Assisted Suicide bill to be debated in parliament

[Nearly Sane]

Bill to be published next week

https://www.theguardian.com/society/2024/nov/06/assisted-dying-bill-to-be-published-amid-mps-concern-over-scrutiny-legislation

And here it is

https://bills.parliament.uk/bills/3774/publications

[Nearly Sane]

Embarrassingly bad interview from Christine Jardine


https://x.com/BBCNewsnight/status/1856472692448194795

[ProfessorDavey]

There is a lot of discussion over the issue of coercion as if this is an issue that isn't currently faced within the medical profession, and indeed in life and death situations. That is entirely wrong as the profession already deal with this on a regular basis.

People already have the right to refuse life-saving treatment, including but not limited to blood transfusions and continued use of a life-support equipment. In these cases a decision to refuse life saving treatment will result in the person dying when otherwise they might have lived. Those decisions could, of course, but subject to coercion, but the medical and legal professions seem to be able to cope with assessing whether the individual has autonomy and whether their consent to refuse treatment is valid, which requires it to be free from coercion. I don't really see why assisted dying cases would be any different in terms of being confident that there aren't coercive issues that render consent invalid.

There are also the reverse types of situation (which arguable may be more common in end of life situations) where a frail person nearing the end of life wants to stop burdensome and ultimately futile treatment but there is pressure from family members to continue with treatment due to an (understandable, but naive) desire to prevent a loved one from dying. Again, our medical teams are very experienced at being able to determine where there is coercion and where there isn't.

[Outrider]

There is a lot of discussion over the issue of coercion as if this is an issue that isn't currently faced within the medical profession, and indeed in life and death situations. That is entirely wrong as the profession already deal with this on a regular basis.

People already have the right to refuse life-saving treatment, including but not limited to blood transfusions and continued use of a life-support equipment. In these cases a decision to refuse life saving treatment will result in the person dying when otherwise they might have lived. Those decisions could, of course, but subject to coercion, but the medical and legal professions seem to be able to cope with assessing whether the individual has autonomy and whether their consent to refuse treatment is valid, which requires it to be free from coercion. I don't really see why assisted dying cases would be any different in terms of being confident that there aren't coercive issues that render consent invalid.

There are also the reverse types of situation (which arguable may be more common in end of life situations) where a frail person nearing the end of life wants to stop burdensome and ultimately futile treatment but there is pressure from family members to continue with treatment due to an (understandable, but naive) desire to prevent a loved one from dying. Again, our medical teams are very experienced at being able to determine where there is coercion and where there isn't.

I work, currently, in the education sector, where child safeguarding is THE priority - we are not just entrusted with monitoring children for signs and evidence of coercion in various areas, but are legally mandated to do it. To suggest that healthcare professionals would be somehow incapable of operating similar standards, as though they aren't doing exactly that in innumerable areas already, is insulting.

O.

[SteveH]

There is a lot of discussion over the issue of coercion as if this is an issue that isn't currently faced within the medical profession, and indeed in life and death situations. That is entirely wrong as the profession already deal with this on a regular basis.

People already have the right to refuse life-saving treatment, including but not limited to blood transfusions and continued use of a life-support equipment. In these cases a decision to refuse life saving treatment will result in the person dying when otherwise they might have lived. Those decisions could, of course, but subject to coercion, but the medical and legal professions seem to be able to cope with assessing whether the individual has autonomy and whether their consent to refuse treatment is valid, which requires it to be free from coercion. I don't really see why assisted dying cases would be any different in terms of being confident that there aren't coercive issues that render consent invalid.

This is also, perhaps, a good counter to the slippery slope argument: it has for a very long time -in fact, I think always - been the case that mentally competent adults can refuse life-preserving treatment, but it hasn't led inexorably to assisted suicide or euthanasia until now - and possibly not this time.

[Nearly Sane]

This is also, perhaps, a good counter to the slippery slope argument: it has for a very long time -in fact, I think always - been the case that mentally competent adults can refuse life-preserving treatment, but it hasn't led inexorably to assisted suicide or euthanasia until now - and possibly not this time.

I'd raised a similar point about DNRs earlier in reply 47 but thinking about it this and DNRs are covered by a principle of bodily autonomy that you can refuse treatment but that doesn't mean you can demand it so I don't think it works.

[ProfessorDavey]

I'd raised a similar point about DNRs earlier in reply 47 but thinking about it this and DNRs are covered by a principle of bodily autonomy that you can refuse treatment but that doesn't mean you can demand it so I don't think it works.

But I don't think this is a case of 'demand' either. In the case of standard medical treatment a competent patient may refuse any treatment, including life saving treatment. They cannot demand treatment unless there is a clinical justification for it to be offered. Nor can they demand treatment free on the NHS which has not been approved to be provided by the NHS (and also where there is a clinical justification for it to be offered). And that will apply both to 'curative' treatment but also palliative treatment based on relieving symptoms only.

In the case of prescription of drugs for assisted dying, these would only be permitted to be provided to people whose condition meets the legal threshold (adult, terminally ill, competent and considered to have less than 6 months to live). No-one who does not meet these conditions will be able to 'demand' medication to allow them to die unless the law was changed further.

And there is another element - perhaps somewhat subtle. This is that the person themselves must administer the drugs - no-one else can do so as far as I understand the proposed law. So the medical involvement is not to administer lethal drugs, but to make those drugs legally available to a person to allow them to administer them themselves.

But back to coercion - the DNR situation is a good analogy - individuals with competence make the decision to DNR regularly and having done so if they have a cardiac arrest they will die but could live with CPR. That decision could, of course, be subject to coercion by family members etc. However the medical profession seem to have the experience and professionalism to be able to assure themselves that consent to DNR is valid and not subject to coercion. If they can do so in that case (and refusal of blood transfusion etc) I don't see why they wouldn't be able to do so in the case of a request for assisted dying. In fact in the latter case there is an additional 'safeguard' in that the person themselves has to administer the lethal medication so have the option to effectively say 'do you know what, I know I said I wanted to die, but actually I don't'. In the case of DNR there is no 'safeguard' at the point where they need the CPR they will often be unconscious and in no position to reverse their decision not to be resuscitated.

[Nearly Sane]

But I don't think this is a case of 'demand' either. In the case of standard medical treatment a competent patient may refuse any treatment, including life saving treatment. They cannot demand treatment unless there is a clinical justification for it to be offered. Nor can they demand treatment free on the NHS which has not been approved to be provided by the NHS (and also where there is a clinical justification for it to be offered). And that will apply both to 'curative' treatment but also palliative treatment based on relieving symptoms only.

In the case of prescription of drugs for assisted dying, these would only be permitted to be provided to people whose condition meets the legal threshold (adult, terminally ill, competent and considered to have less than 6 months to live). No-one who does not meet these conditions will be able to 'demand' medication to allow them to die unless the law was changed further.

And there is another element - perhaps somewhat subtle. This is that the person themselves must administer the drugs - no-one else can do so as far as I understand the proposed law. So the medical involvement is not to administer lethal drugs, but to make those drugs available to a person to allow them to administer them themselves.

But back to coercion - the DNR situation is a good analogy - individuals with competence make the decision to DNR regularly and having done so if they have a cardiac arrest they will die but could live with CPR. That decision could, of course, be subject to coercion by family members etc. However the medical profession seem to have the experience and professionalism to be able to assure themselves that consent to DNR is valid and not subject to coercion. If they can do so in that case (and refusal of blood transfusion etc) I don't see why they wouldn't be able to do so in the case of a request for assisted dying. In fact in the latter case there is an additional 'safeguard' in that the person themselves has to administer the lethal medication so have the option to effectively say 'do you know what, I know I said I wanted to die, but actually I don't'. In the case of DNR there is no 'safeguard' at the point where they need the CPR they will often be unconscious and in no position to reverse their decision not to be resuscitated.

Demand may well be the wrong word but the point is thar it's perfectly easy to see a principle of bodily autonomy and being able to refuse treatment, as different from something is about asking for treatment.

[ProfessorDavey]

I work, currently, in the education sector, where child safeguarding is THE priority - we are not just entrusted with monitoring children for signs and evidence of coercion in various areas, but are legally mandated to do it. To suggest that healthcare professionals would be somehow incapable of operating similar standards, as though they aren't doing exactly that in innumerable areas already, is insulting.

O.

Absolutely correct. And this is the case too in the medical profession where consent is the absolute cornerstone of ethical practice. And for consent to be valid three elements are needed - the person must have the capacity to consent, they must receive sufficient information on which to base their decision, and crucially the decision must be their own free choice, without pressure or coercion. Medical professionals are 'consenting' (hate that term, but it is often used) patients all the time and therefore are constantly needing to consider whether there is any coercion being applied. Indeed one thing medical professionals need to consider is the 'power relationship' which means that the pressure could actually come from the doctor or other medical professional themselves. But they will also be alert to external pressures from family etc.

Now, of course, the care with which professionals will address coercion will be dependent on the significance of the decision. But for a major decision with far reaching ramifications (e.g. refusal of life sustaining treatment, major surgery, DNR etc) they will be very careful to ensure that the decisions are not subject to pressure or coercion as this would mean consent was not valid.

So medical professionals are highly trained in this area so to suggest that the issue of coercion is somehow new and unique to assisted dying and not something they deal with day in, day out is both flat out wrong and also rather insulting to the level of professionalism of our medical staff.

[ProfessorDavey]

Demand may well be the wrong word but the point is thar it's perfectly easy to see a principle of bodily autonomy and being able to refuse treatment, as different from something is about asking for treatment.

OK I get what you are saying, but if the law were changed prescriptions of drugs for assisted dying would be something that people, provided they meet certain criteria, would be able to request. There would, of course, be no obligation on them to request the drugs nor any obligation on an individual to take those drugs if prescribed. That doesn't seem different to other circumstances where consent requires that medical staff inform the patient of the various options available to them, but it is for the patient themselves to determine which of those options they wish to choose. A change in the law would add an additional option to the end of life choices that are available.

[Nearly Sane]

OK I get what you are saying, but if the law were changed prescriptions of drugs for assisted dying would be something that people, provided they meet certain criteria, would be able to request. There would, of course, be no obligation on them to request the drugs nor any obligation on an individual to take those drugs if prescribed. That doesn't seem different to other circumstances where consent requires that medical staff inform the patient of the various options available to them, but it is for the patient themselves to determine which of those options they wish to choose. A change in the law would add an additional option to the end of life choices that are available.

I think there is a difference between accessing treatment and refusing it. It's only a very small point in the argument, and I don't think it affects the rights and wrongs about assisted dying, rather it's a point about the arguments.
Even if I were to think that Steve and my original point were right, it's really of intellectual interest only.

[Nearly Sane]

Absolutely correct. And this is the case too in the medical profession where consent is the absolute cornerstone of ethical practice. And for consent to be valid three elements are needed - the person must have the capacity to consent, they must receive sufficient information on which to base their decision, and crucially the decision must be their own free choice, without pressure or coercion. Medical professionals are 'consenting' (hate that term, but it is often used) patients all the time and therefore are constantly needing to consider whether there is any coercion being applied. Indeed one thing medical professionals need to consider is the 'power relationship' which means that the pressure could actually come from the doctor or other medical professional themselves. But they will also be alert to external pressures from family etc.

Now, of course, the care with which professionals will address coercion will be dependent on the significance of the decision. But for a major decision with far reaching ramifications (e.g. refusal of life sustaining treatment, major surgery, DNR etc) they will be very careful to ensure that the decisions are not subject to pressure or coercion as this would mean consent was not valid.

So medical professionals are highly trained in this area so to suggest that the issue of coercion is somehow new and unique to assisted dying and not something they deal with day in, day out is both flat out wrong and also rather insulting to the level of professionalism of our medical staff.

Surely though if the Health Service is 'broken' as declared by the Health Secretary, a question about safe guards is not an insult to anyone but legitimised the possibility of inadequacies in training, time available, consistency of care?

[ProfessorDavey]

I think there is a difference between accessing treatment and refusing it. It's only a very small point in the argument, and I don't think it affects the rights and wrongs about assisted dying, rather it's a point about the arguments.

Sure, there is definitely a difference between accessing treatment and refusing it - for a competent person the latter is an absolute right, the former is a limited right, limited by the law and the treatment being one of an accepted set of options for the individual's clinical condition. If assisted dying were made legal it would be added to the range of other options (which currently may include further active disease treatment and palliative care) for a competent adult with a terminal illness and less than 6 months life prognosis.

But for a person with those features I don't see why it should be, or would be, any less limited as an option and a right compared to the other options. I don't think you would be expected to, or should be expected to, demonstrate that you have exhausted other options, just as someone currently doesn't need to demonstrate that they have exhausted active disease treatment options before being able to access palliative care. If a competent individual determines that they do not wish to continue to pursue active disease treatment for whatever reason then their decision is respected. That should be the case too for assisted dying. Within the limits of the law (competent adult with a terminal illness and less than 6 months life prognosis) then they should be able to choose not to continue active disease treatment and/or palliative care and should be able to consent to assisted dying and have their decision respected.

Another point - my understanding from other jurisdictions, e.g. Oregon, is that we aren't in the world of palliative vs assisted dying as an either/or choice. Rather most people will move through each stage - so those that ultimately opt for assisted dying will have spent months on palliative case before finally opting for assisted dying when the palliative care no longer works for them. There is often a focus on pain, but actually autonomy, being able to make decisions for yourself and being able to have some kind of quality of life I think are just as important. The challenge for palliative care (even the very best, and I've seen it) is that it trades off pain relief for loss of decision making and autonomy as the person becomes increasingly more sedated.

Certainly, from my perspective, and from watching both my parents and in-laws die I can understand how individuals may not wish to go through that very last stage, which often seems to be hugely distressing for the individual, but without any way in which their distress can be meaningfully managed. But that stage is often perhaps just a few days, maybe a week. So it may well be the case that assisted dying is commonly used in the last few days as a choice to remove that horrible end stage (it certainly seemed horrible for both my parents, who were being cared for in an award-winning palliative care setting), rather than in the last few months.

[ProfessorDavey]

Surely though if the Health Service is 'broken' as declared by the Health Secretary, a question about safe guards is not an insult to anyone but legitimised the possibility of inadequacies in training, time available, consistency of care?

But given that these issues would be just as significant for any major decision - e.g. to stop active disease care and to go onto palliative care, I'm not sure why this should only be an issue where the choice is about assisted dying.

But as mentioned in the post that crossed yours I do not accept that palliative care would be perfect but for lack of resources. I watched both my parents die in just about the most ideal palliative care setting - award-winning specialist facility but within a broader hospital care setting. I have no doubt they received the very best care possible and I don't think state-of-the-art palliative care has moved on since then. Yet the last few days of their lives were really pretty horrible and clearly distressing for them, but given the necessary levels of sedation needed to deal with their pain there was no way in which I, other family members, nor staff could really comfort or reassure. At times it seemed to me that my father was in an endless loop of horrible dreams, but there has no way I could gently wake him up or even reach him in any way. That, sadly, seems to be the reality for some people at the end of life even with the finest palliative care. But that period was for about 5 days before he died - up to then even though he was in severe pain, he was aware and able to interact and engage.

[Nearly Sane]

But given that these issues would be just as significant for any major decision - e.g. to stop active disease care and to go onto palliative care, I'm not sure why this should only be an issue where the choice is about assisted dying.

But as mentioned in the post that crossed yours I do not accept that palliative care would be perfect but for lack of resources. I watched both my parents die in just about the most ideal palliative care setting - award-winning specialist facility but within a broader hospital care setting. I have no doubt they received the very best care possible and I don't think state-of-the-art palliative care has moved on since then. Yet the last few days of their lives were really pretty horrible and clearly distressing for them, but given the necessary levels of sedation needed to deal with their pain there was no way in which I, other family members, nor staff could really comfort or reassure. At times it seemed to me that my father was in an endless loop of horrible dreams, but there has no way I could gently wake him up or even reach him in any way. That, sadly, seems to be the reality for some people at the end of life even with the finest palliative care. But that period was for about 5 days before he died - up to then even though he was in severe pain, he was aware and able to interact and engage.

The issue is  that you claimed that questioning about the care being offered, and in this case I was thinking  of the care in the case of any cases of assisted dying, was somehow insulting to the staff when there may be wider problems. We are not short of major failings in the health service - see the blood scandal, or Alder Hey, nor are we in other institutions, see Horizon, the CoE as two current ones. Asking about safeguards and training in this case is a safeguard not an insult.

[ProfessorDavey]

The issue is  that you claimed that questioning about the care being offered, and in this case I was thinking  of the care in the case of any cases of assisted dying, was somehow insulting to the staff when there may be wider problems. We are not short of major failings in the health service - see the blood scandal, or Alder Hey, nor are we in other institutions, see Horizon, the CoE as two current ones. Asking about safeguards and training in this case is a safeguard not an insult.

I think you are misinterpreting my point - I never implied that it was insulting to suggest that there are challenges facing the NHS.

Nope - when I mentioned insulting, I was specifically referring to those that seem to be implying that the issue of coercion as it applies to consent to medical decisions was somehow something that the medical profession did not currently deal with, but would have to address for the first time were assisted dying to be legalised. That is both wrong as considering coercion in consensual decision making is dealt with on a day to day basis by medical professionals who are required to be very clearly trained in that regard. Having to deal with this in a slightly different decision making context doesn't change the fact that these are issues medical staff already deal with day to day.

On the broader issue - surely that would apply just as much to any other major decision - e.g. refusal of life sustaining treatment, DNR etc etc, so again not new. But actually the bill has much greater safeguards than for other major decisions in that it requires two independent doctors to be involved and a legal decision. None of that applies to, for example, the situation where a patient decides no longer to pursue active disease treatment and go into palliative care, or to sign a DNR. That could be due to coercion, and the pressures of the NHS and/or in the major failings in the health service could play a part in that decision. Yet there are clearly less safeguards than proposed for a decision to choose assisted dying.

So perhaps you might want to argue that the same level of safeguards in the bill should apply to other very major decisions where the consequences are that life is shortened.

[Nearly Sane]

I think you are misinterpreting my point - I never implied that it was insulting to suggest that there are challenges facing the NHS.

Nope - when I mentioned insulting, I was specifically referring to those that seem to be implying that the issue of coercion as it applies to consent to medical decisions was somehow something that the medical profession did not currently deal with, but would have to address for the first time were assisted dying to be legalised. That is both wrong as considering coercion in consensual decision making is dealt with on a day to day basis by medical professionals who are required to be very clearly trained in that regard. Having to deal with this in a slightly different decision making context doesn't change the fact that these are issues medical staff already deal with day to day.

On the broader issue - surely that would apply just as much to any other major decision - e.g. refusal of life sustaining treatment, DNR etc etc, so again not new. But actually the bill has much greater safeguards than for other major decisions in that it requires two independent doctors to be involved and a legal decision. None of that applies to, for example, the situation where a patient decides no longer to pursue active disease treatment and go into palliative care, or to sign a DNR. That could be due to coercion, and the pressures of the NHS and/or in the major failings in the health service could play a part in that decision. Yet there are clearly less safeguards than proposed for a decision to choose assisted dying.

So perhaps you might want to argue that the same level of safeguards in the bill should apply to other very major decisions where the consequences are that life is shortened.

Sorry, but I think this makes no sense. The question surely is whether the safeguarding is adequate ti allow this, and that there may be times when similar safeguarding is currently required doesn't mean that it is adequate for that. If the Health Service is broken as Streetibh claims, then maybe the question is whether the decisions currently being taken are adequate.

Any attempt at shutting down questioning on the adequacy by saying it's insulting just seems to be an attempt to shut down debate in a way that has been done to many times in too many places in our recent history.

[ProfessorDavey]

Any attempt at shutting down questioning on the adequacy by saying it's insulting just seems to be an attempt to shut down debate in a way that has been done to many times in too many places in our recent history.

But that isn't what I'm doing as my comment on 'insulting' was specifically about the implication from some that having to consider the possibility of coercion in consent in medical decision-making was something alien to the medical profession and something that they'd have to deal with for the first time if assisted dying were legalised.

[ProfessorDavey]

Sorry, but I think this makes no sense. The question surely is whether the safeguarding is adequate ti allow this, and that there may be times when similar safeguarding is currently required doesn't mean that it is adequate for that. If the Health Service is broken as Streetibh claims, then maybe the question is whether the decisions currently being taken are adequate.

But surely the whole notion of safeguards is to prevent people in a vulnerable state (in this case those at the end of life) from being forced into a choose that they do not want. So where are the safeguards (not just inadequate ones) for those who at the end of life do no want to endure weeks, or perhaps even just days, of highly medicalised palliative care beyond the point where they can make any decisions, but would prefer to die. Which, of course they could do if their condition required treatment to remain alive (as they could refuse treatment). From what I can see there aren't any - they have no option but to follow an option that they desperately don't want.

So absolutely - we must have the safeguards to protect those that do not want to choose assisted dying but want the current palliative care option at the end of life. But why are those who desperately do not want that for them at the end of life but would prefer to die at a time of their choice when they can make that decision for themselves not deserving of similar safeguards which would the choice to decide to choose assisted dying. To my mind both groups of people are not just equally vulnerable but also equally deserving of safeguards to protect their interests, which ultimately must be about the right for them to make their own choice about end of life.

So actually one of the best safeguards we can have is the option to choose the right course for each individual person who is terminally ill.

[Nearly Sane]

But that isn't what I'm doing as my comment on 'insulting' was specifically about the implication from some that having to consider the possibility of coercion in consent in medical decision-making was something alien to the medical profession and something that they'd have to deal with for the first time if assisted dying were legalised.

Given the stakes who cares? The question was to one of the MPs helping to sponsor the bill and was about whether the safeguards are adequate for the bill. They were unable to answer, and that there might be consideration doesn't mean it's adequate, especially given that the health service is 'broken'. That you have taken umbrage on behalf of some people on that seems to me entirely your problem  and irrelevant to the bill.

[Nearly Sane]

But surely the whole notion of safeguards is to prevent people in a vulnerable state (in this case those at the end of life) from being forced into a choose that they do not want. So where are the safeguards (not just inadequate ones) for those who at the end of life do no want to endure weeks, or perhaps even just days, of highly medicalised palliative care beyond the point where they can make any decisions, but would prefer to die. Which, of course they could do if their condition required treatment to remain alive (as they could refuse treatment). From what I can see there aren't any - they have no option but to follow an option that they desperately don't want.

So absolutely - we must have the safeguards to protect those that do not want to choose assisted dying but want the current palliative care option at the end of life. But why are those who desperately do not want that for them at the end of life but would prefer to die at a time of their choice when they can make that decision for themselves not deserving of similar safeguards which would the choice to decide to choose assisted dying. To my mind both groups of people are not just equally vulnerable but also equally deserving of safeguards to protect their interests, which ultimately must be about the right for them to make their own choice about end of life.

So actually one of the best safeguards we can have is the option to choose the right course for each individual person who is terminally ill.

And if in doing that you don't ensure adequate safeguards for those decisions, and it is surely questionable if that can be achieved in a 'broken' health service, then you aren't doing enough by your own standards to achieve that.

[ProfessorDavey]

And if in doing that you don't ensure adequate safeguards for those decisions, and it is surely questionable if that can be achieved in a 'broken' health service, then you aren't doing enough by your own standards to achieve that.

Do you think there should be safeguards for those people who desperately do not want to end their lives with highly medicalised palliative care beyond the point where they can make any decisions, but would prefer to die at a time of their choice when they can make that decision?

And that will include people who would still want the same even is they had access to the very best palliative care that is possible. Currently those people appear to have zero safeguards as they are simply refused the option they desperately want (or perhaps better put desperately want to have available to them).

[Nearly Sane]

Do you think there should be safeguards for those people who desperately do not want to end their lives with highly medicalised palliative care beyond the point where they can make any decisions, but would prefer to die at a time of their choice when they can make that decision?

And that will include people who would still want the same even is they had access to the very best palliative care that is possible. Currently those people appear to have zero safeguards as they are simply refused the option they desperately want.

I think for it to be a choice it needs safeguards around it. I think calling it a 'safeguard' in this context is a category error.

[ProfessorDavey]

I think for it to be a choice it needs safeguards around it. I think calling it a 'safeguard' in this context is a category error.

Surely a safeguard is something that ensures that a person isn't forced to make a choice they really don't want to. The unavailable of an alternative option is surely the most obvious lack of safeguards as it effectively gives a person only one option, even if that is something they really, really don't want.

I, of course, agree that no-one should be forced to end their life through assisted dying if that isn't what they want. But surely we should equally want to ensure that no-one should be forced to end their life with highly medicalised palliative care beyond the point where they can make any decisions if that isn't what they want.

[Nearly Sane]

Surely a safeguard is something that ensures that a person isn't forced to make a choice they really don't want to. The unavailable of an alternative option is surely the most obvious lack of safeguards as it effectively gives a person only one option, even if that is something they really, really don't want.

I, of course, agree that no-one should be forced to end their life through assisted dying if that isn't what they want. But surely we should equally want to ensure that no-one should be forced to end their life with highly medicalised palliative care beyond the point where they can make any decisions if that isn't what they want.

No, I think that a safeguard is a thing surrounding choices, and certainly contextually that is what is covered here. You used it in that sense for the majority of the discussion, and then have pivoted to thos. I don't think it makes sense in the context.