This article appears in the August 2003 edition of the Catholic Medical Quarterly
The Patient (Assisted Dying) Bill
Lord Joffe's attempt to get a bill through the House of Lord's, which would enable Britain to`go Dutch' and legalise voluntary euthanasia, encountered stiff resistance at its second reading on 6th June. Twenty eight speakers opposed it and twenty five were in support. The opposition contained a full cross-section of peers of all religious persuasions and none, and had the remarkable backing of much of the medical profession, including the Royal College of Physicians, The BMA, and bodies like the Disability Rights Commission. The government has been playing its familiar waiting game; on the one hand saying it has no intention of seeking a change of law on assisted suicide and voluntary euthanasia, on the other repeatedly stirring up debate on the issue. The Lord Chancellor's office has been especially mischievous, publishing a `consultation document' concerning living wills and powers of attorney, and holding `forums' in which interested parties could exchange views, thereby gratuitously encouraging the pro-euthanasia supporters in their relentless campaign.
The bill has now entered its committee stage. If it completes that by the end of the current session of parliament it will automatically fail. The chances of its ever becoming law are negligible but it must be remembered that other bills will be proposed in the future. Two important contributions are presented. One from Bishop Richard Harries Bishop of Oxford who found it difficult to support the bill introduced by the Baroness Knight on a similar topic but opposed the Joffe bill. The other from Baroness Finlay, a professor of palliative medicine.
My Lords, first, I acknowledge that there are some really difficult cases which the Bill seeks to address: people in great distress physically and mentally, and none of us can be sure if we were put in that position we would not want to end our life. Secondly, I recognise that the Bill introduced by the noble Lord, Lord Joffe, has a number of important safeguards. Nevertheless, despite a profound sympathy with those in extreme distress and a respect of the noble Lord and the compassion that lies behind the Bill, I cannot support it.
I believe that to change the law in this way would make elderly, sick and other vulnerable people even more vulnerable, and would totally change the relationship between physician and patient. The noble Baroness, Lady Finlay, stated that so powerfully and eloquently that in the interests of time I shall scrap the first two pages of my speech.
I want to concentrate on the much more testing aspect of this and argue that whatever the effects of changing the law, physician-assisted death is wrong. I take for granted that it is our human vocation to interact with and intervene in natural processes. It is our responsibility before God to plan the number of children we should have, to alleviate sickness to improve our environment and to shape our future. So, the human mind naturally thinks, "Why stop there? We have been given control over so much of our lives, should we not also take control of the moment of our death? Should we not respect human choice even at this point?"
But let us suppose that we are faced with a suicidal teenager. Do we accede to their request to kill themselves? We do not. We try to support them. We try to get them the medical help they need in order that they might live with a positive outlook on life. We do not accept that their stated desire to die is the overriding consideration. On the contrary, we override it by our desire that they should live.
Let us suppose, as the Bill envisages, that we are faced with a seriously ill, perhaps elderly person in distress who says that they no longer want to go on living. Suppose we accede to their request and arrange for them to die in the way envisaged by the Bill. I believe that that sends an implicit message to that person that, "Yes, you are a burden. Yes, your life no longer has any worth. Yes, you are no longer of value".It is to push them away from the here and now where they have a rightful claim on our care.
However much a person might protest and say,"I really do want to die", the message they receive by our acting on their request is that their life is no longer of value.
To love someone sometimes means giving them what they say they want. Sometimes, however, it means refusing them what they say they want. In short, to love that distressed person, to show that they are still of worth in the here and now, means not doing what they say they want.
Palliative care has improved hugely since the pioneering days when St. Christopher's Hospice was first founded. We know that the vast majority of patients can now be kept free from pain. We need to continue to do research on that. We need to ensure that all forms of palliative care conform to the highest in the country, which is now very good. When there is such care, as further research reveals, either patients do not ask for their lives to be ended or, if they do, they can be given the support which enables them to feel that their lives are, after all, still of value and worth.
At this point I should like to refer to the issue mentioned by the noble Lord, Lord Joffe, in his briefing paper; namely, that if the law allowed physician-assisted death, patients would feel much freer to talk about it. I wonder. I agree that creating a climate in which seriously sick or dying people can voice what they are feeling, including feelings of helplessness or that they wish they were dead, is a highly desirable goal. But if the law allowed physician-associated death I wonder whether people would not feel less easy about voicing such feelings for fear that, indeed, they might be acted on. For, of course, there would still be part of them, as there is in all of us, that would want to live.
What enables people to voice their feelings, including their sense of helplessness or despair, is good listening and good counselling techniques which, once again, one would look for as part of proper palliative care. Dr. Tim Maughan, an oncologist, has said that most cancer patients go through a period of severe depression: in a small number of cases he has been asked by his patients to help them to end their lives. He then comments:
"And yet, in each case, if you look with the patients at their situation, talk to them about their relationship with their families and friends, they come to regret making that request".
Many other examples from palliative care make the same point.
As has been mentioned, research shows that people who say they wish to die do so not so much from the pain as from the fear of losing their autonomy and becoming totally dependent on others. I respect that fear and certainly share it myself. But that highlights another crucial difference between what I consider to be a Christian understanding of what it means to be a human being and some current secular models.
Those secular models imply that we are autonomous individuals and that our real value lies in our ability to act and to choose. By contrast, the Christian understanding assumes that we are essentially not isolated individuals but persons in relationships. Indeed, we are persons only in and through our relationships with other persons. That means that our dependency on one another, just as much as our ability to act in support of one another, is part of our very humanity. A life that is dependent on others is not a wasted life. It is not a life without value or purpose.
Appropriate medical care, supported by the moral teaching of the Christian churches, urges that life does not have to be prolonged at all costs. Burdensome treatment which has no prospect of success can quite legitimately be refused. Necessary pain-reducing drugs can be administered even if the known effect is to shorten life. The process of dying can quite properly be left to take its course. But that is very different from deliberately taking steps to kill someone, even if they request it. All that moral theology was so clearly and eloquently outlined by the noble Lord, Lord St. John of Fawsley. I wish that there was enough time to take up the arguments of the noble Lord, Lester, which I believe to be seriously mistaken. I shall write to him on that point.
A few years ago a House of Lords Select Committee considered the subject. The Roman Catholic and Anglican churches submitted a joint statement. It stated:
"Neither of our churches insists that a dying or seriously ill person should be kept alive by all possible means for as long as possible. On the other hand, we don't believe that the right to personal autonomy is absolute. It is valid only when it recognises other moral values, especially the respect due to human life as such, whether someone else's or one's own.
The Roman Catholic church and the Church of England are totally at one on this.
For the reasons I have suggested, to change in the law in the way that the Bill suggests would have seriously deleterious consequences for all vulnerable people in our society. However, even apart from that, I suggest that assisted death is wrong in itself however compassionate the motive behind it might be. Other people, whatever state of mind they are in, and whatever they say, have a value in the here and now and a legitimate claim upon us. We should respond to that by continuing to care for them and by recognising that the condition of dependence, just as much as our ability to act and choose, is part and parcel of what it means to be a person in relation to other persons. I cannot support the Bill of the noble Lord, Lord Joffe.
My Lords, this important debate is driven on all sides by compassion. I speak as a professor of palliative medicine and recently a visiting professor at Groningen University in Holland. However, I fear that the Bill is too broad and does not provide adequate safeguards. My remarks are based purely on my clinical practice.
The Bill fails to increase true patient choice and increases vulnerability of patients and the power of others over them. It requires unbearable suffering to persist, yet suffering cannot be objectively measured.
The Select Committee on Medical Ethics concluded, as has already been mentioned, that adequate safeguards around euthanasia and its oral form - assisted suicide - could not be put in place. One cannot have assisted suicide without also having euthanasia; when assisted suicide fails, someone has to rescue the patient who wakes up. All the evidence emerging from Holland, Belgium,' Oregon and Australia supports the fact that one cannot have adequate safeguards. Involuntary and non-voluntary ending of patients' lives has increased; in Holland some now call for total deregulation. I find worrying the situation involving Dignitas in Switzerland.
The Long Title of the Bill makes provision for pain relief medication. However, good symptom control is legal. Morphine and similar drugs titrated up for pain control, and even sedatives in the terminal phase of illness, do not shorten life. There will always be a last dose but it is the disease that has killed the patient. One does not need to kill the patient to kill the pain. The Dutch use a barbiturate overdose, often combined with curare, to cause death, which results from not breathing, by asphyxia.
What is a serious incurable progressive physical illness? That. includes almost any illness: diabetes, angina and emphysema to name but a few. However, prognosis prediction is notoriously difficult - at best, it is an inspired guess; it is not an exact science.
I fear that autonomy is illusory. Choice is influenced by one's understanding of the options and how they are put to one - it is not free. The Bill requires that patients are informed and understand the options. However, you do not know what something is until you experience it. Informing a patient of palliative care is inadequate. Many patients have been reluctant to go to a hospice yet are amazed how much their quality of life could improve and their despair be lifted. About 300,000 per annum who would benefit cannot access such care.
In 1990, a 35 year-old father of three was referred to me because his GP and two consultants said that they could not give him a lethal injection. He fitted all the criteria of the Bill completely. A malignant, incurable spinal tumour was making him paraplegic. Overwhelmingly distraught, with a prognosis of around three months, he could not enjoy his new baby. I saw him on Monday. He works from his wheelchair caring for his three children, because his beautiful wife died 8 months ago of pancreatic cancer, glad now that no one could comply with his request, which was made in deepest despair.
Unbearable suffering is a totally subjective, multi-faceted experience. It cannot be defined, quantified or assessed. Clinical services should deal with physical problems but, even for that, care is sadly often inadequate. However, those who describe overwhelming suffering have major concerns in emotional, social and existential domains. That requires a different approach, and research into the support that people really need is in its infancy.
Insensitive, hurried care makes suffering massively worse. A desire for death seems to relate to fears about pain, future pain and suffering; fear that good care will not be available when needed; tragic experiences of inadequate, insensitive care; anger at loss of control as disease has snatched health and plans for the future; and social death when a person's role in life and relationships are lost as if they had already died. The Bill does not address temporary unbearable suffering. The desire for death is known to fluctuate with time. Persisting requests with good sensitive care are almost vanishingly rare.
No one wants to be a burden to those one loves. A sense of a duty to die is all too easy to create and all too difficult to detect. Some Dutch doctors describe being weary of pressure from families to end life. The Bill requires only a week's grace for the terminally ill and a month's for others.
A wish to die is a feature of untreated clinical depression. Depression, which is difficult to detect in the seriously ill, occurs in at least 20 per cent of cases, and a trial of antidepressants, which may be the only diagnostic test, will take two to six weeks to begin to have an effect. Patients are particularly sensitive to the tenor of care. They are greatly influenced by the way things are presented. Any clinician will find it easy to persuade patients to opt for one course of treatment or another. That is sad but true. Yet only 10 per cent of GPs in the UK have had formal teaching in palliation - a huge educational challenge. The power of the clinician cannot be underestimated.
Competence and capacity as regards major decisions are very difficult to assess, particularly in the very ill. No robust test exists. It has been estimated that at least 40 percent of so-called informed decisions in routine care are woefully ill-informed.
Disabled people have grave concerns. In the words of Jane Campbell, their lives are viewed as,
"less worthwhile, tragic, burdensome, and even desperate".
They need to be extraordinarily strong to resist this negativity. The Bill runs counter to all this House has done to promote disabled people as citizens of equal value.
A monitoring commission will be costly. yet looking at notes after the event will never detect subtle coercion, pressures or clinical errors. It will not assess the quality of information, how it was given or the quality of care given. The Bill will not increase patient choice and autonomy but will increase the power of doctors and the NHS. The right to be killed by a doctor and the right of a doctor to kill in the course of clinical practice are inextricably linked. Most doctors do not want a duty to consider killing.
The noble Lord, Lord Walton, regrets that he is unable to contribute today. His committee's report has stood the test of time; it is stronger than ever. Euthanasia, however seductive, is to be resisted.