Committee'. I would go further, by proposing that the assessment of someone's mental capacity to consent is inadequate as a means of establishing whether there is pressure or coercion (it was never designed to do so).

Social psychology has a long history of studying social influence. Classic concepts include obedience, compliance, conformity, and persuasion. For all the methodological and ethical limitations of Milgram's studies, they usefully suggested that institutional and personal power and authority could make us take uncharacteristic and extreme courses of action. Now, what if the authority figure is one's doctor dropping the option of assisting us to take our lives into a consultation? Wouldn't that constitute covert pressure? Doctors have had, and continue to have, disproportionate power compared to their patients. This is undeniable.

Steve Reicher has offered more complex conceptualisations of how power may have operated in Milgram's and Zimbardo's studies: participants may have taken on the researchers' agenda and become active collaborators in an enterprise they saw as worthy. In this light, doctors and other health professionals can become a reference group we identify with, a group that, in our view, supports, validates and ultimately legitimises the option to take our own lives. The thought processes of patients (including those terminally ill) cannot be extricated from the deeply rooted historical power differentials and cultural values, no matter how many safeguards are included in the Bill.

Another way to look at social influence is to examine the language used to propose the change in the law: 'I struggle to see how it is just or fair to deny anyone the autonomy, dignity and personal choice that we may want to take control of our final weeks'. 

The deployment of these notions acts as a powerful rhetorical device because they resonate with key unquestioned values in our individualistic culture. Some psychologists have discussed individualism in psychology's theorisation of the self (e.g. Edward Sampson). The terminally ill patient is not an isolated autonomous entity, as presented in the stylised film The Room Next Door, with no close friends or community to care for them, left to deal with their suffering alone, but with the option to 'press the button'. 

As an alternative to this simplistic and technocratic option, we can envisage supporting people at the end of their lives with the best palliative care and psychological support possible. And yes, accompany them as they die. That is what compassion really means: to be with the person suffering (and their families), not turning away and definitely not assisting them to take their own lives. This is indeed a precious part of the role of psychologists and counsellors working in hospices.

Dr Alfredo Gaitán, GMBPsS