Influence doesn't have to speak

Something caught my attention while looking at how other countries deal with assisted dying.

In a Dutch euthanasia case, an independent doctor was brought in to assess a woman with dementia.

Her treating doctor stayed in the room.

He didn’t interrupt the conversation. He didn’t tell her what to say. He apparently didn’t say anything at all.

But the Dutch review committee still found a problem.

The woman looked towards her treating doctor several times during the conversation. The committee recognised that influence can be non-verbal and that his presence alone could have affected her ability to speak freely.

The independent assessment was therefore not sufficiently independent.

That immediately made me think beyond assisted dying.

Because influence doesn’t have to speak.

The person sitting in the room

Think about someone making a will.

A person who stands to benefit from that will might sit quietly while instructions are discussed.

They don’t have to say:

“Leave the house to me.”

They might not say anything.

But what if the person making the will has spent months or years being controlled by them?

What if they depend upon them for care?

What if they’ve learned that disagreement brings consequences?

What if they’ve repeatedly been told that other family members don’t care about them?

What if they know exactly what will happen when they get home if they say something the other person doesn’t like?

What if they’re simply looking towards that person for reassurance before answering?

The presence of the potential beneficiary doesn’t prove undue influence.

It certainly doesn’t automatically invalidate a will.

But from a safeguarding perspective, it should make us ask whether the person’s wishes have been established independently.

Now put an abuser in the room

This becomes even more important when we understand coercive control.

People sometimes imagine coercion as:

“Do this or else.”

Sometimes it is.

But coercive control can work very differently.

After months or years of control, the perpetrator may no longer need to issue the instruction.

The victim already knows the rules.

They know what causes anger.

They know which answers are acceptable.

They know what they’re allowed to spend.

They know who they’re allowed to speak to.

They know what happens when they disagree.

They may have been criticised, monitored, isolated or made to doubt their own judgment for so long that they start looking to the perpetrator for reassurance before making decisions.

Eventually, some of that control can become internalised.

The perpetrator doesn’t have to say:

“Don’t tell the doctor.”

Their presence may be enough.

But the perpetrator doesn’t even need to be in the room

This is where modern coercive control becomes much more complicated.

A private conversation isn’t necessarily private simply because nobody else is physically present.

A victim may know that:

• their phone is monitored
• their messages are checked
• their location is tracked
• their passwords are known
• conversations are routinely recorded
• cameras or smart devices are used around the home
• their online accounts are controlled
• somebody impersonates them digitally
• emails or messages are written for them
• they will be questioned afterwards about what they said
• somebody is waiting outside
• refusing to give an account afterwards will itself have consequences

So asking the alleged perpetrator to leave the consultation room may only remove the visible part of the control.

The victim may still behave as though that person is sitting beside them.

That’s why safeguarding needs to understand coercive control rather than simply create a checklist.

Recording can become control

Recordings can protect people.

They can preserve evidence, prevent misunderstandings and provide an accurate account of what was said.

They can also be used as part of control.

A victim who knows conversations are routinely recorded may begin policing their own speech.

They may say only what they know is safe to say.

An abuser may selectively retain recordings that support their account while other interactions remain unseen.

Short clips may be presented without the events before or after them.

A recording therefore needs context just like any other evidence.

The fact that somebody sounds calm, agreeable or even affectionate towards an alleged abuser doesn’t tell us what happens outside that recording.

Digital manipulation changes the picture again

Communication itself can be controlled.

Messages apparently sent by the vulnerable person may have been:

• dictated
• drafted by somebody else
• edited
• sent from a device another person controls
• produced while somebody is watching
• selectively deleted
• taken out of context

This matters enormously where professionals begin relying upon WhatsApp messages, emails, video calls or electronic consent as evidence of somebody’s wishes.

Digital evidence can be extremely valuable.

But a message coming from someone’s phone isn’t necessarily the same as a message being independently expressed by that person.

Where concerns exist, communication may need to be independently verified.

Medication creates another route to dependency and control

Then there is medication.

Many seriously ill, elderly or disabled people legitimately take several medications.

Polypharmacy isn’t evidence of abuse.

Pain relief, sedation and other medication can be absolutely essential to humane care.

But safeguarding has to recognise the other side of the equation too.

Some medicines, combinations of medicines or changes in dosage may affect:

• alertness
• memory
• concentration
• confidence
• communication
• confusion
• inhibition
• fatigue
• ability to sustain a conversation

Those effects vary enormously between individuals.

The answer isn’t to second-guess legitimate prescribing.

It is to understand the person’s medication environment when assessing an irreversible decision.

And who controls the medication?

This is where medication and coercive control can intersect.

Who orders it?

Who collects it?

Who stores it?

Who administers it?

Who decides when the person needs an “as required” medication?

Who speaks to the doctor about its effects?

Who reports whether the person is confused, distressed or in pain?

Can the individual access their own medication?

Can they refuse it?

Has the dose recently changed?

Does their alertness change depending upon who is caring for them?

Those questions don’t accuse the carer.

Most carers are doing extraordinarily difficult work properly and lovingly.

But dependency upon another person for medication creates power.

Where other safeguarding indicators are present, that power may become relevant.

Medication can also be used as a form of control

Medication can itself be weaponised.

A perpetrator may deliberately over-medicate somebody, withhold medication, interfere with treatment or exploit side effects to increase dependency or reduce resistance.

Someone may be kept excessively sleepy or confused.

Medication may be given differently depending upon who is present.

Essential treatment might be withheld.

Or somebody else may take control of conversations with clinicians and become the main source of information about the person’s symptoms and behaviour.

None of this means that sedation, strong pain relief or multiple medications are evidence of abuse.

They aren’t.

The safeguarding concern arises when medication sits within a wider pattern of control, unexplained changes or inconsistent accounts.

And the direction of influence matters too.

Abuse isn’t necessarily aimed at hastening somebody’s death.

Someone may have an interest in keeping another person alive.

There may be access to pensions, property, accounts, benefits, business assets or an anticipated change to a will.

Control can operate in either direction.

“She agreed”

Agreement isn’t always the end of the enquiry either.

A victim of coercive control may agree because agreement has become their safest response.

They may have spent years learning that resistance produces consequences and compliance produces peace.

That can become so ingrained that the person appears cooperative even when the controlling person isn’t present.

This is one reason coercive control is so easily missed.

The professional sees a decision.

They don’t see the history that produced it.

Then there is dependency

Serious illness can change the balance of a relationship very quickly.

Someone who previously managed their own:

• money
• medication
• appointments
• telephone
• transport
• food
• personal care
• correspondence

may suddenly depend upon another person for all of them.

That doesn’t make the carer abusive.

But it creates opportunities for control that didn’t previously exist.

And where a controlling relationship already existed, illness can intensify it enormously.

The person who controlled the bank account may now control the medication.

The person who isolated them from family may now control who visits.

The person who answered their messages may now speak to doctors for them.

The person who previously undermined their confidence may now be the person upon whom they depend to get out of bed.

That is why serious illness can alter safeguarding risk without changing capacity.

Reassurance can tell us something too

Some victims become accustomed to checking everything with the controlling person.

They look towards them before answering.

They ask:

“Is that right?”

“Was that when it happened?”

“What do you think?”

“That’s what we agreed, isn’t it?”

Sometimes that’s completely ordinary behaviour between people who know each other well.

But in the presence of other indicators it can mean something different.

The question isn’t whether somebody sought reassurance once.

It’s whether there is a pattern showing that their confidence in their own voice has been diminished.

And some victims know exactly what they’re doing

We mustn’t assume every victim has internalised the control.

Some know perfectly well that they’re being abused.

They simply cannot safely say so.

They may know that disclosure means:

• retaliation
• abandonment
• loss of care
• homelessness
• financial consequences
• threats to family
• removal of access to children
• humiliation
• violence
• punishment when they return home

So they deny the abuse.

They may defend the perpetrator.

They may ask for them to remain in the room.

They may become distressed when professionals try to separate them.

That doesn’t automatically prove coercion either.

But neither does their apparent support for the alleged perpetrator prove that they’re safe.

Anyone can be the source of influence

We also need to stop limiting our imagination about perpetrators.

A perpetrator can be:

• a partner
• spouse
• adult child
• sibling
• wider relative
• friend
• neighbour
• attorney
• carer
• paid care worker
• professional
• clinician

Professional status doesn’t remove the possibility of abuse.

Neither does being loving, helpful, respectable or apparently devoted.

Coercive control frequently operates through relationships that outsiders see as supportive.

That’s part of what makes it difficult to recognise.

Why this matters for wills

Will writing gives us a very easy way of understanding the principle.

Suppose an elderly woman changes a longstanding will substantially in favour of the daughter who now cares for her.

The daughter brought her to the appointment.

The daughter explains what Mum wants.

The daughter has the paperwork.

The daughter answers some of the questions.

The daughter sits beside Mum while instructions are taken.

Mum agrees with everything.

None of those facts, alone or together, automatically proves undue influence.

The new will may reflect exactly what Mum genuinely wants.

But how do we know?

The obvious safeguard is beautifully simple:

Speak to Mum alone.

Ask her what she wants.

Ask her why.

Let her disagree.

Let her change something.

Let her say something she wouldn’t say with her daughter sitting beside her.

Then listen to whether the account remains her own.

Private conversation doesn’t prove the absence of coercion either.

But without it, we’ve thrown away one of our best opportunities to find out.

Now bring all of this back to assisted dying

This is precisely why the Isle of Man Codes of Practice matter.

Assisted dying doesn’t create coercive control.

It doesn’t create financial abuse.

It doesn’t create medication misuse.

It doesn’t create digital monitoring.

It doesn’t create dependency.

It doesn’t create carers who control communication.

It doesn’t create professionals who misuse authority.

These things already exist.

The implementation question is whether the assisted-dying system knows how to recognise them.

A safeguard that simply asks:

“Are you being pressured into this?”

isn’t enough.

A private interview alone isn’t enough.

A capacity assessment alone isn’t enough.

A signed form isn’t enough.

A message saying “this is what I want” isn’t necessarily enough.

No single safeguard is enough.

We need to understand the environment around the decision

Where indicators arise, the assessor may need to understand several different parts of the person’s life.

Relationships

Who does the person depend upon? Has that changed? Who speaks for them? Can they disagree safely?

Communication

Who controls the phone, email, passwords and appointments? Can communication be independently verified?

Medication

What is being taken? Has anything changed? Who administers it? Could alertness, cognition or communication be affected?

Money

Who controls the finances? Who benefits from death? Who benefits from continued life? Are there recent wills, gifts, transfers, powers of attorney or property changes?

Care

Who provides it? Can the person complain about that care safely? What would happen if that relationship broke down?

Digital environment

Could the person be monitored, recorded or tracked?

History

Is there previous domestic abuse, safeguarding concern, financial abuse, isolation or controlling behaviour?

Behaviour

Does the person communicate differently when somebody else is present?

Alternatives

Have they genuinely been offered assistance to continue living?

None of those factors proves coercion.

Together, they may tell us where to look.

This is why patterns matter

The dangerous mistake is examining each event separately.

A daughter manages Mum’s medication.

Fine.

She also handles the bank account.

Fine.

She answers Mum’s phone.

Fine.

Mum has stopped seeing another daughter.

There may be an explanation.

A new will has been made.

Perfectly lawful.

Mum now looks towards the daughter before answering questions.

Could mean nothing.

The daughter doesn’t want professionals speaking to Mum alone.

Now we need to stop looking at individual boxes.

What does the pattern show?

That is how coercive control is understood.

And that is how assisted-dying safeguarding needs to understand it too.

The Codes need to recognise passive influence

The Codes should expressly recognise that coercion and influence may operate through more than explicit threats or instructions.

Relevant indicators may include:

• established coercive-control patterns
• dependency
• controlled communication
• digital monitoring
• medication control
• financial control
• isolation
• fear of consequences
• rehearsed language
• apparent reliance upon another person for answers
• changes in behaviour when somebody enters or leaves
• reluctance to speak privately
• another person’s resistance to private assessment
• unexplained changes in wishes
• recent financial or legal changes
• burden-based language
• professional or institutional influence

Again:

Indicators don’t equal coercion.

Indicators equal enquiry.

And there is reassurance in getting this right

This isn’t about frightening vulnerable people away from assisted dying.

It’s actually the opposite.

Someone who has experienced coercive control should be able to know:

You don’t have to prove you’re being abused before we’ll listen.

You can speak without the person you depend upon being present.

You can change your mind.

You can tell us something different tomorrow.

We understand that you may be frightened to disclose abuse.

We understand that you may still love or defend the person controlling you.

We understand that coercion doesn’t always look like coercion.

And most importantly:

The presence of vulnerability doesn’t mean we’ll take your choice away from you. It means we’ll work harder to make sure the choice really is yours.

That’s what good safeguarding should do.

The Dutch got something very right

What impressed me about the Dutch case wasn’t simply that something went wrong.

It was that their review system spotted why it mattered.

The treating doctor hadn’t spoken.

There was no finding that he deliberately coerced the patient.

The committee didn’t need to invent wrongdoing.

It recognised something much simpler:

His presence could have influenced her.

And because the purpose of that particular conversation was independent assessment, that possibility mattered.

That’s sophisticated safeguarding.

We should learn from it.

Because whether we’re talking about assisted dying, wills, powers of attorney, medical decisions, financial abuse, caring relationships or domestic abuse, sometimes the most important person in the room is the one who hasn’t said a word.

Influence doesn’t have to speak.

Fear doesn’t have to speak.

And coercive control doesn’t disappear just because the perpetrator is silent.

Sometimes the control has already done its work.

That’s exactly why the Isle of Man Codes of Practice need to know what they’re looking for.