This article appears in the August 2004 edition of the Catholic Medical Quarterly
The Sanctity of Life, a Meaningful concept in Modern Medicine?
A debate held on October 15th in New Hunts House Lecture Theatre 1.
The meeting was held jointly by the GKT Medical Ethics Group, the GKT
Chaplaincy, and the GKT Christian Union.
It was a part of the Royal Society of Medicine Medical Ethics Series. The
Chairman was Andrew Papanikitas, BSc (Hons) DPMSA.
The Reverend James Buxton, GKT Chaplain, gave a brief introduction, outlining the success of our last joint debate in June, 'Should we display our dead?' a discussion surrounding the ethics of the Body Worlds Exhibition, and mentioned the 'Art of Dying'. This series of events that will be taking place at King's College throughout the academic year, see www.kcl.ac.uk for details. The Chairman then introduced the topic and the three speakers, Professor Doyal, Dr Wilks, and Dr Treloar.
Professor Len Doyal, Professor of Medical Ethics and Law
Queen Mary, St Bartholomew's and The London Medical School.
Professor Doyal told us that as little as 40 years ago, it was relatively easy for the medical profession to endorse the view that life was sacred and that it followed from their duty of care that it should be protected at all costs. Moral understanding was still rooted in religious values, all of which placed priority on the sanctity of life and professional values within medicine were generally consistent with this view. The Hippocratic Oath specifically rejects the appropriateness of taking decisions which threaten life, emphasising instead the primary importance of care. More recent professional codes of ethics do the same.
Over the past three decades, a range of medical developments have challenged this cosy view of medical morality. This has dramatically changed, creating new and difficult moral choices. For example, the question of whether or not to discontinue modern neonatal ventilatory support could not arise before its inception. Now it is a frequent dilemma. For we increasingly understand that though such treatment may save life, success can create a terrible burden for some children and their parents.
Professor Doyal was keen to state that an over emphasis on life itself - without any real consideration of why life is important for humans - will be shown to be inconsistent with the traditional Hippocratic emphasis on doing no harm. Whether or not the life of a person should be medically sustained should depend on the kind of life it is likely to be.
Professor Doyal suggests that if all we mean by 'The sanctity of life' is that life can be - but need not necessarily be - precious and worthy of protection then there is no argument. However, I submit that this cannot be what sanctity entails. Otherwise, why not just use the word precious. It follows from Professor Doyal's arguments that it is not the inherent value of human life that counts. The value resides in what humans wish to try to do with their lives - in the value that they do or might attach to such actions. This is why some lives are not worth living or saving - there is no such potential.
Dr Michael Wilks, Chairman,
BMA Medical Ethics Committee
Dr Wilks began by revising the four general ethical principles that have become attached to medical ethics: autonomy, beneficence, non-maleficence, and justice. The idea of consent is based on a person's autonomy. For consent for treatment to be valid it must be fully informed and be given by a competent adult. Consent is required for elective surgery, 'Do Not Resuscitate' orders, organ retention and organ donation.
However, there is a changing landscape in medical ethics and law. What is possible in terms of medical technology has raised some difficult questions. Medical paternalism is being replaced by an emphasis on autonomy, with adequate information for patients to decide. This has created a distinction between the right to refuse life-saving treatment with the current illegality of receiving life-ending treatment. This was most recently illustrated at the High Court with the case of Miss B, who successfully refused artificial ventilation, and the European Court where Diane Pretty was denied the right to have assistance in ending her own life.
Article 2 of the European Convention on Human Rights, which was made law in the UK by the Human Rights Act 1998, is "Everyone's life shall be protected by law", but Article 3 states, "No one shall be subjected to torture or to inhuman or degrading treatment or punishment". These two articles have already given rise to court cases in the case of Diane Pretty, as well as in the cases of patients in persistent vegetative state. Dr Wilks suggested that prolonging a patient's life usually, but not always provides a health benefit to that patient. Hence it is not appropriate to prolong life at all costs.
According to Dr Wilks and the BMA, the primary goal of medicine is "to benefit the patient by restoring or maintaining the patient's health a far as possible, maximising benefit and minimising harm. If treatment fails, or ceases, to give a net benefit to a patient… that goal cannot be realised… justification for providing the treatment is removed. Treatment that does not a provide net benefit to the patient may, ethically and legally, be withdrawn."
Dr Wilks suggests that it may be a poor goal of medicine to continue treatment that has been assessed as being of no benefit. Such treatment represents a harm to that patient and is therefore unethical. A 'benefit' has an ordinary meaning of an advantage or gain. This is broader than the achievement of physiological goal, and includes both medical and less tangible benefits. Patients' interests are not only defined in terms of physical benefit, but also in terms of what best accommodates their other needs.
However in issues concerning life, death, and the law, a person's intent becomes a major consideration. Does one intend to cease treatment that is not longer a benefit? This includes withholding or withdrawing of life-prolonging treatment and is legal. Does one intend to assist the ending of life, such as in physician-assisted suicide? This carries a 14-year prison sentence. Or does one intend to end life such as in the case of voluntary euthanasia? This is technically murder with a mandatory life sentence.
As Dr Wilks stated before, there is a changing landscape in medical law and ethics, with advantages and disadvantages. The advantages reflect autonomy, relieve physical or mental suffering, respect human rights, and have to an extent removed legal anomaly. The disadvantages include the undermining of professional autonomy, the uncertainty of an informed request, the risk of manipulation of the vulnerable, a new doctor-patient relationship, and an uncertainty of success.
Finally Dr Wilks discussed physician-assisted suicide (PAS), in particular the effect of the 1997 Death with Dignity Act in Oregon. From 1997-2001 there had been 91 deaths under the act, and physicians had been surveyed with regard to patients' 1. Desire for independence, 2. Inability to engage in activities, 3. Poor quality of life, and 4. Readiness to die.
There was a survey of hospice nurses and social workers. Of the 545 eligible for the survey, 397 responded. 179 had cared for a patient requesting PAS. 82 patients had received lethal medication. There were high scores for: desire to control the circumstances of death, readiness to die, desire to die at home, and continued existence viewed as pointless. There were lower scores for: depression, lack of social support, and perception of self as burden. All this was reported in the New England Journal of Medicine: Ganzini et al, N Engl J Med, Vol.347, No.8, 582-588.
Dr Adrian Treloar, Senior Lecturer & Consultant in Old Age Psychiatry
King's College / Oxleas Trust Greenwich.
Ex-student at Guy's hospital. A member of the Guild of Catholic Doctors.
Dr Treloar gave us a transcript of his talk:
Firstly, I should state that the sanctity of life is not about preserving life at all costs. It has been suggested that to respect the sanctity of life means that all treatments must be provided for all people, however sick they are. It has been suggested that the aim is to make life last as long as possible. This is not so. Treatments which are burdensome or likely to be ineffectual or of no benefit should not be provided and cannot be justified under arguments about the sanctity of life.
The sanctity of life is, however, about proper and full respect for human life. All people of all backgrounds whether "disadvantaged" "disabled" "sick" or "healthy" are all of value and the lives which they have must be respected, valued and cherished. I put the terms just used in inverted commas, as we must understand that as descriptors they can be very limited. Most crimes are committed by the healthy. Disabled people can be of the most generous and loveliest people whom you may meet. Having been to funerals of profoundly disabled people where 300-400 people were present, and where all had clearly lost a friend and inspiration, we cannot afford to conflate "disability" with nothing other than bad and unwanted things. Disabled and sick people do cause hard work to others, and do therefore require of us things that others do not, but they also bring huge gifts, opportunities and can profoundly enrich the society upon which they rely for help and care. On a spiritual level, life is seen as a gift of God, which may not be taken away by man. But even if the spiritual dimension is denied, the arguments above show that the dignity of mankind and of human life requires us all to value it properly and fully. The sanctity of life therefore requires that we respect all life and never intend its destruction or ending.
At the end of life this means that good supportive care, curative care where possible and palliative care where not are essential. Some treatments will, of their nature, risk a shortening of life, but where the intention is for example to relieve severe pain, the shortening of life is a secondary effect which is therefore permissible. It is also an effect which is well-understood by patients and their relatives. To deliberately shorten life, for example by denying simply-administered food and fluids, or by sedating a patient to the point where they are too drowsy to eat drink or take medication, is wrong and is often seen by patients and their relatives as the intentional ending of life. Sadly, in the context of the pressures under which health services operate, with both bed and financial shortages, there may be advantages to the system of shorter admissions for those who are dying. This is why the first duty of a doctor as described by the General Medical Council is so important: "To make the care of your patient your first concern".
At the beginning of life we must not discriminate against patients on the grounds of disability. Disability or handicap is a reason for care and not discrimination. As doctors we need to be able to recognise the care and value that disability brings to society as a whole. In a society where there have been successful lawsuits for allowing children with Down's Syndrome to be born, we must work hard to allow mothers and fathers to know that children with disability can and do contribute hugely to the lives of those who care for them. Too often we hear of parents being told that their baby will be severely handicapped, that they will probably die anyway, and that abortion is the only sensible solution. We have heard of mothers who felt they had to repeatedly justify their wish to keep and cherish their baby in the face of a profession who would tell them they were wrong or irresponsible, or worse. When we behave in this way, we are bound to lose the trust of the patients we serve. Again we have heard of mothers who simply try to avoid antenatal care as they cannot face the discussions about screening and elimination of disability which will follow.
There are clear echoes here in older care as well. Many older people remain fearful of hospitals seeing them as places to be avoided and places where people die. If we ever accept a motivation that deliberately shortening life is of itself a good thing, then the fear and mistrust ignites. In Holland we hear that older people refuse pain relief as they are fearful that appropriate analgesia is in fact the start of sedation which will end their life. We should remind ourselves here though, that there are some things that we may well not provide for severely unwell or disabled people. Chemotherapy, which is very distressing and difficult, may well be inappropriate for a severely learning-disabled child, as the ability to understand what is happening and to cope with the suffering involved might be so great that the treatment could not be justified. Complex surgical interventions might also be inappropriate, especially if the patient was going to be unable to participate in the rehabilitation programme required as a result of their severe learning disability. But the principle remains;- proper and full respect for human life is an essential component of what we do. The sanctity of life is a given which we, as a profession, cannot and must not abandon.
What does this mean for doctors and medical students? If you do decide that you will not compromise on the sanctity of life, you must expect some difficulty. You will be subjected to health economic arguments. You will be told that that is how things are done so you may as well accept it. If, for example, you conclude that you should not participate in abortion, you are very likely to be told that you are leaving your colleagues to do the "dirty work" and that you are getting off with less work as a result.
You are likely to be told, as many before you have been, that you can have no future in Obstetrics and Gynaecology or General Practice as a result of those beliefs. You may also find yourself increasingly in difficulty in elderly or disability care. What will you do when a teenager with cerebral palsy, weighing only 10kg (yes, just 1.5 stones) is admitted while his mother is away at the teaching hospital for surgery and the SHO decides not to treat the chest infection as he/she feels this is a life not worth living? Providing care, getting scarce resources for vulnerable people who need them, keeping people in hospital and continuing to treat them, assuring adequate nursing staff levels on wards, and all in the face of the district overspend, may well make you very unpopular. All of these dilemmas will burst upon you at a moment’s notice. Medical students typically find themselves in an abortion or end of life dilemma unexpectedly, on a night on call, or at a similar time when they are quite unprepared.
So I ask you to think carefully about this, and to decide to always respect the sanctity of life. You should be prepared to stake your entire career on it. Work hard to provide really good quality care for your patients. You should resolve never to do what is wrong simply to keep yourself on the right career path. Be prepared to resign before you do what is wrong. If you do this, then I honestly believe that you will find (as I have) that patients value what you do, and that you get real appreciation for quietly, but solidly, respecting the sanctity of their lives, and the lives of their children. Medicine is great fun and tremendously rewarding, especially when you remember what it is all about.
Points from the Floor
The talks over-ran but we did have time for some points and questions from the floor. These concerned when does life begin, and when can it be called 'sacred' or worthy of protection, how does one reconcile the issue of intent which permit two actions to have the same outcome but one is murder and the other is not, and whether or not it is better to die of a painless injection rather than from suffocation or starvation from the withdrawal of treatment.
A straw poll at the end revealed that a near unanimous majority did consider the sanctity of life to be a relevant concept, though the meaning of the concept itself did vary.
The debate was followed by a complimentary buffet, generously provided by The Britannia Pub on Kipling Street, where the discussion continued until late.
To find out more about the GKT Medical Ethics Group and especially if you would like to comment or get involved, visit our website www.medethics.org
To find out more about the Royal Society of Medicine, Student Members Group (such as for details of student member activities, benefits and prizes) visit www.rsm.ac.uk/students
With acknowledgement to the Guy's Kings & St Thomas's Gazette