This article appears in the August 1999 edition of the Catholic Medical Quarterly
Euthanasia by Stealth
Starvation means to cause death by deprivation of food. Nutrition and fluids constitute food. Their withdrawal can have only one possible end: that is death. Professor Raanan Gillon, one of the authors of the BMA's 'Withholding and Withdrawing Life Prolonging Medical Treatment - A Guidance for decision making,' is reported by the Times (June 24th) as saying by withdrawal the intention is not to kill but to allow someone to 'die with compassion'. By promoting this justification he has raised the complex issue of the difference between killing and letting die. What is the difference? Whilst we agree with the professor that it is all a matter of intention the confused manner in which it is presented in the guidance does little to clarify it.
When a doctor withholds or withdraws treatment and death results earlier than it might otherwise have done, the result may have been foreseen but the action taken because the treatment was regarded as futile or unduly burdensome. On the other hand a doctor may fail to treat because he/she believes the patient to be 'better off dead', or others would be better off were the patient dead. The intention in the latter case is manifestly deliberate killing and to be regarded as passive euthanasia, whereas the former case in which the treatment is regarded as futile or unduly burdensome represents 'letting the patient die'.
The Guidance recommends death as a 'therapeutic procedure' for, although it highlights the withdrawal of fluid and nutrition in PVS and states closely resembling PVS, more widespread targets are contemplated:
'The main focus of this guidance is decisions to withdraw or withhold life-prolonging treatment from patients who are likely to live for weeks, months, or possibly years, if treatment is provided but who, without treatment, will or may die earlier'.
These are the 'biologically tenacious' people, who in the eyes of many ought to die but don't: the neurologically disabled, the senile and the incompetent. Cardio-pulmonary resuscitation and repeated aggressive chemotherapy in many instances should be regarded as unduly burdensome in futile situa tions, but it is difficult to envisage the withholding of antibiotics from the competent neurologically disabled.
That we have reached this stage stems from the case of Tony Bland which many astute observers at the time regarded as a watershed in the adoption of a new social policy towards those who lack certain required qualities such as consciousness. He was described by the judges as 'grotesquely alive' 'an object of pity' one of' the living dead' and his life 'humiliating and degrading'.
'Death with compassion' and 'death with dignity' are terms much used by the euthanasia movement; but how caring, compassionate and merciful is it to terminate the lives of those in severe pain or incurable incompetence? Compassion is not the same as giving people whatever they want, or say they want or indeed we think they ought to have. Nor is mercy the strategy of curing misery by killing the miserable. Compassion is wanting the best for the other and having empathy with them in their suffering. Mercy entails staying by their side, offering good therapeutic and palliative care, and through friendship helping them to recover hope, meaning and a sense of being loved. In the Bland case it was argued that 'the law should strive to be in accordance with contemporary medical ethics and good medical practice'. Several of the judges were influenced by the Discussion Paper on the Treatment of Patients in Persistent Vegetative State published in 1992 by the Medical Ethics Committee of the BMA. But that paper at the time was not regarded as an authoritative statement of medical ethics, and now we have another guidance almost as a continuation. Both are the result of deliberations by a small sub- committee of that organisation and represent an unlikely majority view among its members; the current guidance has already received a frosty support outside the profession. It is extremely unlikely that in its confused presentation and if it were to be considered a final statement by the Council of the BMA, that would make it an authoritative statement on medical ethics.
The assessment of treatment is now to be enlarged to take in not merely its therapeutic benefits and burdens but wider less tangible 'quality of life' considerations.
Lord Browne-Wilkinson, for instance, one of the Law Lords, considered that the removal of nutrition and fluid is 'a course of action designed to produce certain death' and concluded:
'what is proposed in the present case is to adopt a course with the intention of bringing about Mr. Bland's death. As to the element of intention, or mens rea, in my judgement there can be no real doubt that it is present in this case; thewhole purpose in stopping artificial feeding is to bring about the death of Mr. Bland.'
Lord Goff noted:
'it can be asked why, if the doctor, by discontinuing treatment, is entitled in consequence to let his patient die, it should not be lawful to put him out of his misery straight away, in a more humane manner, by a lethal injection, rather than let him linger on until he dies'.
It now seems that homicide has been redefined to allow passive euthanasia (killing by withdrawal of treatment or food and water) in the case of those for whom treatment (or the continuation of life which such treatment enables) is deemed by certain members of the medical profession to be of no benefit.
OFFICE OF THE CHIEF RABBI:
PROPOSED BMA GUIDELINES ON LIFE-PROLONGING MEDICAL
The Chief Rabbi, Professor Jonathan Sacks, has expressed his deep regret following the recent recommendation of the British Medical Association (BMA) of new guidelines for the treatment of severely handicapped and debilitated patients. In what represents a significant departure from the House of Lords decision in Airedale NHS Trust v Bland (1993), the BMA seeks to invest doctors with the power to withdraw nutrition and hydration from severely handicapped and debilitated patients without prior consent from the Courts.
The Chief Rabbi has urged medical experts and religious leaders of all persuasions to call for universal recognition of the sanctity of human life. He has also appealed for politicians, regardless of political affiliation, to exert their influence to curb a disturbing trend toward the legalisation of euthanasia.
Rabbi Chaim Rapoport, a member of the Chief Rabbi's Cabinet commented:
"If the BMA's recommendation were to be implemented, it would endow the doctor with a position beyond his or her remit, namely, that of supreme moral arbiter. It would also undermine the role of the patient's close fam ily in such crucial decisions. The most disturbing facet of these suggestions is that they represent a shift from a value system in which human life is considered sacrosanct to one in which its value is relative and subjective.
The British Medical Association has made invaluable contributions to the medical pro fession and society at large. The introduction of a relativistic approach to the value of human life marks a significant and disturbing change, at odds with the classic values of the Judaic tradition. We share with the BMA a concern for human dignity. We are duty bound to employ all available measures to alleviate pain and suffering in the case of a terminally ill patient. However, we believe that life is sacred. It is the gift of God and may only be taken by Him. The withdrawal of food and water from patients, for whatever mo tive, is at odds with this value, so long central to Western civilisation. it is wrong in itself, and a disturbing erosion of a fundamental moral and religious principle."
When questioned about the quality of human life without the capacity to engage in anything meaningful, and the burden to family, medical institutions and society, Rabbi Rapoport added:
"There is only one meaning to 'death with dignity' and that is death after a dignified life, surrounded by caring people. Unfortunately, severe deterioration of the human faculties is often part of the challenge of old age. It is for this reason that, on the High Holy Days, we pray, 'Do not cast us aside in our old age; as our strength fades, do not forsake us.'
Ultimately, the test of our humanity Is our ability to face our fate and that of those close to us with courage, humility and dedication; not to hasten death because dying has become burdensome. It is the duty of religious leaders and physicians to preserve this conviction in the conscience of humanity."
For further information contact Jeremy Newmark on 0181 343 6301 or pager 0976 502 041.