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cmf file 9 (2000) - physician-assisted suicide

Every time that UK politicians have considered euthanasia, they have concluded that it is wrong and that it would be unhelpful to make it legal within our society. Some people are now suggesting that we consider physician-assisted suicide (PAS). However, although some doctors say that it 'feels' different, in reality PAS is simply euthanasia, one step removed.

Being in pain that is so severe that it occupies your life and being incapable of relieving it, is many people's worst nightmare. Similarly some worry that they will reach the point in life where they would like to die in relative peace, only to find that they are forced to receive massive and intrusive medical intervention that desperately attempts to prolong their life. Others panic about lying in a bed for months or years, while incapable of making any responses to family, friends or hospital staff.

These sorts of fears are leading people to ask whether there is a place for physician-assisted suicide (PAS). At first sight this call appears to be driven by compassion for the individual and to be a way of respecting their rights. However, making facilities available to help someone kill themselves may be more likely to reduce the respect that we have for human life in general and is not the most appropriate way of helping that person.

Christians believe that men and women are made 'in the image of God' and one of the results of this is that their lives are highly valuable. A consequence is that God prohibits anyone from deliberately taking the life of another human being. Opinions vary, but some Christians say that there are exceptional circum-stances where it is morally allowable to take life - the exceptions being extreme judicial situations, and in a 'just war'. The Jewish and Islamic faiths have similar prohibitions.

The definitions of euthanasia and PAS emphasise the moral, ethical and legal concept of 'intention'. There is a world of difference between a medical act designed to end life, such as a lethal injection, and withdrawing a treatment which is ineffective or inappropriate [CMF File No. 7]. One is killing. The other is good practice. The medical and legal professions have always recognised the difference.

Two definitions

The CMF defines Euthanasia as the intentional killing, by act or omission, of a person whose life is felt not to be worth living.

The word comes from the Greek eu-thanatos, which literally means 'well-death' or easy-death. It is sometimes referred to as 'mercy killing'. In the medical environment it is normally used when a doctor prescribes and gives a lethal dose of medication.

Physician-assisted suicide is where the doctor prescribes a lethal medication, but the person administers the dose himself or herself.

A call for compassion

Compassion, the feeling of distress and pity for the suffering or misfortune of another person, is a major argument for PAS.

However, the compassion argument is misplaced, because the best way to show compassion for a person is to care for them. A combination of the hospice movement and advanced medical technology now allow pain and distressing symptoms of disease to be adequately alleviated in all but the most extreme cases. Experience shows that once people are comfort-able they often change their minds about wanting to end their lives.

The best way of giving a person true dignity, and respecting their value, is to care for them and make their life as comfortable and fulfilling as possible. This is a much stronger action than simply giving up on them and promoting their death.

In many respects, when death comes, the more natural it is the more dignity it affords.

Asking to be autonomous

Some people have demanded the right to PAS (and euthanasia) because they claim to put strong emphasis on the rights to autonomy (self-determination). However, having the right of autonomy is not easy to define.

In recent years, there has been a healthy move away from medical paternalism, with its restrictive idea that the doctor knows best. But as John Donne said, 'No man is an island, entire of itself; everyone is a continent, a part of the main.' [1] The actions of a person who takes his or her own life have profound effects on those who live through the tragedy. That person exerting their right to autonomy has removed the same right from the survivors.

In addition, the free exercise of autonomy with respect to PAS could decrease our notion of the value or worth of vulnerable people.

Autonomy is fine so far as it reflects the unique individuality of each human being, created 'in the image of God', and ultimately accountable to him. But to use our autonomy responsibly, we need to balance our rights (the things we may do), responsibilities (the things we must do) and restrictions (the things we must not do). Autonomy is not therefore the same as saying that people have the right to do whatever they like.

Furthermore, depression, confusion, unrelieved physical symptoms, a sense of 'being a burden', conscious and unconscious pressures from family, friends, carers or society could all remove the person's true autonomy. It seems highly likely that one or more of these factors would be operating in the vast majority of requests for PAS (see case history).The problem is that when a patient who is in pain or suffering asks to die there is good reason to think that the request is compelled by the pain, and not in fact freely chosen [2], [3].

A case history

Once depression and other symptoms have been treated, patients may change their minds:

Sixty-five year old John was found to have lung cancer following a chest X-ray carried out to investigate a bad cough. The cancer was advanced and could not be cured.

Over the next few weeks, John became breathless when he walked and developed pain in his chest. He also became withdrawn and depressed and worried more and more about the stress his illness was causing his wife.

For several weeks he repeatedly asked his GP to help him to die because he could see no point in carrying on with more suffering. The GP prescribed stronger painkillers, antidepressant tablets, and referred John to a specialist hospice nurse. She visited him and his wife regularly at home and listened to their anxieties and fears. She helped to adjust his medication until the pain was controlled most of the time and his spirits had lifted. She arranged for John to visit the hospice day centre one day a week so that his wife could have a rest.

John talked with other patients there and took up an interest in painting. He stopped asking to die, even though his condition was gradually deteriorating.

He died at home three months later, having told the staff how glad he was not to have died when he had wanted to, but to have been given a chance 'to live', even though he was dying.

Finally, unlike suicide, PAS is not a private act. By definition, PAS requires a doctor to be involved, and so the patient's decision impinges on the doctor's autonomy.

Don't want to be a burden

There is a real danger of people asking to end their lives because they don't want to be a burden to families or friends. The burden could be expressed in terms of time, money or even the emotional cost of caring for someone who is in need.

In asking for PAS people may be hoping to relieve the stress placed on their families. They may also feel that the amount of time and money that the health service is devoting to them would be better spent on others. If PAS was allowed there would be a real danger of people being persuaded to ask for it. This could be by overt cajoling, or through deliberate neglect of the family [see Experience overseas below].

Healthcare professionals may also add to the pressure by their attitudes towards the resources being used to look after the person. In reality, it is very difficult for family members or even involved healthcare professionals to make appropriate judgements about the value of another person's life.

However, the hallmark of a healthy society is how well it looks after its weakest and most vulnerable members. Rather than looking to provide a 'way out' for these people, we should be looking for more effective ways of caring for them.

Trust and service

Doctors have a privileged relationship with their patients. It is one that is fundamentally built on trust - trust that the doctor will always act in a way that seeks to do them no harm. This relationship has been recognised and fostered in a series of ancient and modern oaths and codes of practice.

Legalisation of PAS would give the doctors enormous new powers over life and death. This has the real possibility of removing the patient's innate trust in their doctor.

Policing any law allowing PAS would be extremely difficult, particularly because the key witness in any enquiry would be dead.

At the same time, society would start to lose the idea of the benefits that can come from learning to serve and care for people in need. What could start off as an idea to modernise the way we look at care, could all too easily mean that we lose medical or nursing facilities and our abilities to care for those who are in need but do not want to cut their lives short.

More than that, PAS could start to alter the way that society views both death and disability and, as a consequence, society could become less caring all round. People who are difficult or costly to care for may be seen as second-rate citizens. We could also become detached from reality, believing that there are quick-fix solutions to all difficult problems.

Oaths and Declarations

For more than 2000 years medical practitioners have used oaths and declarations as a way of committing themselves to particular ethical principles. Studying them shows a central respect for the value of human life. >

Hippocratic oath (ca. 400 BC)

'I will give no deadly medicine to anyone if asked, nor suggest such counsel.'

Declaration of Geneva (1948)

'I will maintain the utmost respect for human life from the time of conception; even under threat I will not use my medical knowledge contrary to the laws of humanity.'

International Code of Medical Ethics (1949)

'A doctor must always bear in mind the importance of preserving human life from the time of conception until death.'

Declaration of Oslo (1970)

This declaration reaffirmed the 'utmost respect for human life from the time of conception'.

Statement of Marbella

'Physician-assisted suicide, like euthanasia, is unethical and must be condemned by the medical profession.'

International Code of Medical Ethics (1983)

This code maintained that 'a physician must always bear in mind the obligation of preserving human life'.

The law and suicide

There is a popular misconception that the 1961 Suicide Act gave someone the right to take their own life. In fact the Act decriminalised the act of suicide, but every effort is made to prevent a person from committing it.

The general principle is that people who want to kill themselves are considered to be ill and in need of treatment and care.

This is recognised in the UK government's White Paper on health entitled Saving Lives: Our Healthier Nation [4], in which one of the key goals is to reduce the rate of suicide by 'at least a fifth' by the year 2010. Introducing PAS would be an obstacle to achieving this goal.

Experience overseas

Few countries allow any form of PAS or euthanasia. The principle exception is The Netherlands, where although it is not allowed by statute, the law accepts a standard defence from doctors who have adhered to official guidelines. These require that the patient's request was voluntary and that their distress was unrelievable. It is not a condition that the patient is terminally ill or that the suffering is physical.

When a committee from the House of Lords visited The Netherlands to see how well their system was working they were not impressed [5]. Official Dutch statistics show that of the 3,000 people who died by euthanasia, there was no evidence of any voluntary request having been made by the person in over 1,000 cases [6].

This shows that PAS can be the start of a slippery slope that leads to unrequested euthanasia.

In the USA all of the States with the exception of Oregon forbid any form of mercy killing. On October 27, 1997, Oregon legalised PAS in the face of opposition from the American Medical Association as well as church leaders. The Death and Dignity Act allows for patients who have a significantly and irreversibly diminished quality of life to obtain drugs from their doctor that can help them commit suicide.

Official figures suggest that fifteen people died by lethal overdose in 1998 in Oregon [7]. But the report points to flaws in the legislation that could lead to under-reporting. For example physicians have the option of not reporting a case if it involved the violation of a guideline.

Debate in the USA was rekindled when in April 1999, a court in Michigan sentenced Dr Jack Kevorkian to a minimum of 10 years in gaol for the second degree murder of 52-year-old Thomas Youk, a man who had amyotrophic lateral sclerosis. Kevorkian, who has campaigned for the legalisation of both euthanasia and PAS, claims to have assisted in 130 suicides.

Positive provision

There is a genuine contradiction between good medicine and killing people. The provision of hospices and palliative care have clearly shown that there is a positive alternative to PAS which involves killing pain rather than killing patients. However, that provision comes at a cost. The House of Lords Ethics Committee concluded that: 'Rejection of euthanasia as an option for the individual entails a compelling social responsibility to care adequately for those who are elderly, dying or disabled.'

Of course everybody wants to have a good death for themselves, their loved ones and their patients, but a good death is not the same as simply having a convenient one.

Further Reading

  1. Euthanasia - An edited collection of articles from the Journal of the Christian Medical Fellowship.
  2. Euthanasia and Physician-assisted Suicide - for and against (1998) Dworkin, Frey & Bok. CUP - New York.
  1. John Donne (1623) Devotions, 17
  2. Jochemsen H & Keown J (1999)J Med Ethics; 25: 16-21
  3. Campbell N (1999) J Med Ethics; 25: 242-4
  4. Saving Lives: Our Healthier Nation (1999) CM4386
  5. Report of the Select Committee on Medical Ethics - Session 1993-94. HL Paper 21-I
  6. van der Maas et al (1991) Lancet; 338: 669-674
  7. Chin et al. (1999) New England Journal of Medicine; 340: 577-583
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