Catholic Medical Quarterly Volume 65(1) February 2015
ASSISTED DYING AND ASSISTED SUICIDE:
A NURSING PERSPECTIVE
We interviewed Teresa Lynch,
who is chairperson of Nurses Opposed
How do you feel about the term “Assisted Dying" as it is now set out in the Falconer Bill?
Rather than Assisted Dying, Assisted Suicide is a more honest term for the Bill currently being promoted by Lord Falconer.
It can appear as if the vital argument against assisted suicide is already lost with the recent pronouncements of the Director of Pubic Prosecutions on this topic. Those in favour of a change in the law believe in the rightness of such a move.
Attempts to accommodate the views of the vociferous that this is a compassionate proposal by a compassionate society need to be accompanied by recall of the many terrible deaths as a result of the inherent danger of the Liverpool Care Pathway and the content of the Francis Report.
Assisted suicide is the term when an individual is provided with the means and assistance to commit suicide by another person or persons (for example using drugs, equipment, and so forth) (Royal College of Nursing 2011).
Physician assisted suicide involves a doctor prescribing a lethal drug which is administered by a patient or by a third party, such as a nurse or relative (DH, 2003).
How do you think the campaign for assisted suicide is going?
The opposition to the Assisted Dying Bill is one of the greatest battles over human rights of our time.
Politics, justice, laws, society and the economy may only be at the service of man and his dignity and not vice versa. To be authentic, human rights must have human dignity as their basis. Human rights are not the property of ideologies but rather of a humanity that neither forgets, nor turns its back on natural law.
The human rights of both patients and professionals alike can be addressed by the European Convention on Human Rights - (Article 2 of the ECHR 1999) “a terminally – ill or dying person’s wish to die cannot constitute a legal justification to carry out actions intended to bring about death”.
Considering Opinion polls, we need to look at the fact that a reported 70% of people agree with a change in the law carefully. The past House of Lords Select Committee Report suggested that opinion polls purporting to show that a large majority of people would favour a change in the law are misleading because they are based on a simplistic format for answers to questions without any explanatory context.
Hard cases make bad law. Even in a free democratic society there are limits to human freedom and the law must not be changed to accommodate the wishes of a small number of sadly desperate and determined people, who wish to impose their goals on all. Human rights, otherwise, become warped rights and denigrate man’s dignity as a person if they do not encompass all mankind.
What are the duties of Parliament in dealing with this issue?
A democratically elected Parliament exists to protect the citizens from threats to life and limb from within and without, to make laws for the common good, and to protect fundamental human rights. The British Parliament is obliged to protect the right to life of all citizens.
British Parliamentarians have rightly rejected the legalisation of assisted suicide and euthanasia in Britain three times since 2006 out of concern for public safety - in the House of Lords (2006 and 2009) and in Scotland (2010) - and repeated extensive enquiries have concluded that a change in the law is not necessary.
The right to life is described by the Untied Nations as “inalienable and inviolable” in the Universal Declaration on Human Rights (UN 1948, UDHR) and the UK is a signatory to that document. Like many other European nations, it has been so from the beginning.
The Assisted Dying Bill provides for the lawful killings of innocent human beings in certain instances. Such a law would greatly impair the capacity of Parliament to carry out its duty to impartially protect the right to life of all citizens no matter how weak, vulnerable or impaired those lives may be.
Is there a slippery slope?
As well as legalising euthanasia for those who can take their own lethal medicines, legalised Assisted Suicide would smooth the path to involuntary euthanasia and medical killing of those who cannot take their own medicines. And it would also erode the confidence that people have in Parliament by questioning the reliability of Parliament as the defender of the universally recognised inalienable right to life.
Will safeguards work?
Safeguards need discussion but are not acceptable as a means of making this bill more palatable as the Bill is a wrong moral concept.
Any discussion on safeguards presupposes that the aim of this bill to change current law is legitimate – it is not. The proposals in this bill, together with its inevitable expansion, are totally unacceptable in the eyes of many nurses and doctors.
Many of the so-called ‘safeguards’ in the bill were previously rejected as unsafe when they appeared in Lord Joffe’s Assisted Dying Bill in 2006. But Lord Joffe can be commended for his honesty in giving evidence to his own Select Committee:
'We are starting off, this is a first stage... I believe that this Bill initially should be limited, although I would prefer it to be of much wider application”…( Joffe 2006).
No one should overlook the findings of audits in countries and states where Assisted Suicide is legal that, 'fear of being a burden' underlies many people's request for assisted suicide, rather than pain. What a sad and bad premise for this bill. This fear is compounded by offering the abolishment of the burden of possible or actual suffering together with patients’ lives in the increasing numbers now seen in other European countries. Many of these patients have never been assessed by a psychiatrist for treatable, clinical depression.
History has shown that 'safeguards’ in law very soon are considered as mere impediments to be overcome, then later, become meaningless. Those who turn a blind eye to this truth, wilfully deny current reality and frail human nature.
Any right thinking person knows that suggestions that a change in the law will only strictly apply to a small minority, is a fantasy.
Why do patients ask for Assisted Suicide?
Professional opinions and past experience of this field of care should not be overlooked in the deliberations on this bill to become law. I have so often experienced, inner strength and compensatory forbearance afforded to patients at the most vulnerable time of their lives. Showing hope and courage so often for the sake of their loved ones.
In my professional experience, patients look to their carers to affirm their lives, not offer them death as a defeatist, cheap and easy option. I spent several years as manager in a Palliative Care Unit of a leading Cancer hospital there was no demand for assisted suicide.
Are Euthanasia and Assisted Suicide different?
Legalising Assisted Suicide for the terminally ill is a stepping stone to legalising euthanasia and in both cases the intention is the same: if patients in law have the right to ask for a lethal prescription to take the drug themselves, why not for a lethal injection, particularly if they are physically unable to take the drugs, or having taken them are suffering a complicated, difficult death.
It is as well to acknowledge that Dignitas drugs do not always work in the way some patients might imagine. Who then is responsible for achieving the wished for death? As the Dutch have said, thinking you can legalise one without the other is a fantasy. Assisted suicide is Euthanasia by the back door.
What is wrong with this bill?
Lord Falconer’s Bill contravenes fundamental human rights by providing for some people in some circumstances to “alienate” their right to life, and by seeking some persons to act as accessories to that killing.
We may be living in what is described by many as an increasingly secular society. However, this is not accurate. Although fewer people may attend and practise their belief in specific buildings, the levels of belief and spirituality in our nation are huge, according to Christopher Herbert, former Bishop of St Albans. The ability to do something does not mean I have the moral right to do it. Prohibition on killing is a foundation of the Judeo-Christian tradition and such a prohibition is long-held by right-thinking followers of other religions. So if the commandment 'thou shall not kill' or help someone to kill themselves is discarded where do nurses (and doctors) stand?
Medicine and nursing in the 21st Century ever seek to increase the percentage of patients achieving a pain-free existence in the terminal phase of illness. Patients with end stage disease are a constant challenge to the vocational skills of their caring team, whose culture is vital to inspire confidence in vulnerable patients. Why now, when palliation is more possible than perhaps ever before, do we need assisted suicide? What other factors are underlying yet another attempt to make a momentous change and such a monumental mistake?
No one, of any age or degree of illness, is granted a pain-free existence. To suffer is part of the human condition. What makes suffering bearable is the constant, invaluable support by family and friends, and of course, the carers in their loving concern, support, and practical care for pain, wounds and misery. This is particularly important where the patient may have no one in life.
To get back to basics, repetition of the long-held prohibition 'thou shall not kill' is vital in resisting the perennial and dangerous calls for a change in UK law. Jesus, who said: 'let your yes be yes and your no be no' was never lacking in compassion, but offered true healing for those he encountered in desperate and miserable situations.
Assisted suicide is, to put it bluntly, the cheapest treatment for a terminal illness. This means that in places where assisted suicide is legal, coercion is not even necessary. If life-sustaining expensive treatment is denied or even merely delayed, patients will be steered toward assisted suicide. Such views are then imposed on the vulnerable elderly, disabled, and on the chronic sick, whether young or old. This Bill puts all people at serious risk and Palliative Care principles are undermined. Assisted Suicide must never be included in the armoury of patient care.
This bill engenders unnecessary fear in society about death and dying. It implies a ‘them and us’ culture. The caring words; ‘compassion, choice, dignity and control’ can cloak the harsh pragmatism that perpetuates the myth that the lives of some people are not worth living. Those with disability are among the strongest opponents to a change in the law which currently protects them.
Where is the nursing and Midwifery Council on this issue?
In 2004, the Royal College of Nursing members at Congress debated the issue of palliative care, to address known gaps in the provision. The overwhelming result of a vote taken was to lobby for better Palliative Care services. In 2005, the RCN invited members to comment on the proposals of the Joffe Bill. The overall result was opposition to the Bill.
But if Assisted Suicide is legalised, nurses will be the ones expected to fulfil the requirements of such a profound change in the law in yet another of their extended roles taken over from clinicians. Many nurses, of religious conviction and none, will rightly resist this unnecessary development and refuse to implement such a law. Nursing recruitment and retention heavily relies on committed people, young and of more mature years from all cultures and creeds trained to offer life-affirming care. Many junior and senior nurses are extremely concerned about this bill and any moves towards its legalisation.
Nurses who are resistant to implementing this proposed law will hope for protection from The Nursing and Midwifery Council empowered by Parliament. It issues and reviews on a regular basis the nurses' Professional Code of Conduct. It states that because, “The patients trust you” (page 1) “You must be open, honest” and act indiscriminately and inclusively, “with integrity” (page 2). It also documents that nurses must be able to act as the patient advocate and use evidence- based practice. The evidence in countries where assisted suicide is legalised, is that there is erosion to the point of destruction of effective Palliative Care and terrible abuse of the law.
What about Conscientious objection?
For doctors to refer patients to another doctor for assisted suicide is to participate in it morally, and makes them morally culpable. The Nursing code of conduct, however, also states that we must adhere to the laws of this country. This may compromise nurses who do not agree with legalised assisted suicide. Dedicated professionals who will not wish to abandon their patients to assisted suicide may find their vocation cannot be reconciled to a prevailing culture of death. It is not clear how, if the law changes, the Nursing and Midwifery Council might be able to (or wish to) support nurses who conscientiously object.
We entered the professions to offer a positive model of healthcare. Nihilistic approaches to patients in need of effective, compassionate care can only be overcome by respect for the skills and expertise of those who certainly did not enter their profession to kill their patients.
The NMC, in their Care Booklet, stress that nurses must promote dignity and self-worth. This involves showing empathy and encouragement. For patients or their relatives to feel that the patient would be better off dead, does not promote their self-worth. And yet, if Assisted Suicide is legalised, many will equate dignity with death and killing will become an option for the poor care which should be responded to with truly compassionate and dignified care.
What then, are dignity and compassion?
We are bombarded with the term “Dying with Dignity”. A natural death is dignified, if proper palliative care is undertaken. Moreover, human worth and dignity is not contingent on physical condition. Dignity is not a commodity to be traded in, nor is it to be handed over to the state. It demands our response of respect, honour and reverence, to be preserved, and maintained by a culture of love. It cannot be degraded, it is irreducible in each and every human being.
The Nursing and Midwifery Code says that we must make the care of the patient our first concern. The verb to Care is from the Anglo Saxon 'to trouble oneself ', or 'to put oneself out'. This means that according to the code all nurses will meet needs of their patients inclusively, without discrimination to bring about an improvement in the present inability, if possible, or to maintain as much of their quality of life as possible. True care does not undermine the relationship with patients. It involves compassion for the patient who is dealing with serious illness, not abandoning them to the realisation that we will eventually offer death as a way out.
Requests for assisted death usually arise from a person who is depressed, or whose symptoms are not controlled, and/or are fearful of what is before them, like abandonment. If symptoms are not relieved and fears not addressed, by referrals to the appropriate members of the MDT for their specific expertise, we are not meeting the holistic needs of the patient and this is a derogation of care and a breach of our Code of Conduct.
What about autonomy and patient choice?
Many patients are happy to relinquish their once cherished notion of 'autonomy' due perhaps to their exhaustion, weakness, and touching trust in the goodwill of their carers for their best possible medical and nursing interests. We have a duty to ensure such trust is never misplaced.
I have worked with nurses from Holland who have told me that they came to this country in an attempt to maintain their skills in Palliative Care and where:
'the speciality in the UK is still considered to be safe for patients in comparison with Holland where poor patients are devising wrist bands prior to admission to hospital, stating 'no euthanasia' or travelling to where euthanasia is not legal to avoid themselves being put at risk of it'.
No patient should ever be caused to be fearful of the law in a hospital or home care setting and the imposition on them of a 'duty to die'.
It is degrading to nurses and doctors to expect them to become killers instead of carers. But it is a mistake, however, for us to think that the majority of rightthinking people are immune to evil influences and that only those predisposed to evil influences succumb to them. George Gissing wrote, long ago, “Even the good man becomes ready for any evil to which contagion prompts him”.
A Belgian study of reporting in 2012 found that 32 per cent of assisted deaths were performed without request. The nurses involved had considered that they would be better off dead, whilst 47 per cent of assisted suicides in the Flanders region go unreported.
It was found that those who died by assisted suicide without request were usually a “vulnerable patient group” who were incompetent, did not have cancer, were admitted to hospital and were over the age of 80.
I believe this Bill if passed will 'cross the rubicon' in its inevitable destruction of:
- the absolute expectation of trust between patients, families and carers
- the destruction of palliative care.
Dame Cicely Saunders promoted the Hospice movement in this country and her quote summarises what nurses and doctors are trained to do:
"You matter to the last moment of your life, and we will do all we can not only to help you die peacefully, but to live until you die."
Our patients warrant a professional relationship of goodwill unimpeded by false compassion or by their carers acting as agents of the state. Attempts by nurses to resist expected changes to their truly caring role would, no doubt, result in being bullied and hounded out of the profession for a lack of so-called 'compassion' when not willing to comply with such a law.
Ultimately, do the people of this country really want caring professionals to leave their chosen careers as a terrible consequence of this proposed law when the need by patients for those who truly care is more urgent than ever?
How would you conclude?
Legal physician assisted suicide should be rejected by Parliament no matter in what form it might be presented. No amendment or safeguards can make such a Bill acceptable in a civilised society which has committed itself to the Universal Declaration on Human Rights and the European Convention on Human Rights.
- High quality palliative care should be available to all who need it - this would overcome many of the reasons people call for clinically assisted suicide
- Involving nurses in assisted suicide would undermine the nurse-patient relationship and frighten vulnerable people
- Mindful of the nursing code which expects nurses to comply with law of the country in which they practise, it would be difficult for nurses to opt out of legal expectations of assisted suicide legislation
- Many nurses, Christian and otherwise, have moral or religious objections to assisting suicide.
- The Bill normalises the concept that some lives are not worth living which is contrary to a core nursing belief in the intrinsic value of life
- The most vulnerable patients may choose death in order not to burden their families
In my professional experience, patients look to their carers to affirm their lives, not offer them death as a defeatist, cheap and easy option.
We are all more than purely physical beings. Total patient care means being responsible for assessing all patient needs: physical, social, psychological or spiritual. In my long nursing experience, I have had patients say when they knew we were always trying to help them: ‘this is the happiest time of my life’. Time preserved, allows unfinished business to be addressed and completed and relationships healed.
Teresa Lynch RGN.
Teresa is the Chairperson of Nurses Opposed to
276 King Street, London W6 0SP.