Let’s talk about assisted dying
BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b2883 (Published 16 July 2009) Cite this as: BMJ 2009;339:b2883All rapid responses
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It would seem strange to observe a citizens migration from the native
land of Tommaso Moro, theorist of “Utopia”, (a country where the priests
used to take care of sick people until their death) to other countries,
like Switzerland, the Netherlands and Belgium, where, apparently, in
different ways, this “Utopia” was already achieved.
But, deeply analysing the matter, it is possible to carry out a wrong
approach to the problem of “assisted dying”.
The same expression “assisted dying” may lead to the misunderstanding that
we are talking of treatments only aimed to make the path to death, in any
case impossible to avoid, less painful.
It is obvious that, in such case, no citizen of the U.K. France, Germany
or Italy, would migrate to the “Promised Land” to meet his needs.
In the U.K. and in almost all other countries of the European Union, even
those with a very strong Christian tradition, the respect of patient’s
autonomy has become a must and the limit of physicians behaviour: if the
patient refuses consciously a treatment the doctor should refrain even if
it leads to a precocious death.
In the U.K. the case of Miss B has been highly instructive in this field.
In Italy the event of Welby and even more the one of Eluana Englaro, who
was unable to express her present will, have outlined a route which is
difficult to amend.
The case of miss Pretty interested even the European Court of Justice
ending with an answer which is, since years, well established in clinical
practice: “It is a right of the patient to accept or refuse a treatment,
being his freedom a not available good to a third party, even aimed at
guaranteeing his health or survival.
In the U.K. and other countries of the European Union, the law is more and
more tolerant with regard to palliative treatments to terminally ill
patients even if they shorten the life.
And all this doesn’t give rise to a reaction of the Catholic Church, much
more open than other cultural trends which continue to notice the toxic
results of drugs, such as Morphine, instead of highlighting their
analgesic effects. The doctrine, dating from “Tommaso D’Acquino”, of a
double effects of a drug justifies its use even when an undesired side
effect may shorten the life (specially if death occur for sure in a short
time)
Which is, than, the problem? What moves dozens of British citizens to
places where dieing appears easier?
The matter is that we are not talking of terminally ill patients who may
accept or refuse palliative treatments but of patients who, not only
refuse treatments for their depression, but ask for drugs whose only
exclusive effect will be to cause the death.
This point of view, not only clashes with the House of Lords tradition but
also with the rule of “Ippocrate” which states “Primum non nocere”
In his oath, the ancient physician from “Cos” forced his followers to
promise they never would give to anyone a poison, even if required.
The matter of “assisted dying”, therefore, doesn’t interest just the
patient autonomy, but cracks the basic principles of the medical
profession, since tries, by law, to impose to a physician a behaviour
which is against his mission devoted to curing ill people.
Reference
1. Clare Dyer. Woman makes legal history in right to die case. BMJ, 2002;
324:629
Competing interests:
None declared
Competing interests: No competing interests
'Part of the problem', says Ann McPherson 'is that those deciding on
the question of assisted dying are not facing immediate death themselves'.
How I agree! They cannot know what others suffer. They cannot imagine what
it feels like.
Having suffered the effects of aggressive cancer treatments myself,
which included weeks of increasing, unrelieved, off the scale pain and
episodes which drove me to banging my head on the wall, and seriously
considering use of the railway line to 'end it all', my experiences surely
validate my opinion. Since then, I have felt strongly that only those who
have experienced acute, prolonged pain and/or excessive suffering (or
tasters of worse to come) should be the decision makers when it comes to
assisted suicide.
I have written of my experiences in medical journals (HSJ 1996, BMJ
1998) and now fully in a book, Nothing Personal: disturbing undercurrents
in cancer care,(Radcliffe) where I describe pain amounting to torture and
a prolonged procedure involving wire implants ripping my insides while my
flesh was being pulled in two directions by muscle spasm. Defecation
brings daily reminders. I challenge anyone to go through such experiences
and not be in favour of assisted suicide.
In my next life I hope to be a stray dog. As such (according to TV
vet programmes) I would have good prospects of immediate referral, scans,
diagnosis and treatment - but especially, humane disposal.
Competing interests:
None declared
Competing interests: No competing interests
The popularity of assisted suicide in the UK seems to be growing both
among the general public as well as among health care professionals.1,2
Almost every new case of a person or a couple travelling to a private
clinic in Switzerland to obtain this kind of service reaffirms the demand
to legalise the ethical ‘right to die with dignity’ at home ‘as to allow
those who cannot afford to travel to enjoy it too’.3-5
The philosophical underpinnings of this right make great sense: sad
as it is, life may sometimes become irreversibly intolerable for the
subject involved; in such cases, suicide may happen to be the only refuge;
hence those who need assistance in this matter ought to receive it from
others.
That said, the increasing interest in this right cannot be attributed
to its philosophical foundations. The great seventeenth century British
philosopher, Thomas Hobbes, taught us that we do not tailor our interests
according to their philosophical justifications, but rather the other way
around.6 Indeed, the history of the trend in question should be sought in
its political economy, that is to say, the ecology of the pertinent
interests, stakeholders, and relations of power from which it has emerged.
The bioethical literature, albeit being largely philosophical and not
historical, seems to have been aware of this point. It has attributed the
trend to the introduction of medical technologies that can prolong life
sometimes at the expense of its quality and the concomitant emergence of
severe chronic and debilitating conditions that defy medical intervention.
More specifically, the patient’s ‘right to die’ has been attributed to the
wider social history of the principle of respect for the patient’s
autonomy, while the right of the doctor to hasten the death of some
patients has been attributed to conceptual transformations within
medicine, referring primarily to the definition of ‘death’, ‘medical
futility’, and ‘best interests’.
This ‘official’ history may seem to reflect nothing but the
increasing humanisation of contemporary medicine. However, it is partial
and misleading. As a matter of fact, the bioethical literature has turned
a blind eye to the role of various economic interests that either make the
life of some people intolerable or benefit from hastening their demise, or
both. Even more so, it has ignored their dominance over the aforementioned
factors.7 Indeed, there is little doubt that if dying patients had been
laying a golden egg each day they were kept alive the evolution of our
ethics would have taken a radically different course notwithstanding any
concerns we might have had about ‘the tyranny of technology’ and the
patient’s autonomy.
Occasionally, however, the role of economic factors in shaping the
history of our end-of-life ethics reveals itself to the naked eye. For
example, The Times, which recently spoke highly of “death with dignity” on
page 2, told us on page 12 that “NHS ‘loses’ £286m intended to ease last
days of dying patients”.8 To ignore the constitutive link between this
‘loss’ and our ethical discourse could be a dangerous mistake. This link
may have a far-reaching implication for ‘the right to die with dignity’:
the right might turn out to be nothing but a thin ideological façade that
conceals and thus reaffirms social relations that show very little respect
for life. Indeed, ‘the right to die with dignity’ could receive an utterly
cynical meaning in a world that denies people a meaningful right to live
with dignity.
Of course, one might still wish to argue that this does not apply to
our world, since our denial of the right to live with dignity is the
result of the ‘tragic’ scarcity of resources, not cynicism. This argument
falls flat, however. The economic crises of the past century have
unexceptionally been related to overproduction, not underproduction. To be
more precise, they have been the outcome of increasingly unequal
distribution and redistribution of wealth. Against this backdrop and
particularly in view of the obscene amount of public money we were told
didn’t exist that is currently being spent by our government to re-inflate
the credit bubble that has just burst, it would not be an overstatement to
say that ‘the right to die with dignity’ turns the doctor into a shortage
manager on behalf of AIG and RBS.
For this reason alone, health care professionals ought to refuse to
participate in assisted suicide even if they find the principle to be
morally acceptable. If the government wants to promote assisted suicide,
it should train special people for that purpose. Vocal advocates of
assisted suicide, preferably bankers, politicians and bioethicists, would
make natural candidates for this unskilled job. In any case, the new
professionals should wear a black gown so that they could be easily
distinguished from those whose gown is and should remain white.
1. R. Bennett, D. Rose. 25 July 2009. Public supports assisted
suicide for terminally ill people. The Times. Available at
http://www.timesonline.co.uk/tol/life_and_style/health/article6726928.ece
[accessed 29 July 2009].
2. RCN moves to neutral position on assisted suicide. 24 July 2009.
Available at
http://www.rcn.org.uk/newsevents/news/article/uk/royal_college_of_nursin...
[accessed 29 July 2009].
3. A. Hirsch. Assisted suicide: Legal turmoil. The Guardian, 14 July
2009; p. 3. Available at
http://www.guardian.co.uk/society/2009/jul/14/assisted-suicide-law-edward-
downes. [accessed 29 July 2009].
4. Charlotte Higgins and Owen Bowcott. Sir Edward Downes and Lady
Downes arrange natural finale. The Guardian, 15 July 2009, p. 3. Available
at http://www.guardian.co.uk/society/2009/jul/14/edward-downes-assisted-
suicide-law [accessed 29 July 2009].
5. Editorial. Dignity and death: as the quality of life becomes a
greater factor in medical ethics, the issue of assisted suicide must not
be left to one small clinic in Switzerland. The Times. July 15 2009; p. 2.
6. T. Hobbes. 1996 [1651]. Leviathan. Oxford: Oxford University
Press; I.11.21
7. M. Epstein. Legitimizing the shameful: end-of-life ethics and the
political economy of death. Bioethics 2007; 21(1):23-31.
8. D. Rose. NHS ‘loses £286m intended to ease last days of dying
patients. The Times, 15 July 2009; p. 12.
Competing interests:
None declared
Competing interests: No competing interests
I have read with interest the articles relating to assisted dying/euthanasia.
i feel i need to air my views.
we had similar cross path and debate over TOP(termination of pregnancy). the aim was to legalise it to prevent back street/illegal TOP.
we did win the debate.
At present we dont bat an eye lid for any TOP.
inconvenient and unplanned pregnancy are the good enough indications for TOP to proceed.
there is a group of girls who have used this method as method of contraception!!
i fear that if euthanasia is legalised then in time to come we shall go lax for its indication.
Competing interests:
None declared
Competing interests: No competing interests
In the ongoing debate about assisted dying, one could easily be
forgiven for believing that dignity at the time of death is only to be
found in assisted dying. Dignity is a very complex matter, and difficult
to define in a single sentence, but I believe that the vast majority of my
patients have a dignified death in a caring and supportive environment,
surrounded by family and caring professionals. No, the real issue in the
debate is control over the timing of death, not the dignity of dying. In
Ann McPherson's article, (doi:10.1136/bmj.b2827), she says; ". . . more
than 800 people in the United Kingdom are known to have signed up to
Dignitas because they hope to ensure that they will be able to die with
dignity. This confirms my personal experience during my 40 years as a
general practitioner that some people who are facing a terminal illness
still want, in spite of adequate pain relief, to die more quickly and with
more certainty about how, when, and where they will die."
The problem is that by affording that option to a tiny minority who
want that control, we create a considerable risk to a vulnerable majority.
Competing interests:
None declared
Competing interests: No competing interests
During a recent small group discussion with public health colleagues,
the subject of compassion came up. I mentioned my belief that public
health was driven by a commitment to social justice, nourished by a
developed sense of statistical compassion.
They had not heard of statistical compassion, perhaps not surprisingly as
I had picked the phrase up a number of years ago, from an early edition of
Cecil's Textbook of Medicine. An introductory chapter was written by Walsh
McDermott on the subject of Medicine in Modern Society. In this, he drew a
comparison between individual compassion and the 'group' compassion of the
public health or community physician. He further described statistical
compassion as 'an imaginative compassion for people one never gets to see
as individuals and indeed can know only as data on a graph'.
We have long been aware of the phrase attributed to Sir Austin Bradford
Hill, that health statistics represent people with the tears wiped off. It
is time to bring back McDermott's phrase as an important aspect of public
health.
There is much interest these days in public health leadership and in the
essential competencies required. Perhaps we should give some attention to
the motivating factors behind successful public health. Of these, a well
developed sense of statistical compassion should surely come very high in
the list.
Competing interests:
None declared
Competing interests: No competing interests
Why fear the slippery slope of assisted suicide? A need to consider elderly patients with early diagnosis of dementia.
The latest law Lords’ judgment in the case of Debbie Purdy makes
Fiona Godlee’s question “why do we fear the slippery slope?” (1) essential
in the current debate about assisted suicide. Clare Dyer (2) highlighted
the latest development in the fight over changing the law (2) but there
are many unanswered questions. It is possible to regulate against
exploiting older adults who lack capacity but it is impossible to
legislate against moral and subtle pressure being put on people who have
been diagnosed with early dementia and still retain capacity. The National
Dementia Strategy aims to promote early diagnosis which would enable
patients to make their own decisions regarding future care. But if the law
were to be changed to legalise assisted suicide those patients who have
been diagnosed with early dementia and still have mental capacity could
face pressure whether from within or imposed by those who could benefit
from saving expenditure on long term residential care to consider the
option of suicide. We can imagine pressure on this group of patients to
consider ending their lives to spare their families the burden of looking
after them as well as to reduce pressure on NHS resources: it has been
suggested that people with early dementia have a ”duty to die” (3).
Though
there is evidence of British public support for the concept of assisted
suicide in dementia (4), it seems that carers training and positive
experience reduce the likelihood of supporting this option (5). There is
not enough evidence regarding how cultural background and religious
beliefs influence attitudes towards assisted suicide in dementia. Any
significant discrepancy based on culture or religion could lead to a
serious split in dementia care and cost along the lines of cultural
background which would consequently develop two tiers approach in care.
Also, doctors’ attitudes, which are very different from the public’s,
would make this issue far more complex (6). As the National Dementia
Strategy, 2009, is offering hope to many dementia sufferers, there is an
urgent need to study the effect of the availability good dementia care on
public support for assisted suicide in dementia as well as what the role
is of culture and religion.
1. Godlee, F, Let’s talk about assisted dying, BMJ 2009;339:b2883
2. Dyer, C, the fight goes on, BMJ 2009;339:b2868
3. http://www.telegraph.co.uk/news/uknews/2983652/Baroness-Warnock-
Dementia-sufferers-may-have-a-duty-to-die.html, 5th August 2009.
4. Williams N, Dunford C, Knowles A, Warner J., Public attitudes to life-
sustaining treatments and euthanasia in dementia, Int J Geriatr
Psychiatry. 2007 Dec;22(12):1229-34
5. Salib E, Tadros G., Passive euthanasia in dementia: killing ... or
letting die?, Med Sci Law. 2001 Jul;41(3):237-40.
6. Roger Dobson, UK doctors’ attitude to assisted dying differs strongly
from the public’s, BMJ 2009;338:b1338.
Competing interests:
None declared
Competing interests: No competing interests