Disposable people?

In 2008 an insurance company of a 64-year-old woman with lung cancer refused to pay $4,000 a month for chemotherapy but offered instead to pay the $50 charge for drugs for physician assisted suicide. This was just an extreme example of the kinds of unintended consequences which can flow from legislation like Oregon’s Death with Dignity law.

This was the central point of a fascinating talk by Professor BroDr Browne Lewiswne Lewis, currently in the UK under the Fulbright Scholarship programme, who was speaking at a Gresham College lecture in London on Monday.

After giving a quick history of euthanasia in the US she explained that subtle changes in terminology as well as other details played a key part in getting assisted death on to the statute books of some states. Groups in favour choose to describe euthanasia as “physician aided death” while opponents call it “physician facilitated suicide”.

Dr Lewis herself has settled on the term “physician assisted suicide” (PAS) because she points out the physician does not actively “facilitate” the process of dying but does assist it by supplying the drugs. And, as the patient is the one dying ultimately by their own hand (a key provision of the law) this is by definition suicide.

Oregon was the first state to pass legislation legalising PAS in a people’s ballot measure in 1994 and it was on this law that Dr Lewis focussed. The key provisions of the Oregon law were that the law permits PAS if the subject is:

  • Capable
  • Adult
  • Resident
  • Diagnosed with terminal disease (six months or less to live)
  • Making an informed decision
  • Making the request for the prescription in writing…
  • …which is objectively the same handwriting as usual
  • Gets a second opinion
  • And waits for the 15-day waiting period

There are several groups included, but without specific protections, and several groups explicitly excluded.

Included but not protected are the:

  • Elderly
  • Disabled
  • Mentally ill
  • People of low income
  • People of colour

Excluded from the provisions are:

  • Under 18s
  • Persons predicted to live more than 6 months
  • Those suffering from dementia

These provisions throw up some series ethical concerns, argues Dr Lewis.

In the case of the elderly, for example, there is evidence of some old people feeling they almost have a “duty to die” she says. Also they are clearly potentially vulnerable to pressure from relatives, particularly those for example doing the bulk of the caring or who stand to benefit from any inheritance.

In the case of the physically disabled similar concerns raise their heads, in addition to concerns about pressures driven by economic factors: doctors and insurance companies could encourage PAS because of the considerable costs of long term care.

With those of low income this worry is more concrete as the case at the very beginning of this post illustrates. Before PAS was legal the most cost-effective option choice for lung cancer treatment was chemotherapy and the insurer therefore offered to fund it. After PAS was legalised in Oregon there was a cheaper option – the $50 lethal drugs. The poor may find themselves with no options, she argues.

With persons of colour, Dr Lewis says, the worry is that there is considerable evidence that they are not getting appropriate treatment in general at the moment, so if we can’t even ensure this, she argues, then how can we be sure they won’t be encouraged to “self-terminate”.

Another key problem with the Oregon legislation is that, although there is a requirement to seek a second opinion, there is no limit to the number of doctors you can ask. This leads to “doctor shopping” which reduces the protections in the face of the pressures listed above. Dr Lewis says there have been many deaths where the doctor signing off PAS was not the first consulted.

There are other concerns, too. Why six months? What if you are given 12 months but by 6 months your condition will have deteriorated to the extent that you fail the test for informed decision-making or applying in writing?

Also, what about non-terminal cases such as a person suffering from progressive irreversible brain disorder who is not predicted to physically die? Should they not have the same options?

And what about the under-18s. Psychiatrists have argued that a terminally ill 17-year-old is psychologically older than their compatriots.

With this list of reservations you might think Dr Lewis was against the law. In fact she supports it – it’s just that she thinks it’s provisions and safeguards should be tightened up.

She says, as Oregon was the first the enact the legislation the State is very much sought after as a blue print but that because of this there is resistance to making changes which could improve safeguards considerably.

For example, doctor shopping could be protected against if, when one doctor says yes and one says no there was an independent board to adjudicate.  She believes the terminality threshold should be updated, too. “I don’t think there is anything magic about six months.”


Lessons from Save the Children

Justin Forsyth

In an engaging and powerful talk on Tuesday at the RSA out-going Save the Children Chief Executive Justin Forsyth shared five lessons he says he has learned in his time at the charity.

1. Build powerful platforms not powerful organisations. Charities can no longer do everything alone and teaming up with other charities to build platforms is now essential. He gave the example of the Humanitarian Leadership Academy which describes itself like this: “We will work together across the humanitarian sector to ensure that information, knowledge, learning and resources are shared to make us all more efficient in this time of growing pressure.”

2. Unexpected allies are more powerful than usual suspects. He cites the unlikely alliance of Bono and President Bush in the very effective campaign to tackle the HIV crisis in the developing world.

3. It is as important to have an exceptional team as an exceptional idea. This, he says, is “very important for sustaining good work.” Charities, in particular, he says, “can forget to focus internally”. This was especially critical for building sustainability, he said.

4. The power of the mass rather than elite. The unexpected success of the G8 Summit in Gleneagles in 2005 was made possible because of the Live 8 movement which was going on at the same time, he believes. Engaging the power of the masses “gives us permission to be edgy”.

5. Who you are should determine what you do, not the other way round. This means charities should always be true to their founding principles, he says. “If you don’t you don’t look authentic and you weaken your mandate.”

Aside from these five insights, Forsyth also had more to say on a range of topics in response to questions. Here are a selection:

“The biggest weakness of any organisation is self-righteousness, and charities too prone to this.”

“There is real power in riding waves rather than planning campaigns. The modern media environment can change the conversation across the world.” Examples he cited were the outcry following a rape in Delhi and the seismic response to pictures of three-year-old Aylan Kurdi lying drowned on a Turkish beach, both of which had dramatic political consequences.

There was a need to “move the debate on from the CEO’s salary and admin costs to measuring the real impact we have in the world.”

“Engagement gets left behind in the drive to raise money,” he said, and “fundraising can become industrialised”. He argues that charities haven’t changed the “very old fashioned” way they raise funds. He doesn’t believe the “market” is saturated. “We can raise much more if we engage better with people, particularly through the use of digital technologies.”

Forsyth takes up a new post of deputy executive director of UNICEF next month.


How to have a good day


How do you have a good day? Caroline Webb thinks she knows and has written a book to explain her theories. Webb, previously a consultant with McKinsey and now running her own consultancy, laid out some of the foundation ideas in a talk at the RSA on Thursday.

She calls her philosophy “realistic optimism” and says it is based on general insights from behavioural science and aims to look for “wiggle room” within the constraints we all face.

Her talk focussed on three themes – bending reality, stretching time and growing intelligence.


She illustrated what she meant by bending reality with a story. When she was working for McKinsey she was asked to join a project involving a large-scale corporate change program. This was exactly the kind of project she was least keen on doing. In addition, the kick off meeting turned out to be by video conference, a medium which she always found difficult, frustrating and prone to misunderstandings.

A colleague turned up for the meeting who she called, pseudonymously, Lucas: a young, tall, well-dressed and very enthusiastic German. As she sat in a foul mood, with the meeting confirming all her worst fears, Lucas was powering through deck with undimmed enthusiasm.

After the meeting was over she sat down with Lucas to discuss what a disaster the meeting had been, only to find he was incredulous. He was convinced that the meeting went very well. When he recounted the evidence she was amazed to find so much that was positive.

This led her to the first insight – the brain sees what it expects to see. The conscious brain can only process a fraction of the stimulus it receives, she says, so the sub-conscious brain provided and edited version. The sub-conscious uses cues such as what is currently top of mind to set that filter. This is what is behind the phenomenon of confirmation bias, she says.

So, she reasoned, if you are deliberate about what is top of mind, what your mood is, then you can determine what gets filtered in. This, she now says, she always does, with dramatic results.


Of course you can’t really stretch time, she says, unless you park yourself at the edge of a Black Hole (and that has all sorts of complications attached to it!). However, she argues, the conscious brain can only do one thing at a time with any degree of facility. She illustrated by getting the audience to count to seven really fast – no problem. Then she asked us to recite the letters ‘a’ to ‘g’ as quickly as possible. Again, no problem. Then she asked us to combine the two – ‘a1’, ‘b2’ etc. Disaster.  “Multitasking loses mental energy,” she said. It is slower and more error prone. So, she reasons, do one thing at a time and you can make the day go further.


The final example was increasing intelligence. Again, a bit of a cheat – “you can’t really increase your basic intelligence” she admits. However, intelligence degrades markedly with stress. This is because, she says, when faced with danger the body is evolutionarily adapted to adopt a “flight or fight” response which results in the automatic part of the brain taking over and putting much less energy into the conscious brain.

It isn’t just the sudden appearance of a sabre-toothed tiger which triggers this response – “it takes almost nothing to trigger this response,” she says.

Again, she illustrated this point with another story from her days at McKinsey. She enrolled on a coaching course and found that she absolutely loved it. She wanted to build a career around coaching but was convinced that there would be no role within McKinsey (a place she loved) where she could do this. As a consequence she because badly conflicted – follow her dream and leave, don’t and stay. She could see no way out.

However, as part of the course the participants were encouraged to practice coaching techniques on each other so she did just this with her seemingly intractable problem. “Jill”, the colleague she was doing the exercise with, asked Webb to visualise the ideal situation – which was clearly continuing to work at McKinsey, but as a coach. She realised she had shut this option off completely because she had already convinced herself it was a non-starter and the flight-or-fight reflex had kicked it.

So her solution these days is – visualise the optimum outcome before coming to any conclusions. This puts your brain in “discovery mode”. You can then use all of your conscious intelligence on ways to make that outcome a reality.

“I’d say doing these three things was a pretty good recipe for a good day,” she said.