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Four reasons derived from respect for autonomy why euthanasia should not be legalised:

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1) Following the patient's autonomy impacts that of the doctor

It is self evident that where a patient's autonomy is followed to the extent of their receiving a prescription for lethal medication or being put to death at the end of a needle, the autonomy of the doctor is compromised.

The obvious riposte is: So what? There is a Conscience Clause in Lord Joffe's Bill. Doctors with objections do not need to be involved. But we know that the Conscience Clause in the 1967 Abortion Act has only worked partially, and that the legalisation of abortion has kept many doctors (of different faiths and none) away from obstetrics and gynaecology and from general practice. However, it is possible to get away from abortion issues as a doctor and still have plenty of career choice. But there is no branch of medicine where a doctor can entirely avoid issues of death and dying.

Further, the abortion conscience clause has only applied partially to professionals in some disciplines and not at all to some members of the health team. What impact therefore might euthanasia legislation have on the recruitment and retention of appropriate staff in all disciplines? Staffing is a key issue for the National Health Service and it would be foolish to add to an ever-growing problem.

2) Most patients have 'a question behind the question'

It is the experience of those working with the dying that the (relatively few) who currently ask for euthanasia usually have another question behind their question. This may be a physical question: they want a distressing symptom palliated. It may be a psychosocial issue: they want an honest discussion with their family about approaching death. It may be a spiritual question such as 'Why me?' or 'Why now?' When the real issue is dealt with, following the old adage 'no treatment without a diagnosis', the request for euthanasia goes away.

So to perform euthanasia, even with the proposed safeguards, would far more often undermine autonomy than underline it.

3) But there are some deliberated requests!

Why not euthanasia for them?

There are indeed a very few deliberated requests. Supporters of euthanasia ask with considerable compassion and force why, with safeguards, there cannot be a law to accommodate exceptional cases. The answer is a development of the one just given. For all the possible reasons hinted at in (2), and bearing in mind the uncertainty always about prognosis, to change the law to allow euthanasia for this small minority within a minority would mean that euthanasia would be performed far more often when all would agree it was 'wrong' than when some would see it as 'right'. For the sake of protecting that majority, the minority forego a right they don't actually have anyway.

This may be utilitarian but that is the way it has to be within complex, modern inter-connected societies. We all readily accept limitations on our 'freedoms' in order to protect vulnerable others - road traffic regulations being one example. And John Donne's famous words 'no man is an island' hint at the issues of community and relationships which are always there in the euthanasia debate. Respect for the right of autonomy has to be balanced with the restrictions that acknowledge responsibilities.

4) Allowing 'voluntary euthanasia' leads to euthanasia which is not

'Slippery slopes' do exist in the euthanasia debate. If we change the law to allow voluntary euthanasia for those who are suffering and have the capacity to ask for it, surely compassion means we should similarly provide euthanasia for that patient who is suffering at least as much but does not have the capacity to request it? This slippery slope of logic is an inevitable consequence of doctors ever deciding that any patient's life is not worth living. (Proponents of voluntary euthanasia may want to argue that it is the patient who decides - but they must be reminded that the doctor has to agree with them!)

There are other slippery slopes too, of practice and of changes in doctors' attitudes. The progression from voluntary euthanasia to non-voluntary euthanasia (the patient does not have capacity to make the request) or involuntary euthanasia (a patient with capacity is not consulted) is well documented in the Netherlands.

The 1991 Remmelink Report was a statistically valid analysis of all the 129,000 deaths in the Netherlands in 1990. 3% of them were by euthanasia. Of that 3%, 1 in 3, that is, 1% of all deaths in the Netherlands in 1990, were euthanasia 'without explicit request'. In 1990 Dutch doctors killed more than 1,000 patients without their request. This is not respect for patient autonomy but doctor paternalism of the worst kind, and European medicine has been there before.

Conclusion

The swing over the last 30 years from doctor paternalism to patient autonomy in UK medicine is to be welcomed, but autonomy has to have limits. These four arguments show that the person who truly supports patient autonomy rejects euthanasia.

A modified extract from 'Autonomy and the UK euthanasia debate' shortly to appear on the Centre for Bioethics and Public Policy website, www.bioethics.ac.uk

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