This article appears in the November 2005 edition of the Catholic Medical Quarterly
Why Break the Great Taboo?
The moral basis of the medical profession is under serious threat in the United Kingdom, for there are moves afoot in Parliament to permit euthanasia and assisted suicide. The Assisted Suicide for the Terminally Ill Bill (HL), introduced by Lord Joffe, is under consideration in the House of Lords. Lord Joffe has been given a platform for debate at the Royal College of Physicians of London. The British Medical Association moved from a position of opposition to euthanasia to one of neutrality in 2005. The Royal College of General Practitioners tried to do likewise but were prevented from doing so by their membership. The "Medical Establishment" can no longer be said to speak for the silent majority of British doctors.
The case for euthanasia is based largely on the premise that an individual has a right to be killed at the time of their choice to avoid distress due to indignity, dependency, pain and discomfort at the end of life. The concept of endurance is foreign to advocates of voluntary euthanasia; they do not recognise any religious codes that might constrain their personal autonomy. The need to be in control is dominant. Yet time and again, the experience of those who become dependent is that life, even a restricted life, continues to be worthwhile. Much can be endured with loving support.
Death may seem an attractive option to those who are tired, lonely, old or housebound, losing their faculties, or simply depressed. It may seem attractive to young people who are homeless, bored, socially isolated, unemployed, addicted to drugs or alcohol or jilted by a lover. Life has countless sources of physical and emotional pain, which some are tempted to resolve by death. Some people who fear disability write advance directives specifying that they should be killed under certain circumstances, for example if they became mentally incapacitated.
Some people consider that killing a person who is suffering mental or physical distress is a compassionate act. It is a strange sort of love that kills! It is surely more compassionate to help a person cope with pain and distress, than to kill them. The patient's suffering will end; but their friends and family may be left a legacy of guilt.
Some people, exhausted by caring and at their wits end, may comply with a person's request to be killed. In one such case, reported in The Daily Telegraph of September 3rd 2005, a retired nurse struggled to care for his dying wife at home at her request, and finally suffocated her when his life had become "a living hell" and she expressed a wish to die. Years before they had made a pact to kill one another if they were terminally ill. He pleaded guilty of manslaughter by reason of diminished responsibility and was given a conditional discharge by a sympathetic Judge who felt he had suffered enough. Cases like this point to the need for far more support for carers rather than a change in the law.
Good palliative care is a strong defence against euthanasia. The experience in the hospice movement is that very few people ask for euthanasia when troublesome symptoms are controlled. Skilled palliative carers, operating within the doctrine of double effect, can relieve most symptoms without shortening life. As symptom control improves, requests for euthanasia should become increasingly rare. Yet some advocates of euthanasia would prefer to opt for a quick exit by lethal injection or drug overdose if this was a legal option. A person determined to be self-sufficient may reject compassionate support. ‘Love wants to give...’ wrote Boylan, ‘but nothing can be given to the self-sufficient.’1
In 1997 the British Medical Association produced their controversial guidance suggesting that artificial hydration and nutrition could be withheld or withdrawn from patients who lacked self-awareness. As a result this practice gained ground in our hospitals despite concerns about the legal situation. Guidance issued by the General Medical Council in 2002 was the subject of a legal challenge, but senior judges disagreed; so an excellent opportunity to end this dubious practice was lost.
Factors that fuel demands for euthanasia in the USA.
Excessive medical zeal is said to top the list, according to O'Rourke.7 Ronald Cranford is alleged to have said that it is the custom in the USA for physicians to utilise all life-support systems without asking: "Is the therapy effective for prolonging life, and is it an excessive burden to the patient?"'
Assessment of excessive burden should include not only matters such as physical pain and suffering, but also psychological, social and spiritual burdens. Some would say that the social burden on the family should also be taken into consideration (as happened in the case of Robert Wendland8).
Many people consider it inappropriate to maintain physiological function when thought and emotional expression cannot be restored. The courts of several States have maintained that life-sustaining mechanisms are neither ethically nor legally required if only physiological function can be maintained.7
The ‘desire to be in control of one's life’ is a factor. Yet as David Peretz points out: `The desire to be in complete control of one's life is irrational and unhealthy; we aren ot masters of our fate in regard to many important events in our lives.'9
O'Rourke concluded: 'Participation in euthanasia would not only pervert the course of health care, it would also destroy all trust and confidence on the part of patients.’7
A religious perspective
Seen from a Judaeo-Christian viewpoint, opposition to euthanasia on moral grounds stems from the Ten Commandments that were given to mankind by God, through the prophet Moses. The commandment "Thou shalt not kill" has come down virtually unchanged through countless generations to the present day.10 Yet in our secular society the views of those who try to follow God-given laws tend to be discounted in the corridors of power.
It is unsafe to assume that all who call themselves Christians will be opposed to euthanasia. Some churchmen cover their pro-euthanasia views with a thin veneer of somewhat dubious theology. Hans Kung, for example, favours autonomy and argues that God's gift of freewill to humanity extends to a responsibility for deciding the manner and time of our death.11 Kung believes that the role of the churches should be to find a theologically responsible middle way between "moral rigorism and moral libertinism in order to contribute to a consensus and not polarise and divide society by extreme positions..."12 Yet there are certain absolute moral values that cannot be ignored if society is to survive. One such is a prohibition against intentional killing, unless in self-defence, capital punishment, or just war.
According to John Austin Baker, formerly Anglican Bishop of Salisbury, it is now recognised by all serious scholars that the command "Thou shalt not kill" is a rule against assassination, the Hebrew word denoting this in a fairly distinct way - hence the old rendering, "Thou shalt do no murder."13 The implication is that theological arguments against all kinds of killing may not stand up to rigorous scrutiny.
In modern usage the term assassinate is sometimes used in the context of character assassination - ie the destruction of a person's reputation and role in life. One example of this is the devaluation of the elderly and disabled in society. In some primitive societies when old people become socially dead, they become expendable and are at risk of death-hastening activity.14 This trend is now apparent in our own society.
Modern medical technology has created supremely difficult ethical problems. We have yet to learn how best to apply medical technology that prolongs life. Under some circumstances, as Karl Barth conceded, "a doctor may have to recoil from a prolongation of life which would be equivalent to human arrogance in the face of death."15
Arrogance is perhaps a questionable term to use to describe the feelings of a doctor who hesitates to dispense with a life, and seeks to prolong it by the means available. It is not arrogance to discover vaccines and use them for the cure of disease. Why therefore should it be considered problematical to use tube feeding if normal feeding is no longer possible? The problem for a doctor may centre on concern about the quality of the life that is prolonged: the problem for economists is the expense. Wisdom is needed to discern when to act and when to refrain from action - wisdom, knowledge, gentleness, and humility, rather than arrogance in the face of death.
Moral difficulties can be eased by an approach that turns a blind eye to death by omission, butancient morality warns of dire consequences for those who ‘come presumptuously’ to slay their neighbour ‘with guile’16. It could be argued that those who deliberately refrain from supporting life, for example by withholding tube feeding or dehydration, kill by guile.
Christ attached great importance to giving the thirsty a drink. We cannot possible guess what Christ would have thought of tube feeding, but He would have treasured the person in need. Christ healed the sick, and did not forsake them. When Christ's help was sought for the dying he intervened in favour of life. Surely those who follow his example should do the same.
The freewill factor
Those who demand control over their own lives diminish the role of God. Even Christ, the Son of God, prayed that he might be delivered from a painful death on the Cross, yet yielded his life to the higher authority of God, with amazing results. Followers of Christ must also trust in God, however hard the road. As the late and revered Cardinal Basil Hume said "It is better to walk through darkness, the Lord guiding you, than to sit enthroned in light that radiates from yourself."17
The Benedictine rule of obedience is not part of the spiritual armour of ordinary people. We are free to ignore divine guidance, for God has given us freewill. This can create problems for, as Bishop John Austin Baker explained:
"We do not in fact condemn all suicide, even if we are traditional believers. No one criticises Captain Oates for going out into the Antarctic night to try to give his friends a chance of survival. No one criticises the captured agent for using the cyanide pill to ensure that he does not betray his comrades. There are cases where we do not wait for God to end our lives.
I have to say that it seems to me that God left it open to us; within certain limits, to decide when and how we should die. Our lives are not predetermined, ,We may choose to leave the manner of our death to the progress of our disease or the violence of our enemies, and there may be (as with Jesus) good reasons for doing so, reasons we can offer to God as furthering his will. But that is where the focus of the moral and spiritual argument is to be found. A Buddhist, for example, may well leave disease to take its course, as the Buddha himself did, because he or she had become detached from all desire, whether for survival or relief and that is seen as spiritual perfection. The crucial case is that of the person who can no longer take any decisions for themselves. There are very good arguments for not artificially taking the life of such a person, whether by commission or omission, and those of us who are religious believers may well want to say that that principle is God's will for humankind. But I am not sure how much further we can go."18
However attractive the concept of choice and freewill may seem, it has its drawbacks. The reality is that some people have no choice, for many deaths are the result of accidents or unpredictable events such as a major heart attack. Of course you can argue that some heart attacks are self-inflicted through chain-smoking, or a killing life-style, but this does not apply in all cases. It is a fallacy to assume that we are in control of every aspect of our lives. Some put their faith in advance directives in an attempt to gain some degree of control. Advance directives have certain attractions but they also have their dangers.19
Autonomy is not absolute
Autonomy, if taken to extreme, leads to anarchy, as people choose to ignore ancient codes of conduct. One person's freedom to choose to die can become another person's freedom to kill. Choice could become no choice for the weak and vulnerable, if involuntary euthanasia ever became the norm. Autonomy must be ring-fenced by laws that mark the boundaries that no man or woman may cross with impunity. Laws that have served generations well should not be readily discarded.
Those who campaign for euthanasia and physician-assisted suicide tend to overlook thefact that autonomy cannot be absolute. The Revd. Professor Robin Gill, a member of the BMA Medical Ethics Committee, gave evidence to the Select Committee on Lord Joffe's Bill on behalf of the Church of England and said that what was needed was ‘principled autonomy’, meaning that "the rights of the individual always go hand in hand with the duty of the individual or other people."20
The Anglican Bishop of St. Albans, the Rt. Revd. Christopher Herbert agreed with Robin Gill and drew attention to the biblical story of Cain and Abel to focus moral thinking. The story can be found in the book of Genesis, Chapter 4. Cain and Abel, were the sons of Adam and Eve. When Cain murdered his brother Abel, God questioned him as to his brother's fate whereupon Cain lied and asked "Am I my brother's keeper?" God's response was to curse Cain and sentence him to a life as fugitive and vagabond. Bishop Herbert commented: "It has been the basis of Judaeo-Christian ethical thinking that the answer to that question was "Yes". We are not atomised individuals: we are bound up in the bundle of life together, with accompanying rights and duties towards one another."20
Doctors owe a special duty of care and protection to their patients. We are their trusted keepers. To kill patients, even at their request,would be a betrayal of this trust. If euthanasia and assisted suicide become lawful, doctors must have the right to refuse to lower their moral standards to comply with a patient's request to be killed.
If doctors refuse to kill their patients, a separate group of individuals may be trained tokill people. In the Dignitas Clinic in Switzerland a former hospice nurse gives the lethal potion. One day - perish the thought - there might be a "dial a death sqaud" or death parlours next to the undertaker, or euthanasia sessions at the crematorium with piped music and friends in attendance. If we cross the Rubicon and allow euthanasia and assisted suicide who knows where we will draw the line in our crazy, immoral society.
The importance of corporate life
Bishop Mark Santer when addressing the British Medical Association in 1994 emphasised the importance of personal relationships and said: "... The Christian faith declares that human beings are made in the image of God...Interpersonal relations therefore have a sacred quality, because they reflect the life of heaven: they reflect the life of God."21
A retired,Anglican Priest, Revd. William Simons, having considered the views set out in a draft ofthis essay, offered the following thoughts on indvidualism:
"Modern Western culture is basically individualistic. The Bible isn't. Modern man's main concerns, ethically, are the rights of the individual. The main concerns of the Bible are those of the corporate or collective life of man, the kingdom of God.
"Men and women indeed have individual rights - as children of God, made in his image. We fought for them against Nazism and Communism. The opposite of these two ideologies, Capitalism, has triumphed. But as the first two asserted dictatorship of the Collective, so Capitalism asserts the dictatorship of the individual. He is allowed, as an individual, to dictate what is right and wrong, including his right to kill himself
"The Bible's Collective, the Kingdom of God, was often dictatorial in the Old Testament: but not so under Jesus, the king of Love. The Bible speaks not of the individual's rights so much as his duties; not right but righteousness. His right duties are `dictated' to him by God and his community.
"Individuals are not independent, they are interdependent: on each other, on the king or government, within their family and the local community, and within Nature - as a Harvest Festival shows. St. Paul expresses our inter-dependence by saying we are members one of another, in Christ's Body. Jesus said we were like branches or shoots of a vine, cut off from which meant death. Both then proclaim our unity with our fellow men and women, and with Nature ie our Oneness, in contrast to individualism.
"If I committed suicide I would hurt my wife and children. Even if I were single I would still hurt people because I would be proclaiming defeat and despair, instead of the Gospel of Victory and Hope
"We are called to be co-creators with God, not self-destroyers without God... "22
The importance of love
No law can be perfect. All laws have to be interpreted with compassion and good sense, for the benefit of the individual and society. St.Paul was critical of those who follow the letter of the law slavishly. For him "all the law is fulfilled in one word, even this; Thou shalt love thy neighbour as thyself."... "Bear ye one another's burdens, and so fulfill the law of Christ" he told the Galatians, and to the Romans he wrote "We then that are strong ought to bear the infirmities of the weak, and not please ourselves."23 Those words are still true today. Supportive love can be costly, but without such love society will fall apart. Love can lift burdens and make the intolerable tolerable. Euthanasia and assisted suicide are no substitute for love.
The views of the House of Lord's Select Committee on Medical Ethics of 1993/4
Under the chairmanship of Lord Walton, the Committee recommended that there should be no change in the law to permit euthanasia, but added: "Rejection of euthanasia as an option for the individual entails a compelling social responsibility to care adequately for those who are elderly, dying or disabled."
Their Lordships strongly commended the development and growth of palliative care services in hospices and in the community. They felt that double effect was not a reason for withholding treatment that would give relief, as long as the doctor acts in accordance with responsible medical practice, with the object of relieving pain and distress, and without intention to kill.24
Opponents of euthanasia look to the hospice movement for support, yet their trust may prove misplaced. Palliative carers who ignore the issue of hydration at the end of life play into the hands of the opposition. Sometimes when suffering cannot be completely relieved even with the best possible care, terminally illpeople are treated with sedation without hydration, until they die - a practice that has been described as "slow euthanasia"2. Would alethal injection be preferable? I think not.
The economic incentive
Care is costly. If the dying and the disabled consumed less healthcare resources, there would be billions of extra money to finance healthcare for those who were left. Dr. Evan Harris, a member of the Medical Ethics Committee of the British Medical Association speaking in a debate in the House of Commons, drew attention to a utilitarian argument that claims that an act of omission is the same as an act of commission, and only the end result matters.' If your hidden agenda is tocut costs and clear geriatric `bed-blockers' from your wards, it may be irrelevant to you whether you achieve this by lethal injection or by starvation and dehydration. The end result will be the same, namely a dead patient and an empty bed. From a legal point of view intentional killing by any method is currently unlawful, but withholding or withdrawing artificial or assisted hydration and nutrition is widely condoned.
When economic factors override morality, society becomes corrupt. It happened in Nazi Germany, and it could happen again, wherever age discrimination and intolerance of disabilityare rife. In some societies the decrepit elderly who have lost their faculties are considered useless - and are abandoned.' Brogden, a Professor of Criminal Justice and author of a chilling book entitled `Geronticide, killing the elderly' states starkly, that `social extermination of the elderly may be the price paid for economic progress.'5 If euthanasia or assisted suicide were to be made lawful in the UK, elderly patients would undoubtedly be killed toclear a bed for others `more deserving', or to relieve the frustration of relatives or staff whowere tired of waiting for them to die.
Those, who seek to legalise assisted suicide or euthanasia, are playing with fire. Their energywould be better spent finding ways to support the disabled, the elderly and the dying throughtheir time of trial. This means increasing resources for healthcare, to make good care available for all. This way the "uncured" would not be resented, and the chornically ill could be given the care that they need.
Advocates of euthanasia tend to ignore evidence from the Netherlands that does not suit their purposes. They deny that Dutch palliative care kervices are poorly developed, and overlook the fact that euthanasia is out of control. It is alleged that many people are killed without their consent in the Netherlands. In the Netherlands medical students are taught to give lethal injections. Dutch doctors are saidto be so tired of killing that they are resorting to "terminal sedation" as an alternative.
Advocates of euthanasia would have us believe that covert assisted suicide is already practised in the UK, so why not make it legal? Crime is also pretty widespread, but that is not a reason for making it legal. It is up to each nation, through its democratically elected representatives, to decide what constitutes acceptable behaviour, and what does not. Those who disagree with current trends must stand firm and shout their objections from the rooftops.
Wesley J. Smith, an eloquent opponent of euthanasia warned in 1995 that:
"Today in the United States, disabled people with brain damage are being systematically dehumanized so that society will accept the "compassion" and utility of killing them."6
In the wake of the Bland judgement of 1993, Judges in the UK have permitted patients in thepermanent vegetative state (PVS) to have tube feeding withdrawn with resultant death.
The role of palliative care
The National Council for Specialist Hospice and Palliative Care Services for England, Wales and Northern Ireland have defined voluntary euthanasia as "direct killing of patients at their own request to prevent further suffering." In 1997 the National Council endorsed the conclusions of the House of Lord's Select Committee on Medical Ethics of 1994 and concluded:
"...respect for individual autonomy cannot be an absolute value. Regard for the dignity of theindividual cannot require health professionals to respect autonomy to the extent of honouring requests for euthanasia, nor can it ignore the potential adverse effect on health professionalsor society in general.
"Council reaffirms that the intention of good palliative care for dying patients is to relieve their physical, emotional, social and spiritual suffering in the context of respect for their individuality, and without intent to shorten life.
"Council believes there is no place for the direct killing of patients at their own request".25
Efforts to improve palliative care in the community would be at risk were euthanasia lawful. Strenuous efforts are now being made, through The NHS End-of-Life Programme to improve symptom control in the community, and reduce the number of elderly people admitted to hospital to die. Residential and nursing homes for the elderly are being targeted. Palliative carers and trained geriatricians should work together: otherwise End of Life Care could become a death-orientated exercise.
The Board of Social Responsibility of the Church of Scotland, said in 1995:
"...legalisation of euthanasia will not produce a solution to the needs of the individual sufferer, nor will it address the health care challenges of contemporary society. It is the expression of anattitude to life which belittles the sovereignty of God, diminishes the importance of sustaining relationships, and inhibits the pursuit of life-affirming answers for people inneed and distress...
Those who oppose euthanasia must be active in promoting positive alternatives...in order that the momentum toward intentional killing may be curbed... The Church must stand upon the infinite worth of the individual in a societywhich may easily become mesmerised by the cost of care."26
The Anglican Church
Under the leadership of Archbishop Rowan Williams, Anglicans gave a resounding "No" vote to euthanasia and assisted suicide at theirAnnual Synod in York in 2005. The Archbishop expressed concern that the legislation proposed was being driven by economic considerations. More recently Archbishop Rowan Williams has said: "What begins as a compassionate desire to enable those who long for death, because of protracted pain, distress or humiliation, to have their wish, can, with the best will in the world,help to foster an attitude that assumes resources spent on the elderly are a luxury..."27
The Select Committee on the ."Assisted Dying for the Terminally Ill' Bill 2004/5 The role of the Select Committee was to concentrate on the proposed Bill, rather than try to decide the rights or wrongs of euthanasiaor assisted dying. So their hands were tied to some extent. Having heard the evidence presented over the course of a year, some committee members were convinced that euthanasia and assisted suicide were immoral -but others were not.
A final warning
On October 6th 2005, a few days before the House of Lords' debate on the Joffe Bill, nine religious leaders from six major faiths including the Church of England and the Roman Catholic Church jointly wrote an open letter to warn that legalising assisted suicide and voluntary euthanasia would radically alter the moral basis of society. They warned that the so-called "right to die" would inexorably become "the duty to die." Economic pressures and convenience would come to dominate decision-making.
The main arguments for euthanasia are :-
- Self determination and autonomy
- The compassion that kills out of "mercy"
- Fear of pain, indignity, disability, old age
- Fear of dependency
- Avoidance of misplaced medical zeal
- Economic factors and distributive justice
Advocates of euthanasia disregard the sanctity of life and consider it their right to dispose of life as they see fit. They find religious scruplesthat prohibit intentional killing "unconvincing or unacceptable" and are inclined to view euthanasia as a "regrettable medical intervention which is occasionally indicated, but requires scrupulous control."28
The main objections to euthanasia are:-
- Undermines religious beliefs and God-given laws.
- Radically alters the moral basis of society
- Undermines the sanctity of life
- Destroys trust between patient and doctor
- Destroys medicine as a healing profession
- Psychological damage to dissenting relatives or staff
- Risk to vulnerable members of society
- Decisions dominated by economic pressures
- Risk of abuse of safeguard
- Erosion of the taboo "Thou shalt not kill."
- So-called "right to die"would become "duty to die."
Boylan E. Quoted by Hume B. in "Searching for God." p181. Hodder and Stoughton 1977.
Billings JA, Block SD. Slow euthanasia. Journal of Palliative Care, 1996; 12: 21-30.
Harris E. House of Commons Official Report. Hansard, January 28th 2000, p 742.
De Beauvoir, S. (1973) The Coming of Age. Harmondsworth: Penguin Books as quoted by Brogden M. in `Geronticide.' (see reference 5 infra.).
Brogden M. in `Geronticide, Killing the Elderly'. Jessica Kingsley 2001,$3.
Smith S.J. Killing Grounds. National Review March 6th 2005.
O'Rourke K. Euthanasia: on the horizon? Comments on Internet, www International Anti Euthanasia Task Force, January 2000.
Smith Wesley J. Seeking the death of Robert Wendland. Sacramento Bee; November 14th 1997.
O'Rourke quoting Peretz D. Hastings Centre Report 1981; 11:40.
The Bible, Old Testament, The Ten Commandments: Exodus, Chapter 20, verses 12-17.
Kung H. p32-40 in "A Dignified Dying." Kung H. and Jens W. SCM Press, 1995.
Ibid page 36.
I am indebted to Bishop John Austin Baker for this insight about Exodus Chapter 20, verse 13.
Brogden M. Geronticide. Chapter 3 p 55-77 Death by Social obligation. As ref. 5.
Barth K. quoted by Curran C in Politics, Medicine and Christian Ethics, p 154. Fotress Press, Philadelphia, 1973.
The Bible, Exodus, Chapter 21, verse 14.
Hume B. Searching for God, p174, Hodder and Stoughton 1977.
Austin Baker J. Personal communication, June 2000. Quoted with permission.
Craig G.M. Some thoughts on advance directives. Catholic Medical Quarterly, p7-14, Feb. 1999.
Herbert C. The chilling `therapeutic option' Church Times September 30th 2005 page 10.
Santer M. Address to the British Medical Association, Birmingham, July 3rd. 1994 © Santer M.
Simons W.A. of Northampton UK. Personal communication. Letter of October 3rd 2002.
The Bible. See Galatians 5 verse 14; Galatians 6 verse 2; Romans 15 verse 1.
Report of the House of Lords' Select Committee on Medical Ethics 1993/94. Paras 278,279,281,282,287 and 296. HMSO, London.
Voluntary Euthanasia: The Council's View. NCHSPCS. London, July 1997.
Report of the Social Responsibility of the Church of Scotland. Comments on Euthanasia. Para 7.3, May 1994.
Williams R. W warning to a throwaway society. From a speech given on Sept. 6th 2005 for the Centenary of Friends of the Elderly. Church Times Sept. 9th 2005 p9.
Helme T. Editorial. Towards euthanasia legislation. Hospital Update, 1995; 21: 351-353.