More MS news articles for April 2002

Legalising active euthanasia and physician assisted suicide

http://bmj.com/cgi/content/full/324/7341/846

Assisted suicide is not always as easy as suggested
People's autonomy is not absolute
Seeking this presumed moral good is immoral
Strong evidence base must be adduced for euthanasia
Patients need medical help to live with dignity until they die naturally
Denying people voluntary euthanasia causes unnecessary suffering
Summary of responses

Assisted suicide is not always as easy as suggested

EDITOR - Doyal and Doyal argue that there is no difference between assisted suicide, as requested by Diane Pretty, and the withdrawal of life sustaining treatment.1 However, there are many complex issues to be considered.

Firstly, how patients come to make an informed autonomous decision must be considered. Many patients with motor neurone disease fear a distressing death, but several studies have shown that this is rare, particularly with good palliative care.2 Moreover, assisted suicide is not always as easy and peaceful as is often suggested: a Dutch study reported complications, such as nausea and vomiting, in 7% of cases, and problems of completion, with longer times to death than expected, in 15%; doctors intervened and performed euthanasia for 18%.3 A decision for assisted suicide can be made clearly and autonomously only if such issues have been fully discussed.

Secondly, the reasons why people ask that their lives should be ended prematurely must be considered. One study suggested that in 80% of cases the reason is fear of the future (either of a distressing death or of being kept alive), and depression may be responsible for 14% of cases.4 These issues need to be addressed, particularly for a person with motor neurone disease who may have read of the possibility of a distressing death, often from the discussion of cases such as that of Mrs Pretty in the media.

The effects on all involvedthe family and close carers, the health and social care professionals, and society itselfmust also be considered. Many families find the discussion of assisted suicide difficult, and if complications occur then the memories are far from positive, with family members left with longlasting questions. Many professionals find it difficult to assist in the death of a patient, and one study showed that 24% of the doctors who had been involved in a case of assisted suicide regretted their decision.5 These professionals may be left with many questions about their actions.

There is a distinction between the taking of life and the withdrawal of inappropriate treatment to allow life to take its natural course and death to occur. Legalising physician assisted suicide would carry a high risk of undermining the care of all dying patients.

David Oliver, medical director.

Jackie Fisher, consultant physician.
Wisdom Hospice, Rochester, Kent ME1 2NU

1.  Doyal L, Doyal L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001; 323: 1079-1080 [Full Text]. (10 November.)
2.  Neudert C, Oliver D, Wasner M, Borasio GD. The course of the terminal phase in patients with amyotrophic lateral sclerosis. J Neurol 2001; 248: 612-616 [Medline].
3.  Groenewoud JH, van der Heide A, Onwuteaku-Philipsen BD, Willems DL, van der Maas PJ, van der Wall G. Clinical problems with the performance of euthanasia and physician-assisted suicide in the Netherlands. N Engl J Med 2000; 342: 551-556 [Abstract/Full Text].
4.  Zylicz Z, Finlay I. Euthanasia and palliative care: reflections from the Netherlands and the UK. J R Soc Med 1999; 92: 370-373 [Medline].
5.  Emanuel EJ, Daniels ER, Fairclough DL, Clarridge BR. The practice of euthanasia and physician-assisted suicide in the United States: adherence to proposed safeguards and effects on physicians. JAMA 1998; 280: 507-513 [Medline].

People's autonomy is not absolute

EDITOR - In their editorial Doyal and Doyal ask, "should she [Diane Pretty, who has motor neurone disease] not be able to invite [her doctors] actively to end her life?"1 The right to total personal autonomy is a cornerstone of the pro-euthanasia case, but there is a fundamental problem with this approach. It pictures us as being individual individuals, rather like bricks strewn across a builder's yard, with no relationships, so whatever happens to one brick doesn't affect any others.

We aren't like this. We are more like bricks in a house, where we have close relationships and responsibilities to those around us, friends and family, and we are connected to society as a whole. Our autonomy is balanced by our responsibilities. I don't exert my right to drive to a supermarket at 150 mph because I accept my responsibility not to endanger others.

In his rapid response Fergusson argues that euthanasia is unnecessary,2 but suppose that one person still wanted it. For that to happen the law would have to be changed from one that protected everyone's life absolutely to one that left vulnerable people unprotected. In this case the one person ought to waive their right to autonomy because of their responsibility to others.

There is another problem with autonomy: for a choice to be valid it has to be free. Sadly, our society and, sometimes, families don't value old people; they are often made to feel that they are in the way and not useful. Tragically, this is often how the older generation feel about themselves. They know about the NHS's limited resources and may feel guilty about using them up. If euthanasia was legal they would inevitably feel pressured to do the decent thing and die, to stop using up others' resources, be it a hospital bed or the children's inheritance.

Euthanasia is not the answer. Rather, we need to provide meticulous palliative care and by so doing show that people are valued, by our profession and our society.

Malcolm Savage, Christian Medical Fellowship staff worker.
4 Montgomery Avenue, Nether Edge, Sheffield S7 1NZ

1.  Doyal L, Doyal L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001; 323: 1079-1080[Full Text]. (10 November.)
2.  Fergusson A. Fancy philosophical footwork but choreography is not coherent. Electronic response to: Why active euthanasia and physician assisted suicide should be legalised. bmj.com 2001. http://bmj.com/cgi/eletters/323/7321/1079#17410; accessed 26 March 2002.

Seeking this presumed moral good is immoral

EDITOR - Doyal and Doyal make a cogent case for legalising assisted suicide, arguing that what is important is the justifiability of the outcome.1 Given that death is at times in the best interest of the patient, they assert that bringing about this end is therefore a moral good.

I agree with the authors that the point is not whether death is caused by action or inaction. But the difference of intention remains important.

If you decide that it is time to switch off my ventilator and, against all expectation, I continue to breathe spontaneously I hope you would be gladeven if it only delays the inevitable. Your intention was not to kill me: you thought that such extraordinary means were no longer justified in view of what you believed was an unavoidable death.

If I am not in pain yet you inject me with a large dose of diamorphine your intention is to end my life. But suppose that I do have considerable pain and you inject me with a large dose of diamorphine. Here the principle of dual effect is an essential divider: your intention remains the relief of pain, but appropriate intervention is justified even if it also shortens life. When you move on to seeking my death you move also to very different moral ground.

Death may at times constitute a moral good. But how are we to decide? Are we sure that we have the patient's interests at heart and are not influenced by other considerations? Is even the patient able to decide in the emotional turmoil of a serious illness? Even when we believe that death is a moral good, it is a unique one if only for the reason that no one knows what it is like. It is, to borrow a word from the cosmologists, a singularity; and we cannot look beyond it. How are we to weigh the benefits of this unknown entity?

I would suggest that for this unique, sometimes presumed, moral good, uniquely it is immoral to seek it. It may at times be welcomedeven embraced. But we have neither the wisdom nor the moral clarity to use medicine to achieve it.

Andrew G Rivett, senior clinical medical officer, communicable disease control.
Southampton and South-West Hants Health Authority, Southampton SO16 4GX

1.  Doyal L, Doyal L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001; 323: 1079-1080 [Full Text]. (10 November.)

Strong evidence base must be adduced for euthanasia

EDITORIn recent years we have become much more aware that medicine is an inexact science. Up to 10% of all admissions are associated with an adverse event. Harm is caused to patients as a result of incomplete knowledge, human errors, and system failures.

In a climate of increased accountability and a frank acknowledgement of the limitations of medical science it seems foolish to be promoting the increased use of a treatment as final as euthanasia or assisted suicide without a strong evidence base. An individual case such as that of Mrs Pretty cannot inform the development of legislation, which needs to account for a broad range of scenarios.1

The first question that must be answered in a variety of scenarios from teaching hospitals to rural general practice is "how reliable are doctors' predictions of the timing and the inevitability of death?" This may seem burdensome to those eager to start using the "treatment" but is consistent with the rigour applied to all other interventions.

Peter Barratt, doctor.
Nedlands, Western Australia 6009, Australia

1.  Doyal L, Doyal L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001; 323: 1079-1080 [Full Text]. (10 November.)

Patients need medical help to live with dignity until they die naturally

EDITOR - The arguments of Doyal and Doyal rest on an assumption that certain patients are right to want to die and should be killed if they request euthanasia.1 This assumption is morally wrong, dangerous, and likely to add to the suffering of vulnerable patients, rather than alleviate it.

I am a full time wheelchair user with spina bifida and also have emphysema and osteoporosis. In addition, my spine is collapsing, causing extreme pain, which is not always controlled even with morphine. These conditions make me the sort of person that the Doyals would consider suitable for "voluntary" euthanasia or physician assisted suicide.

The Doyals would probably say that as they advocate a voluntary system I need not fear being killed without my consent. However, there is a problem with this. Some years ago I had a settled wish to die, which lasted many years. Had euthanasia been legal then I would have requested it, and under the current Dutch criteria (often cited as a model to be followed) I would have qualified.

I am alive now only because my friends intervened to save my life on the occasions when I attempted suicide. Over a long period they enabled me to re-establish a sense of my own dignity and worth. Diane Pretty, on the other hand, is surrounded by people who tell her she is right to feel undignified and degraded, and encourage her to fight for a right to be killed.

Even now there are times when my suffering seems too much to bear and I say that I want to die. The Doyals may say I could sign a document saying I want to be kept alive, but of course this could be revoked as long as I remained competent. The fact that I am not terminally ill, as Mrs Pretty is, probably makes my case for being killed even stronger. Mrs Pretty will die soon whatever happens, while I face many years of suffering.

I am terrified of euthanasia being legalised. It would only add to the problems of living with pain that is often unbearable, except that I have to bear it. What I need is medical help to live with dignity until I die naturally. If the Doyals got their way the chances of this happening would recede rather than be advanced.

Alison Davis, patient.
35 Stileham Bank, Milborne St Andrew, Blandford Forum, Dorset DT11 0LE

1.  Doyal L, Doyal L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001; 323: 1079-1080 [Full Text]. (10 November.)

Denying people voluntary euthanasia causes unnecessary suffering

EDITOR - There is plenty of unavoidable suffering. We should welcome an opportunity to mitigate the misery of a lingering death of a person who longs to die. Legalising voluntary euthanasia by a well crafted law would provide such an opportunity. One would think that all reasonable people would agree, and most do, as opinion polls clearly show. But a vociferous minority is intent on raising all possible objections. One of that minority's responses is, "Since 1961 it hasn't been a crime to commit suicide. They can do that."

The case of Diane Pretty illustrates the shallowness of such a response.1 Her case undoubtedly has unique features, but I have known many other people near the end of their lives who needed our help to achieve a good death and were denied it.

Five years ago one of my closest friends, also a retired teacher, also with a large family of supportive adult children, spent the summer, from June to September, committing suicide. Despite every available medical investigation and treatment nothing had helped her rapid loss of short term memory. She could not read or watch television; by the end of a sentence she had forgotten the beginning of it. It was clear that she was soon going to be able to do nothing for herself, and she decided that such a life was unacceptable.

She persuaded her children that this was the right decision for her. While alone she swallowed all the drugs she could lay hands on, but she recovered consciousness, and so she decided on starvation as the only remaining non-violent means of ending her life. She didn't eat but could not bear the discomfort of doing entirely without water; people dying of physical illness usually die in about 12 days, I believe. She began her abstinence on 22 June and died on 20 September.

Imposing this sort of death on an animal is illegal because it is so cruel. When a person is being denied the right to choose to forego the unacceptable closing phase of his or her life it is much more cruel. Legalising voluntary euthanasia will be one step nearer having a truly civilised society.

Jean Davies, retired teacher.
56 Marlborough Road, Oxford OX1 4LR

We have permission to publish the details of this case from the family concerned.

1.  Doyal L, Doyal L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001; 323: 1079-1080 [Full Text]. (10 November.)

Summary of responses

We received 110 electronic responses and 12 letters to this editorial by Doyal and Doyal arguing for the legalisation of euthanasia and physician assisted suicide.1 Fifty six electronic responses were posted within a week of the editorial being available on bmj.com and 70 within a week of publication of the printed journal.

Excluding the six published responses above, 30 responses supported euthanasia and physician assisted suicide and 54 were against. The remainder tried to synthesise both sides of the debate, discussed the specifics of the Diane Pretty case, compared the BMA's stance on euthanasia with the arguments in the editorial, and queried why only one side of the debate had been published in the BMJ at this time. The sheer volume of the responses and the emotional nature of the debate made it difficult for us to choose which few responses were to be published above and, indeed, which responses are quoted in this summary.

Sri Varman, director of surgery in Cleveland, Queensland, Australia, opened the debate by declaring universal moral bankruptcy: "The system we all have legalises the killing of a 3 month old fetus . . . yet denies a woman with an incurable debilitating and fatal illness to die with dignity at the time of her choosing."

Andrew Thornton, a general practitioner in Wiltshire, highlighted how the law is an ass: "A doctor can legally starve or asphyxiate a patient who is on life support but not kill them humanely. The law forbids us to use on humans the humane methods we are allowed to use on animals and would, rightly, prosecute us for starving or asphyxiating a dog." This thread of the debate was taken up by several respondents to bmj.com.

Another thread was euthanasia as an act of commission or omission. Roger Woodruff, a director of palliative care in Melbourne, argued that Doyal and Doyal's "discussion of benefits and burdens smacks of paternalism" and is not relevant to treating terminal illness. Such patients "want care, they want comfort, they want to be allowed to die with dignity; they don't want to be killed. There is a huge difference between allowing terminally ill patients to die, competent or otherwise, and actively killing them."

He ends with talk of the slippery slope, another thread of the debate: "Legalised voluntary euthanasia for the terminally ill leads to involuntary euthanasia, including those not terminally ill, people with treatable psychological disorders, and those who feel a burden. The Dutch have proved this beyond any doubt."

How can we define the direction in which the slope travels, asks Daniel Munday, acting consultant in palliative medicine at a hospice in Warwick. "External reference points, such as the `sanctity of life,' even within the moral maze of clinical practice at least provide us with some hope of knowing where we are. Maybe it is time to re-examine this principle which we have so readily discarded. It might provide a beacon for those of us foundering in `a sea of relativity.' "

Andrew Warsop, a general practitioner in London, adds: "If human life has some intrinsic value incommensurable with notions of burden and benefit, then death cannot constitute a moral good . . . . If one construes `care' as meaning the care of the life of one's patient (as opposed to, say, avoidance of suffering) active euthanasia always constitutes a failure in a doctor's duty of care."

Dying people must be protected like other vulnerable groups in society with the provision of pain and palliative care services a core function, argues Paul Keeley, research fellow in palliative medicine in Glasgow. "We need to reassure those in pain that we will not walk away from them. Spiritual and existential suffering is as old as humankinddoctors, it strikes me, are good at treating sickness and physical pain but do not have the skills to try to soothe mankind's deepest fears in the face of death."

He and other respondents to bmj.com state strongly that doctors should not be called on to do the killing that may be sanctioned by society.

Their point is taken up wryly by Daniel Albert, a general practitioner in Leeds. While agreeing that the arguments of Doyal and Doyal seem logical, he says that they "are frequently put forward by other philosophers. . .[but] far less frequently by practising doctors . . . . Firstly, it all feels quite wrong. Secondly, our patients might read our articles and wonder if it is they we have in mind.

"And of all professionals, why should it be physicians who get the killing job? The technology is after all simple. The skill will be to assess the meaningfulness of life. Who better than a philosopher to do this?

"The correct phrase is therefore `philosophical killing.' And it would make a good masters degree for graduate philosophers with a practical bent: MA in applied philosophical killing."

Sharon Davies, letters editor.
BMJ

1.  Electronic responses to: Why active euthanasia and physician assisted suicide should be legalised. http://bmj.com 2001. bmj.com/cgi/eletters/323/7321/1079; accessed 26 March 2002.
 

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