Published: 1st March 1993
In Spring 1993 CMF was invited to make a Submission to the House of Lords' Select Committee on Medical Ethics, whose terms of reference were:
'to consider the ethical, legal and clinical implications of a person's right to withhold consent to life-prolonging treatment, and the position of persons who are no longer able to give or withhold consent; and to consider whether and in what circumstances actions that have as their intention or a likely consequence the shortening of another person's life may be justified on the grounds that they accord with that person's wishes or with that person's best interests; and in all the foregoing considerations to pay regard to the likely effects of changes in law or medical practice on society as a whole.'
Responses were sought to nine specific issues.
Christian Medical Fellowship is interdenominational and has as members more than 4,000 British doctors who are Christians and who desire their professional and personal lives to be governed by the Christian faith as revealed in the Bible. We have members in all branches of the profession, and through the International Christian Medical and Dental Association are linked with like-minded colleagues in well over 50 other countries.
We regularly make submissions on ethical matters to Governmental and other bodies and are grateful for this opportunity to comment on the difficult issues falling within the Terms of Reference of the House of Lords' Committee.
The following extracts from our Affirmation on Christian Ethics in Medical Practice are relevant to this Submission:
We hold the Bible to be the revealed Word of God and find this helpful in our approach to thinking about issues related to euthanasia, but recognise the complexity of the questions before the Committee.
We find from Scripture that the biblical concept of justice is balanced by the biblical concept of mercy, and hope that our own resolution of this balance will be clear in the following attempts to respond to the nine specific issues raised. Our answers here will inevitably refer to points explicit or implicit in the Committee's Terms of Reference, and for the sake of brevity we will comment on these Terms only in passing.
Contrary to popular belief, this is not in fact a biblical expression but it is a biblical concept, derived from an understanding of:
Thus we 'maintain the deepest respect for individual human life from its beginning to its end' -- but we do recognise that human life in the physical sense has a natural end. A goal of medicine is to recognise that natural end, and we see no requirement to give all possible treatments to all possible patients in all possible situations just because those treatments exist. It is precisely this sort of meddlesome medicine which does not recognise that the natural end is drawing near that has led to over-treatment of some patients and is part of the background to the Committee's discussions.
In other words, while believing it is always morally wrong and always unnecessary (see Section 8 below) intentionally to kill patients, we also recognise that a time may come when interventionist treatment need not be started or continued, and the patient should be allowed to die, with all appropriate care given. This is not euthanasia but good medical practice.
Over the last 20-30 years there has been a general move away from 'paternalism' (best summed up in the old language of 'doctor's orders' and 'doctor knows best') and towards 'autonomy'. Literally meaning 'self-determination', the concept is of 'rights' -- in particular the right implicit in the well-known saying 'Whose life is it anyway?'
It is sometimes suggested that the 'sanctity of life' concept is solely a religious one, and that the language of 'autonomy' is secular and humanist. We do not accept this. As Christians, we are happy with the language of autonomy in so far as it reflects the unique individuality of each human being, created 'in the image of God', and ultimately accountable to Him.
However, we further recognise that humans are created for relationships, and are inevitably in relationships in society. We are glad therefore that the emphasis on rights in the first paragraph of the Committee's Terms of Reference is balanced by the concepts of responsibilities and restrictions implicit in the final paragraph on 'the likely effects of changes in law or medical practice on society as a whole'.
As Christians we view these three concepts as follows:
We are concerned that in a number of areas in medical ethics and elsewhere society has recently over-weighted rights and neglected the necessary balance with responsibilities and restrictions. We emphasise though our support for autonomy and our conviction that patients and their families should always be consulted as much as possible.
Autonomy is one of the main arguments used in favour of voluntary euthanasia, and we use this section to make some further comments here.
We believe these four points mean that respect for autonomy is an argument against voluntary euthanasia, and trust that the Committee will consider them in its deliberations on the second paragraph of its Terms of Reference.
We accord human life the highest value but recognise that it has a natural end and we have no duty to prolong dying. We respect autonomy and therefore reject voluntary euthanasia. We believe that conflicts between the two moral principles only occur if either is carried to an extreme.
As a fellowship of doctors we are nevertheless concerned that this issue has been expressed here as 'a doctor's duty of care'. Healthcare nowadays almost always involves many people: a hospital or general practice multidisciplinary healthcare team (involving nurses, physiotherapists, occupational therapists, technicians, social workers, administrators, the chaplain, etc) and of course family members and voluntary carers.
Many different people thus have a 'duty of care'. Doctors do indeed have a duty of care but they are also, and perhaps primarily, responsible for treatment. We believe that confusion between the concepts of medical treatment and basic care in the recent series of verdicts on Tony Bland, for example, did not help the decision-making process, and we hope the Committee will be able to clarify the position.
We do not see that the Courts needed to be approached about medical treatment decisions such as whether antibiotics could be withheld in the event of Tony Bland getting a chest infection, but do believe that more weight should have been given to the opinion of the nursing profession that feeding (even by naso-gastric tube) is always part of the basic care of all patients, except at the very end of their lives.
We have made it clear in (1a) above that there is a limit to the doctor's duty to give medical treatments, and we repeat that it is morally wrong to prolong the process of dying. However, we would argue that care must always continue and would wish to pay tribute to our colleagues in other disciplines and to the family and voluntary carers of our patients who do most of the caring at the end of life.
We are concerned that unless this confusion between medical treatment and basic care is resolved, recent and subsequent decisions may undermine this essential contribution.
Medical treatments may become inappropriate; basic care must always continue, and the many different groups of carers need every encouragement.
The Christian Medical Fellowship has always argued that the concepts of 'active' and 'passive' euthanasia are unnecessary and confusing. We believe it is more helpful to use the concept of intention. What did the doctor intend when he or she performed the act? What did the doctor intend when he or she omitted to act?
A deliberate intervention to end life is always morally wrong and should remain unlawful. An omission may be an example of euthanasia (and therefore morally wrong) if its intention is solely to cause death. However, an omission would be an example of good medical practice if its intention was, say, to maximise the quality of life remaining to the patient, or to respect the wishes of the patient and his family. The difference lies in the intention.
We recognise the danger that perhaps only the doctor truly knows his or her own intention, and for this reason would advocate that decisions of withholding or withdrawing treatment would normally be taken after the maximum possible discussion, with the patient, with family members, and with other members of the healthcare team, and according to accepted medical practice.
We are not impressed by academic debates which look at the philosophical question implicit in this issue in a vacuum, using artificial examples. Doctors and others will always have to implement medical ethics decisions in the front-line, and we believe that in the real world the concept of 'intention' greatly clarifies decision-making. It is a Christian concept, and one that is enshrined in our present law on homicide, as Mr Justice Ognall made clear in the Dr Cox case.
(We would emphasise again that while medical treatments can properly be withheld or withdrawn, care must always continue.)
The distinction to be made is not therefore between 'passive' and 'active' euthanasia but between good medical practice and killing patients.
The deliberate intervention to end life is always wrong. The morality of decisions concerning withholding or withdrawing medical treatment depends on the intention.
Because of our respect for autonomy, we accept that competent patients can refuse treatments and refuse care. For the reasons given in Section 1, we do not accept that patients should be able to make doctors kill them.
Cases of patients who are unable to express their own wishes are obviously difficult. Our Affirmation on Ethics records our special concern for 'the helpless' and we would draw the Committee's attention to the biblical principle that, contrary to the natural tendency, it should be the strong who give way to the weak. In other words, the disadvantaged may require positive discrimination in the form of extra-special care. Those 'unable to express their own wishes' are obviously in a special category of 'the helpless'.
Because of our total rejection of intentional killing, we would always rule out euthanasia as an option. (It would of course by definition not be voluntary euthanasia in these situations.)
Decisions about withholding or withdrawing medical treatments should be taken on the same basis as outlined in (3) above, except of course that the patient cannot be consulted. Even if treatment is withdrawn, care should continue.
We express especial concern about arguments involving the language or concepts of 'best interests' and believe that the Tony Bland case may illustrate that too much attention was paid to the best interests of others. For example, whilst we recognise the reality of resource constraints, society must never permit such considerations to lead to intentional killing.
There is no fundamental difference of principle in the approach to competent and incompetent patients. Intentional killing should never be considered for either group; withholding/withdrawing treatment decisions are more difficult with incompetent patients who deserve special protection; care always continues. 'Best interests' arguments need rigorous analysis as to whose best interests are being considered.
We want to give our patients the maximum possible involvement in their healthcare, and therefore accept that Advance Directives can be of some help in indicating patients' wishes.
However, we agree strongly with the British Medical Association that they should never become legally binding. Our reasons are as follows:
Finally, we question the real motive of Lord Allen's Bill, and its sponsorship by the Voluntary Euthanasia Society. The VES Advance Directive states 'that any distressing symptoms (including any caused by lack of food or fluid) are to be fully controlled by appropriate analgesic or other treatment, even though that treatment may shorten my life'. Legal powers are being sought to starve and dehydrate people to death. If these powers were obtained, it would not be long before it was argued that this was not 'compassionate' and that a lethal injection should rather be given as soon as the decision was taken. Thus we are concerned that legalised Advance Directives would sooner or later allow euthanasia in by the back door. We are opposed to them as legally binding documents.
Given the special problems of the incompetent, we recognise that some strategy is needed. In principle, we think that proxies are safer than pieces of paper signed years earlier, but in practice there would have to be many safeguards. There has been much less discussion about this concept and we wish to study carefully the recent Consultation Paper from the Law Commission on medical ethics and the mentally incompetent.
Advance Directives have some value as indicators of patients' wishes but should not have the force of law. We oppose Lord Allen's Bill. We give cautious approval to the concept of proxy decision-makers.
In general, we see the law as an inappropriate instrument for the sensitive decision-making needed in situations at the end of life. Given the one ultimate legal safeguard that intentional medical killing by act or omission would always be unlawful, we would argue that the law need have no place in any of these decisions.
They would be made by full discussion with all involved in the clinical situation, and according to accepted medical ethics, expressed in Codes of Conduct if necessary. We recognise that medical technology and practice are changing but believe that consensus views of all the relevant professions would be achievable, provided again that intentional killing was ruled out by force of law.
We would prefer no involvement of the courts except in maintaining a prohibition on intentional killing.
Following from Section 6, we are however concerned that there are implications in the series of decisions on Tony Bland which may have confused the previous legal safeguard and thus made the whole relationship between medicine and the law in this area far more uncertain.
If the law has to be involved further, we would support legislation which clarified the distinction between medical treatment and basic care and ensured that minimum standards of care always continue until natural death. Legislation should also reaffirm the previous prohibition on intentional killing, whether by act or omission.
We recognise that further legislation may now be forced upon us and if so believe it should ensure that care always continues until natural death. The previous prohibition on intentional killing should be reaffirmed.
Our response to this issue gives an opportunity to counter the other main argument used in favour of voluntary euthanasia, namely that of 'compassion', and to justify our earlier statement that euthanasia is always unnecessary. Hopefully, everyone in healthcare is committed to reducing suffering and all would agree that to leave people suffering unnecessarily would be immoral. The questions are, what means for relieving suffering are legitimate and what means are not? Is it ever necessary to kill the patient in order to kill the symptoms?
Quite simply, the hospice movement and its derived specialty, palliative medicine, have answered that last question with a resounding 'no'. In the presumption that our hospice colleagues will be making submissions and going into considerable detail here, we will confine ourselves for the sake of brevity to making a few general points.
As stated, the 'compassion' element of the voluntary euthanasia argument stands or falls on force majeure. Over-simplified choices have been presented: 'Either we have voluntary euthanasia legislation or patients must die in terrible agony from terminal cancer'. By research of the highest standards and creative care, the hospice movement has come up with a middle way, so that pain and other unpleasant symptoms are controlled in all but a tiny percentage of patients. So successful has this been that pro-euthanasia organisations no longer campaign on the grounds of pain.
A powerful argument against permitting any sort of euthanasia to be legalised is that it would rapidly remove any incentive to be creative in caring when we can no longer cure. We believe it is no coincidence that in The Netherlands where euthanasia is now sanctioned legally, there is very little of a hospice movement.
The drive for euthanasia now comes not from pain but from the concept of 'death with dignity'. We fully recognise that some diseases produce very distressing symptoms, but as Christians argue that man's dignity derives from being created 'in the image of God' and is reflected in the way in which the healthy view the sick, the way in which the strong view the weak. In other words, people should not lose dignity continually as diseases progress but should gain dignity from the way in which they are treated and valued.
In this context we hope the Committee will recognise that the very existence of pro-euthanasia legislation would send a strong signal that some lives were of too low a quality, perhaps 'not worth living', and would thus reinforce the negative images already all-too-prevalent in our society. This important comment is particularly relevant to the final paragraph of the Committee's Terms of Reference.
The success of palliative medicine where terminal illness is concerned gives us confidence that if the will were present, it is within society's ability to produce creative responses to problems like AIDS and dementia. There are already many encouraging initiatives and we are pleased that Christians are in the forefront of them. Conversely, we believe that if euthanasia in any form were permitted, we would soon lose that high standard of healthcare of which the UK can justifiably be proud.
We are not of course pretending that all is well. People do still have bad deaths and suffer unnecessarily -- but we would say this is bad medicine, and the answer to bad medicine is not killing patients but good medicine. We believe that good palliative medicine and similar initiatives should be encouraged, and we recognise that this means that society would have to pay the proper costs of such healthcare.
The hospice movement and good palliative medicine have shown how much can be done for the dying if the motivation is there, and should be encouraged. Similar initiatives need developing in other areas. Pro-euthanasia legislation would remove much of the incentive to care properly.
We are seriously concerned about The Netherlands, where as reported in The Lancet on September 14th 1991, the Remmelink Report of the Dutch Ministry of Justice confirmed that of the 128,786 deaths 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. We do 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.
Further evidence of euthanasia which is not voluntary occurs with the newborn. In The Lancet of March 27th 1993 Professor Versluys admits that 'about 10' babies are killed every year by acts of commission. In The Independent of February 17th 1993 it was reported 'a male child born with deformed genitalia is put to death because the doctors and his parents concur that he will have a poor quality of life'.
Much is made by those who advocate euthanasia of 'guidelines' and 'strict safeguards'. The Remmelink Report and other official Dutch figures confirm that their 'guidelines' are not followed -- one criterion is notification after death to the appropriate authority so that compliance with the guidelines can be confirmed. There were 3,300 euthanasia deaths in 1990 -- the number reported was 454. The fact that Dutch society tolerates situations like these further undermines respect for 'law'.
These figures speak for themselves. They demonstrate clearly that euthanasia which is tolerated (and now 'legally sanctioned' in The Netherlands) cannot be policed -- not least because the 'key witness' is dead. We trust that the Committee will assess the Dutch situation carefully, when we are confident that it will conclude against the legalisation of euthanasia.
The medical culture is different in the United States, with a possible tendency by UK standards to over-treat patients. This can make comparisons difficult. Further, there is a range of experience there because of different policies in different States on, for example, assisting suicide. The situation is under review by the American professions, but we would draw the Committee's attention to the outcome of referenda held in two States -- in November 1991 the voters in Washington rejected euthanasia by 54-46%, and in November 1992 California similarly rejected it by exactly the same margin.
In addition, there has been a huge natural experiment going on across the USA since December 1991 on the effect of legalised Advance Directives, which initially do not seem to be making much difference. In the March 1993 Bulletin of Medical Ethics a review of an American paper concludes: '. . . the piece of paper itself does little, positive or negative: it will only be useful if it encourages doctors and patients to discuss the options more fully'. We would urge the UK to wait and see the outcome of this experiment.
Experience from The Netherlands confirms the truth of 'slippery slope' arguments against euthanasia. We recommend that the UK learns from Advance Directive legislation in the USA.
We hope that this brief discussion gives a clear overview and illustrates that our Christian principles would continue to work in practice. We believe that 'justice' and 'mercy' can be balanced, and that an appropriate Christian expression of 'autonomy' and 'compassion' can be achieved.
We hold that intentional medical killing is always wrong and with that safeguard protected in law believe that end of life decisions could best be made by all those involved in caring for patients, together with patients themselves where possible.
The whole of society would benefit further from improvements in medical practice in the context of a reaffirmation of our present law.
We repeat our gratitude for the invitation to contribute to these difficult discussions and wish the Committee well in their deliberations.
Steven Fouch (CMF Head of Communications) 020 7234 9668
Alistair Thompson on 07970 162 225
Christian Medical Fellowship (CMF) was founded in 1949 and is an interdenominational organisation with over 5,000 doctors, 900medical and nursing students and 300 nurses and midwives as members in all branches of medicine, nursing and midwifery. A registered charity, it is linked to over 100 similar bodies in other countries throughout the world.
CMF exists to unite Christian healthcare professionals to pursue the highest ethical standards in Christian and professional life and to increase faith in Christ and acceptance of his ethical teaching.