Ethics

Introduction

Each of the seven editions of the CMF Journal from January 1992 to July 1993 carried an article on a different aspect of the euthanasia debate, which was then raging nationally. These articles were later lightly edited and bound together as a CMF booklet[1], which came out in 1994.

This article is a brief overview of the world scene, attempting to answer the question: What has happened in the last three years?

'There should be no change in the law to permit euthanasia'
were the first words in the press release from the House of Lords Select Committee on Medical Ethics, which accompanied their full Report[2] published on February 17th 1994. This Committee had been set up after the Dr Cox and Tony Bland[3] cases, and it sat for a year taking written and oral evidence. Christian Medical Fellowship made a Submission[4], and individual members of CMF gave oral evidence on behalf of several different bodies.

The Committee was widely expected at first to come down strongly in favour of legalising voluntary euthanasia, then as 1993 went on there was the expectation that a small majority might conclude against legalisation, but then in 1994 came their unanimous rejection of a change in the law. Why was this?

It is worth quoting at length from the press release[2] which effectively summarises their full Report:

'Contrary to many expectations, the 14 members of the committee have reached a unanimous conclusion. They acknowledge that in difficult individual cases euthanasia may be seen by some to be appropriate, but argue that wider social considerations make its practice undesirable. 'The issue of euthanasia is one in which the interest of the individual cannot be separated from the interest of society as a whole.' The committee argue that individual cases are not sufficient reason to weaken the prohibition on intentional killing which protects us all.'

They also conclude that if the law permitted euthanasia, elderly and vulnerable people would feel 'pressure, whether real or imagined' to request it, and that it would not be possible to set secure limits on its practice. 'It would be next to impossible to ensure that all acts of euthanasia were truly voluntary, and that any liberalisation of the law was not abused.'

Although rejecting euthanasia as an option, the committee do call for a number of other changes.

They recommend improved public support for the hospice movement, more training in palliative care, and more research into pain and symptom control.'

Why then is there still so much pressure?

Right in principle and right in recommendations for practice, this Report received overwhelming support in a high-quality debate in the House of Lords on May 9th 1994, during which a long extract from a CMF Journal article was read out, and in a white paper response[5] from the government at about the same time.

So why wasn't this wisdom the last word on the matter? Why, less than three years later, is there still so much pressure? The answers are fourfold:

1. As far as the media are concerned, good news is no news. There remains widespread ignorance that this Committee ever sat and that the whole examination ever took place!
2. Some patients are still having bad deaths. There will always be pressure for euthanasia while patients have bad deaths.
3. Much of the UK remains unconverted. One of the many achievements of the 1993 campaign was the unanimity amongst the Christian church[6,7] that euthanasia was wrong. Scripture is clear[8], and Christians have realised how both the earthly and eternal perspectives of Christianity change the debate.
4. In addition, there have of course been developments internationally and in the UK itself which have put the pressure on. These will now be reviewed.

International Developments

Australia
At one stage it looked as if several of the different Australian States would legislate for euthanasia, but in the end only the Northern Territory went for it. Northern Territory has a land mass about the same size as France and Germany combined, but has a population of only 150,000. Many of these are Aborigines. Chief Minister Marshall Perron had seen a ministerial colleague die of cancer in 1989 and then in 1994 watched his mother suffer what was described as 'an agonising death'. Normally conservative in his life and politics, he proposed a Bill for voluntary euthanasia and this was voted into law (by 13-12 on the first and most crucial vote and then by 15-10) on May 25th 1995.

An interesting alliance of the 'three As' - the Australian Medical Association, the Anglican church and the Aborigines - sought to block this legally. At the time of writing, two challenges, in Northern Territory's High Court and in the Federal Court in Canberra, still stand, and in terms of legal process these have a significant chance of succeeding. However, one challenge failed, and the law technically came into force on July 1st 1996.

Whether he jumped the gun or not, Dr Philip Nitschke, a middle aged GP and euthanasia enthusiast in Darwin moved the public perception on dramatically when on September 22nd 1996 he ended the life of 66-year-old former carpenter Bob Dent, who had suffered with prostatic cancer since 1991. Some perceive Mr Dent as ending his own life when he answered three questions on a laptop computer supplied by Dr Nitschke, pressed the space bar, and activated an IV infusion of three drugs (thiopentone, pentobarbitone, and atracurium)[9]. The pro-euthanasia lobby welcome this technology, claiming it keeps the patient in total control, and although the Northern Territory legislation is clearly called the 'Rights of the Terminally Ill Act', it is being promoted as an example of physician assisted suicide. The relevance of this apparently new concept in the whole debate will become clearer later in this article.

USA
State-wide citizens' referenda to allow lethal injection euthanasia had failed narrowly in Washington in 1991 and in California in 1992, but in November 1994 the state of Oregon passed Measure 16 by 53-47%. This gives qualifying patients (capable adults and residents of Oregon) with six months or less to live the right to ask the attending doctor for drugs to end their lives 'with dignity'[10]. Again, 'physician assisted suicide' has seemed more palatable.

Appeals started and this statute is currently awaiting a final US Supreme Court ruling, probably early this year. However, in a worrying ruling in March 1996 affecting nine western States, a US Federal Appeals Court judge concluded that a dying patient has 'a strong liberty interest in choosing a dignified and humane death rather than being reduced at the end of his existence to a childlike state of helplessness, diapered, sedated, incompetent'[11].

This verdict was echoed a few weeks later when the Second Circuit Court of Appeals struck down a New York State law that prohibited physicians from helping their patients die[12]. Both these decisions are to reviewed by the Supreme Court.

However, it is not necessarily the courts who really rule. All this time, retired Michigan pathologist Jack Kevorkian has been continuing to end patients' lives. By mid-September 1996 he had notched up 40 killings[13], and courts had so frequently failed to convict him that it is currently unlikely he will be prosecuted again. Law that is not enforced is law that is not respected, and law that is not respected has effectively been overturned.

In what was in my view its most outrageous leading article ever, the British Medical Journal described Jack Kevorkian as 'a medical hero'[14]. The subsequent correspondence was decisive: seven letters 'against' published, and 'we received 17 other letters about the editorial, all of which expressed views similar to those published here' [15]. We may think that 24-0 isn't a bad score, but has that editorial done lasting damage around the world?

The Netherlands
It was the visit to Holland of some members of the House of Lords Select Committee that was the single most significant factor influencing their eventual unanimous rejection of euthanasia. The Remmelink Report of 1991[16] had shown that of 128,786 deaths in the Netherlands in 1990, 1.8% were due to 'euthanasia', 0.3% to 'assisted suicide', and 0.8% to 'life-terminating acts without explicit and persistent request'.

In other words, euthanasia was performed on more than 3,000 people in the Netherlands in 1990, and in more than 1,000 of those it was not voluntary. In its Submission to the Lords Committee[4] CMF did not 'accept the morality of those cases in which euthanasia was 'voluntary', but here is unequivocal evidence of the reality of the 'slippery slope' - where 'voluntary' euthanasia is tolerated, there is an inevitable progression to euthanasia which is not voluntary'.

The slide down the slippery slope has continued in Holland. In June 1994 the Dutch Supreme Court convicted but declined to punish a psychiatrist for assisting the suicide of a physically healthy patient with 'a depressive disorder in the narrowest sense'[17]. Where children are concerned, 'dissension exists regarding active euthanasia in the newborn, both opinions being respected'[18], and most recently we read that, allegedly, 'Dutch patients complain about poor access to euthanasia'[19]. This claim results from a survey by the Dutch Voluntary Euthanasia Society which 'will counterbalance the national review of euthanasia policy ordered by the ministries of health and justice...'

This review had not been published at the time of writing this article, but the Dutch are known to be stung by international medical criticism of their euthanasia practice and their relative lack of high-quality palliative care.

Back in the UK

These events overseas have had considerable media coverage in the UK, and have influenced the perceptions of a media and a public who've forgotten the conclusions of the extensive 1993-94 enquiry.

Possible euthanasia cases
There have been a number of high profile cases that did or didn't get as far as the Courts:

Nothing more was heard after the September 1993 report[20] of high levels of morphine being found in the exhumed body of a 25-year-old who had died of spinal cancer, and at about the same time a teenager was cleared[21] of aiding and abetting the suicide of a friend with multiple sclerosis to whom he'd given paracetamol tablets.

In a bizarre verdict in October 1994, the coroner for Avon included the word 'euthanasia' in his verdict on the death of an 87-year-old woman with some symptoms of Alzheimer's disease who had suffocated herself with a plastic bag[22], and in December 1994 the Crown Prosecution Service decided not to prosecute a man who killed his terminally ill wife by a massive overdose of diamorphine from a syringe driver[23]. The CPS is claimed to have had sufficient evidence to prosecute, but 'apparently decided it would not be in the public interest to do so'.

On November 29th 1995 the CPS announced it was not going to prosecute a father who confessed in a tabloid newspaper and then at Poole police station to killing his seven-week-old terminally ill daughter because he could not bear to see her in such suffering[24]. Police had been advised there was insufficient evidence for a realistic prospect of conviction.

On March 27th 1996 a 'dedicated home help' walked free from Winchester Crown Court[25] after being 'charged with attempted murder and administering diamorphine to endanger the life of or inflict grievous bodily harm', concerning a client of hers who died in Southampton General Hospital in December 1994. The judge, Mr Justice Ognall, who had presided over the Dr Cox trial, stopped the case, ruling that her prosecution was not in the public interest, and a QC added that the case went 'beyond the strictly legal into greater emotive significance'.

Derek Rowbottom[26] admitted on national television in April 1996 that he had attempted to kill his mother in hospital with a morphine overdose, but after a lengthy CPS investigation he was not charged. 'His lawyer said the CPS took the view that there was no medical evidence that what the man did contributed to his mother's death.'[27] Widespread coverage of the Rowbottom case led to the headline in The Independent 'Dozens confess after son's 'mercy killing''[28].

In the case most recent at the time of writing, 37-year-old Paul Brady pleaded guilty in Scotland to culpable homicide, and was formally admonished but not given a custodial sentence. He admitted killing his 40-year-old brother who had Huntington's disease by smothering him with a pillow after an overdose of temazepam and alcohol[29].

Other cases
There have been two other high-profile cases involving children in Britain:

Two-year-old Thomas Creedon who had suffered from severe brain damage since birth died of natural causes on February 26th 1996, but his parents had campaigned for his artificial tube-feeding to be stopped, and the issue had reached court. This particularly difficult case had caused considerable debate[30].

Since July 1995 the parents of brain-damaged toddler Ian Stewart have campaigned continuously for his life to be ended by lethal injection[31].

Motor neuron disease patient Annie Lindsell has campaigned in Parliament and elsewhere for her 'right' to eventual euthanasia[32], and another MND patient recently 'won her case' for euthanasia 8-4 before a TV 'jury'[33].

Since the death in March 1993 of PVS patient Tony Bland, after the Law Lords confirmed his tube feeding could be stopped, there have been about 10 similar deaths, all following applications to the courts. Law Commission proposals[34] which included liberalising recommendations on this matter, as well as potentially dangerous legislation on advance directives and other controversies (amidst many good and necessary proposals for the mentally incapacitated, it must be added) were shelved[35] in January 1996, and at the time of writing the proposed public consultation programme has not begun.

As if all this were not difficult enough to follow, there have been other high profile cases about withholding medical treatments[36,37] which some have confused with euthanasia.

The media appear to seek soundbites and sensation, the medical profession has a lot else on its plate, the legal profession is moving in, and the public is understandably confused. So what happens next?

Physician Assisted Suicide

The Voluntary Euthanasia Society and the Scottish equivalent, the VESS are getting better organised. They know where they are going. Both have draft Bills for physician assisted suicide ready in case one of their (very few) supporters in the House of Commons gets a lucky ticket in the Private Members' Ballot.

They have chosen this approach as a soft way in to euthanasia - it was physician assisted suicide that was eventually successful with the voters of Oregon, it is PAS that is (wrongly) perceived by some as being the Northern Territory of Australia's approach, it is PAS which is popular with euthanasiast diehards because it (apparently) leaves them with the final control, and naive doctors may feel PAS is morally or practically different from euthanasia.

Few who have really considered the ethics can see any significant moral distinction, and most of the weighty practical objections remain. The House of Lords' Committee was dismissive: 'We recommend no change in the law on assisted suicide'[38]. Should such a Bill make a Private Member's appearance in Parliament, it can quickly be dismissed.

But do the VES/VESS expect to change the law upfront? They are relying on superficial public sympathy, questionable opinion polls, and getting away with it in the courts. If health professionals could perform euthanasia and be acquitted in court, which was the process in the Netherlands from the 1970s onwards, then they would come back later to 'clarify the law'.

VES General Secretary John Oliver:
'I doubt that the politicians will have the balls to change it themselves... they are too frightened of broad ethical debates and of the pro-life groups accusing them of Nazi-style eugenics. Instead, change will probably come in the form of judicial review, with the law being reshaped in the courts - exactly as it was in Holland, in fact.'[39]

So what do we do?

First, we remember that we have the arguments, and that we hold the ground. Although reporters new to the issue are invariably liberal and initially pro-euthanasia, every new story gives the opportunity to point out that in the lifetime of this Parliament, we have assessed the case for voluntary euthanasia more thoroughly than ever before in human history, and have concluded against it. The counter-arguments are watertight and that summary from the House of Lords' press release at the beginning of this review really says it all.

The counter-arguments

1. The compassion case for euthanasia stands or falls on the answer to the question: Do we have to kill the patient in order to kill the symptoms? The palliative medicine movement has shown that we can get good symptom control, and that patients can cope with residual symptoms provided they can find meaning and direction in the time that remains to them.
2. Patient autonomy is important, but there is no absolute autonomous right to euthanasia. The Lords' Report includes the words from Romans 14:7 'For none of us lives to himself alone and none of us dies to himself alone'.
3. The only logical argument for euthanasia is the economic one, and at the moment a large majority sees it instantly as immoral. At a time when like all countries in the developed world the UK has to make rationing decisions, euthanasia on economic grounds is a potential reality to be feared. Surely even those initially most sincere and idealistic in their support for voluntary euthanasia must recognise that?

Good medicine
Second, we must recognise that there are bad deaths happening still, but that is bad medicine, and the answer to bad medicine is not killing people, it is good medicine. We must work to improve professional standards.

Christian hope
Third, we must seek the conversion to Christ of our nation.

Conclusion

At a time when the national abortion debate is beginning to move our way at last, the pressure for euthanasia must still be taken very seriously. We have the arguments, we of all people should be able to inspire good medicine, and we must pray and work for the soul of the nation.