Contribution from the Guild of Catholic Doctors
Royal Colleges of Physicians and General Practitioners Working Party
Thank you for giving us the opportunity to contribute this to the combined Colleges Working Party on Euthanasia.
The definition of terms is central to an informed discussion. The Catholic understanding of euthanasia has always been "an act or omission which of itself and by intent ends life for merciful reasons". (S.C.D.F. 1988)
This definition however, does require further explanation particularly in relation to omission. Catholic thinking does not hold that life must be prolonged by all means possible and only ordinary means are obligatory. Here ordinary would be taken to mean commonplace or usual. It would not extend to artificial ventilation or haemodialysis or chemotherapy. It would certainly not exclude however, water or nourishment given by a simple nursing procedure such as gastric tube.
Other procedures such as the per cutaneous endoscopic gastroscopy (PEG), is clearly an operative procedure requiring informed consent and is part of medical treatment. The use of the tube once in situ, however, would constitute assisted nutrition. For a nurse to pass an N.G. tube would be regarded as part and parcel of basis nursing care and indeed is commonly considered to be part of the category of total nursing care accepted by nursing authorities. The other area in which tubal feeding is entirely routine and ordinary is in the new_borns, who have not achieved sufficient maturity for coordinated swallowing. Furthermore, we would note that many patients who have lost their capacity to swallow regain it at some stage.
VERY DEPENDENT PATIENTS
The way in which we approach and care for our most compromised patients is truly a touch stone of medical practice and indeed of the humanity of doctors themselves. The denial of one of the essentials of life, namely water, with the suffering that is entailed is simply not acceptable in British medicine.
Were it to be generally accepted, then there would be a gradual erosion of values. First there would be an extension of the categories of patients considered to have an insufficient "quality of life". It would begin with those thought not likely to recover sentience, extend to those who are not quite in this condition, and then on to others who have suffered major neurological loss but retained sentience. Ultimately a large pool of the elderly with senile dementia might be encompassed as well as handicapped new_borns and young people with devastating illness. We have noticed such a drift towards patients with swallowing difficulties even if these are only of minor degree and who have been inappropriately sedated. Subsequently they become totally dependent and may die from dehydration or malnutrition.
Whilst the Colleges and Associations concern themselves with the headline topics of "euthanasia" and "doctor assisted suicide" there is a growing public awareness that medical care is becoming deficient regarding the nutrition of vulnerable persons. We hold most strongly that the Colleges should address the questions of good medical practise in this area and advise against inappropriate sedation or nutritional and hydrational neglect. Anyone who has seen the harrowing death that follows the withdrawal of water cannot doubt that it is one of the most powerful arguments in favour of euthanasia. Thus it is inconsistent for medical authorities to neglect this area whilst publically declaring they are against euthanasia.
THE BMAs DOCUMENT "WITHHOLDING AND WITHDRAWING LIFE PROLONGING MEDICAL TREATMENT"
We note that this document actually employs terminology which is in itself prejudicial to very vulnerable patients. Why does it speak of life prolonging when what is really meant is life sustaining in the non_dying? Likewise, why does it refer to artificial nutrition rather than the assisted giving of food and fluid? That is not to say, of course, that there are not truly artificial methods of nutrition such as total parental nutrition but it is misleading to equate this with simple tube feeding. Furthermore, we think this confusion is intended in order to medicalise decisions which are effectively life and death decisions concerning the nourishing of helpless people.
There is concern also about the phrase clarification of the law which in the past has usually become synonymous with relaxation of the law and the taking of these decisions from independent courts into medical hands. Bedside decision making will always be arbitrary unless there are strong and nationally recognised guidelines in place. So far neither the Colleges nor the BMA have addressed this issue.
The principle thrust of the document appears to be the protection of doctors from possible criticism or prosecutions. Whereas this is an important aspect, it should be secondary to an affirmation of good and ethical medical care and the well being of patients. After all this document was produced by an ethics committee not a legal one.
THE ROLE OF THE COLLEGES
The role of the Colleges is clearly of utmost importance. The working party has very helpfully set itself the task of defining legal and illegal practises and advising the profession. We understand that they are not going to call for a change in the Law. This is to be welcomed but the Colleges and their working party are not however empowered to call for a change in the Law and opinion in Parliament is clearly against both relaxation of the prohibition against aiding and abetting suicide and legalising euthanasia. Therefore, the Colleges is very properly reflecting the legal climate. On the other hand the way in which the Colleges view these other vital issues which are of growing concern to members of the public and the profession, is an indicator of their outlook and will ultimately determine fimrther developments.
We therefore urge them to address these important matters in their final document.
We thank you again for this opportunity to make our views known and will be happy to enlarge upon them if required to do so.