Rapid Responses to:

EDITORIALS: Len Doyal and Lesley Doyal Why active euthanasia and physician assisted suicide should be legalised BMJ 2001; 323: 1079-1080 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Moral Bankruptcy

Sri Varman   (9 November 2001)

Doctors as killers

Sally Rynne   (9 November 2001)

Why euthanasia and physician assisted suicide should NOT be legalised

Alison Davis   (9 November 2001)

A Physician's Duty

David Silverman   (9 November 2001)

The rights of Drs in suicide

George Dodds   (10 November 2001)

Death

R A Phillips   (10 November 2001)

Underutilized Executioners

Joel Thurm   (10 November 2001)

Fancy philosophical footwork but choreography is not coherent

Andrew Fergusson   (10 November 2001)

It is my right

David Henshaw   (10 November 2001)

Doctors do no harm

D Mistry   (10 November 2001)

A precedent for euthanasia

Santoch Rai   (10 November 2001)

Greater Good

Louise Beckham   (10 November 2001)

If autonomy is valuable, euthanasia should be permissible.

Danny Sullivan   (10 November 2001)

Confusion of Morals

Edward E Rylander   (10 November 2001)

Hypothetical moralisations

Roger Woodruff   (10 November 2001)

Observe what is happening elsewhere

Michael H K Irwin   (10 November 2001)

Desperate patients should be appropriately helped, not eliminated

Michele Tringali   (10 November 2001)

No to euthanasia

Paul McArdle   (10 November 2001)

I would want medical help to end my life if it became intolerable

Diane Munday   (10 November 2001)

Protection for those who wish to live

Elisabeth Le Strange   (11 November 2001)

Be guided by our humanity.

M D Oliver   (12 November 2001)

A blurring of distinctions

Iain B Craighead   (12 November 2001)

response to editorial 10th Nov

Yolanda Holderness   (12 November 2001)

When does means justify the ends?

Dilip Menon   (12 November 2001)

Medicine as dictated by ethicists

Andrew Farkas   (12 November 2001)

Specious arguments do not assist informed debate.

Timothy J Fetherston   (12 November 2001)

“…in the face of so much moral right, where is the wrong?”1

H van Woerden   (12 November 2001)

Why not legalize assited suicide?

Michael Loren   (12 November 2001)

Evidence and euthanasia

Peter Barratt   (12 November 2001)

The last right?

Simon Chapman   (12 November 2001)

A Response to Dr. Andrew Fergusson

Michael H K Irwin   (12 November 2001)

The Evil of Ignorance

Antony Tobin   (12 November 2001)

How do you influence legislation?

Anders Nordentoft   (12 November 2001)

Legalising Euthanasia would be a bad move

Huw Morgan   (12 November 2001)

Too simple by far

Margaret Whipp   (12 November 2001)

Don't be mislead!

Karen Sanders   (13 November 2001)

Who decides? Empowering patients

Roger M Goss   (13 November 2001)

"Active euthanasia"

C M Gaston   (13 November 2001)

Active euthanasia and physician assisted suicide:where is the wrong?

David Jeffrey   (13 November 2001)

Doctor assisted suicide

Tarra   (13 November 2001)

Re: The last right?

Peter Bradley   (13 November 2001)

Thanks to the Doyals

Jeremy Holford-Miettinen   (13 November 2001)

If only pro-choice doctors felt able to speak out more!"

Don Aston   (14 November 2001)

Outlaw medical killing

John Scotson   (14 November 2001)

?

Mark Blackwell   (14 November 2001)

A confused argument for legalised euthanasia

Stuart M White   (14 November 2001)

Euthanasie in Europe - the dilemma of differnt national laws concerning legalisation

Wolfgang Sohn   (14 November 2001)

The nature of editorials

Francis H Sansbury   (14 November 2001)

Should we add killing too?

Atsu Seake-Kwawu   (15 November 2001)

Two points to make in response.

Martin Hughes   (15 November 2001)

After death?

Julian Kennedy   (15 November 2001)

Legalisation of euthanasia? Not from this argument

Richard Hayward   (15 November 2001)

The Judge is right in his decision.

M S Basharuthulla   (16 November 2001)

Legal right to assisted suicide is an insurance against suicides

Anders Nordentoft   (16 November 2001)

Nothing to with best interest

Kalman Kafetz   (16 November 2001)

Deadly compassion.

Gregory Gardner   (16 November 2001)

Not enough for "good chaps" to agree

Gervase Vernon   (16 November 2001)

Francis H Sansbury can be gratified at once

Richard Smith   (16 November 2001)

Re: Who decides? Empowering patients

Timothy James   (16 November 2001)

Dead wrong

Paul Keeley   (16 November 2001)

Kakothanasia

Marinopulos Ioannis   (16 November 2001)

A view from the slippery slope

Daniel Munday   (16 November 2001)

Poor Reasoning

Roger Albin   (16 November 2001)

The Law is an Ass

Andrew Thornton   (17 November 2001)

The Doyals do not refute their opponents

Andrew Warsop   (17 November 2001)

Other things to consider

Martin Jackson   (17 November 2001)

Only God the Sir of Life, physician the servant of Life

Matias Diaz Sanchez   (17 November 2001)

Re: Doctors as killers

Mohan Chawla   (18 November 2001)

Re: It is my right

Mohan Chawla   (18 November 2001)

Caution is the word

Manvikar Purushottam   (18 November 2001)

No justification for killing anyone for any reason

Sahar Jameel Kalyal   (19 November 2001)

Why active euthansia and physician assisted should be legalised - the arguments are flawed

Michael Jarmulowicz   (19 November 2001)

Medical Ethics Alliance intervene tooppose Mrs Pretty

Anthony Cole   (19 November 2001)

Doctors rights, patients wronged.

Edward Hanlon   (19 November 2001)

What is wrong today will be legal tomorrow

Graham Todd   (19 November 2001)

The last enemy

M Trimble   (19 November 2001)

Euthanesia and Physician Assisted Suicide

W Eric Scott   (19 November 2001)

Re: The Law is INDEED an Ass

Peter Bradley   (20 November 2001)

Why euthanasia should not be legalised

Liz Croton   (20 November 2001)

Blurred ethical arguments should not be used to justify killing

Adrian Treloar   (21 November 2001)

Upon what morality can euthanasia be based?

Gareth Payne   (21 November 2001)

Active euthanasia and physician-assisted suicide

Andrew Rivett   (21 November 2001)

The end does not justify the means

Andrew Perrett   (22 November 2001)

Flawed arguments against active euthanasia

Martin Klein   (22 November 2001)

Compassion and rationality

Nigel Phillips   (22 November 2001)

Patient autonomy requires information

David Oliver, J Fisher   (22 November 2001)

Slippery slope arguments

Colin Ferguson   (22 November 2001)

Euthanasia - an Overview and a Balanced Approach

Dayantha Fernando   (22 November 2001)

Compassion and Common Sense

V E W Ball   (22 November 2001)

Autonomy not absolute

Malcolm Savage   (22 November 2001)

The stories I have heard

Simon Allen   (22 November 2001)

End the suffering

Stephanie Bacon   (22 November 2001)

COMPASSION AND CHOICE

D Hardy   (22 November 2001)

The state's power over our bodies should be ended

Amorey Gethin   (23 November 2001)

"one more voice"

Val Martin   (24 November 2001)

patients need medical care not legalised euthanasia

M D D Bell   (25 November 2001)

Euthanasia and physician assisted suicide

Robert Twycross   (26 November 2001)

The implications could have grave consequences

G Barr   (27 November 2001)

On not arguing the case

Luke Gormally   (28 November 2001)

A patient's view

M van Ments   (29 November 2001)

Criticism of Editor

Andrew Cooper   (29 November 2001)

Withholding and withdrawing medical treatments towards the end of life

Sanjay Shah, Mari Lloyd-Williams   (2 December 2001)

Consequences of the editor's choice

Mark Houghton   (4 December 2001)

Re: Consequences of the editor's choice

Wayne Lewis   (5 December 2001)

Circumstances Alter Cases

Hugh Wynne Eur Ing   (6 December 2001)

Denying us voluntary euthanasia causes unnecessary human suffering

Jean Davies   (7 December 2001)

"Patients want to know where we stand"

Mark Houghton   (14 December 2001)

The law is there to protect both patients and doctors

Sally E Bashford   (26 December 2001)

Debate on active euthanasia and physician assisted suicide

David T Shakespeare, Peter Szlosarek   (15 January 2002)

Re: Francis H Sansbury can be gratified at once

Francis H Sansbury   (17 January 2002)

Ethical Diversity, Consistent Law

Daniel L Johnson   (29 January 2002)

Denying our humanity

Guido G Geutjens   (7 April 2002)

Re: Specious arguments do not assist informed debate.

Agnes Wood   (28 May 2002)

Re: Re: Specious arguments do not assist informed debate.

Michele Tringali   (29 May 2002)

Moral Bankruptcy 9 November 2001
Sri Varman, Director of Surgery Cleveland, Queensland, Australia Send response to journal: Re: Moral Bankruptcy	Sir, The system we all have legalises the killing of a 3 month old faetus which has the potential to be born as a normal healthy child and live may be 80 years of fruitful life. Yet, the same system denies a woman with an incurable debilitating and fatal illness, to die with dignity at a time of her choosing. We are all morally bankrupt.
Doctors as killers 9 November 2001
Sally Rynne, Administrator Royal College of Surgeons Send response to journal: Re: Doctors as killers	Speaking as a non-medical person, I would not wish to be treated by any doctor who is willing to kill patients, even at that patient's request. It should never be a doctor's job to act as executioner for those who no longer wish to continue living or whose life is so 'deficient' that it is not considered worth living. All of us will eventually die, some with 'dignity', some without, we have very little choice about this in any case. I cannot imagine anything more undignified than being 'put down'. The various sophisticated arguments about euthanasia always seem to boil down to one thing: that the medical profession interferes so much already with the lives and deaths of patients, that legalizing euthanasia is just one more little step. I hope that it is a step that the medical profession will refuse. Or, that doctors who feel uneasy about killing people (euthanasia is surely a euphemism) will be able to declare this is some public way, so that we can choose our doctors with regard for their ethical stance on this issue, and even selfishly, to safeguard ourselves from their tender care should we ever become incapacitated. Doyal and Doyal's article is almost comically inappropriate in the light of the recent Shipman case. Would they like to reframe their argument in the light of Dr. Shipman's illegal euthanasia?
Why euthanasia and physician assisted suicide should NOT be legalised 9 November 2001
Alison Davis, Patient Send response to journal: Re: Why euthanasia and physician assisted suicide should NOT be legalised	Dear Sir, The arguments of Professors Len and Lesley Doyal rest on an assumption that certain patients are "right to want to die" and should be taken at their word when they request euthanasia. I suggest that this assumption is morally wrong, dangerous, and likely to add to the suffering of vulnerable patients, rather than alleviating it. I have several severe disabling conditions that make my life difficult and, at times, extremely painful. My spine is collapsing, causing extreme pain which is not always controlled, even with morphine. When my pain is at its worst I cannot move or speak. The pain can go on for hours, and at times I am afraid that it will never stop. In addition to this, I am a full-time wheelchair user because I have spina bifida, and I also have emphysema and osteoporosis. These conditions make me the sort of person many would consider "better off dead" and a suitable candidate for euthanasia or physician assisted suicide. No doubt Professors Len and Lesley Doyal would say that since they are advocating a "voluntary" system, I need thus have no fear. There are two problems with this. The first is that they also consider it morally acceptable to kill patients who cannot express any consent, on the grounds that their condition makes death in their "best interests." The second is that some years ago, I did want to die. It was a "settled wish" lasting many years, and had euthanasia or physician assisted suicide been legal then, I would have requested it. Under the criteria of the Dutch law, often cited as a model to be followed, I would qualify for this legal killing. I am alive now only because my friends refused to go along with my sincere belief that my life had no value. Over time, they enabled me to re-establish a sense of my own inherent dignity and worth. Diane Pretty, on the other hand, is surrounded by family and supporters who agree that her life objectively is "undignified" and "degrading", and believe that death is the right answer to her suffering. Even now there are times when the suffering seems too much, and I say I want to die. Would I be safe as such times, if Professors Len and Lesley Doyal had their way? I suppose they might say that I could write a kind of "reverse living will" stating that I want to be kept alive; but as long as I am competent I could revoke such a document. Professors Len and Lesley Doyal suggest that to avoid the problem of a "slippery slope" decisions must be made by doctors about "when a request for helping dying is appropriate." This, of course, makes it the doctor's choice rather than that of the patient. It also implies that some patients are "right to want to die" and should be helped to die, while others are "wrong to want to die" and should be helped to live. Such a system speaks more of the prejudice against sick and disabled people that some doctors hold, than about objective and morally defensible facts on which tenable criteria could be based. The fact that I am not terminally ill, as Mrs. Pretty is, if anything makes me a more compelling candidate for euthanasia, since I have to live with my suffering for an indefinite time, while Mrs. Pretty, whatever happens, will soon get her wish to die. The possibility that euthanasia might be legalised terrifies me, and would only add to the difficulties of living with pain that is often unbearable, but for the fact that I have to bear it. I suggest that what suffering people actually need is help, from both medical staff and from society itself, to live with dignity, and eventually to die peacefully and naturally. If Professors Len and Lesley Doyal get their way, the chances of this happening would recede rather than advance. Yours faithfully, Alison Davis
A Physician's Duty 9 November 2001
David Silverman, Private Industry, Corporate Officer United States Send response to journal: Re: A Physician's Duty	It is the job of physicians to provide excellent end of life care, to alleviate pain and suffering amongst the dying and those (temporarily) left behind. It is not the job of physicians to kill people. Killing is not part of caring, just as death is not part of life.
The rights of Drs in suicide 10 November 2001
George Dodds, Psychiatrist Falkirk Send response to journal: Re: The rights of Drs in suicide	Whatever the arguments for and against suicide, patients have no right to require another to assist them in their actions and certainly not by trying to pretend that it is a physician's duty - patently it is not in any ethical system. Physicians, too, have rights including protection against unlawful, unethical and damaging requests.The effects on a physician of assisting suicide could be emotionally damaging in the longer term in unexpected ways. I would also raise concerns as to the motives of those who assist eg unadmitted feelings of aggression, helplessness, depression and even unconscious or overt sadism. Often we lack wisdom and skill in what is an arduous art and that is one reason why long standing ethical and moral principles are necessary and useful.
Death 10 November 2001
R A Phillips, Vice Chair Swindon CHC 25 Leverton Gate Swindon SN3 1ND Send response to journal: Re: Death	Len and Lesley Doyle are correct in their views - life should end if it becomes too burdensome or one is incapable of benefiting from further life itself. At the moment, people fear death - many are incapable of talking about death - it is the last taboo. If only, we could say when we have had enough of life and know that the medical profession could respond. We treat animals better than humans! Best wishes Rosemarie Phillips
Underutilized Executioners 10 November 2001
Joel Thurm 28144 Send response to journal: Re: Underutilized Executioners	How can any "civilized" society condone the transformation of physician to executioner? Isn't bad enough to be sued for "wrongful death"? Now, you want to allow an incompetent executioner(physiician) tio be liable for "wrongful life" as well. How many elderly patients will be deterred from seeking care if they fear that their MD will write the wrong patient Rx for them? If you want that service to be performed correctly and free of error have the State Executioner revived to practice that trade!
Fancy philosophical footwork but choreography is not coherent 10 November 2001
Andrew Fergusson, Head of Policy Centre for Bioethics and Public Policy, 51 Romney Street, London SW1P 3RF Send response to journal: Re: Fancy philosophical footwork but choreography is not coherent	No one of compassion can fail to feel sympathy for Diane Pretty, but the old adage ‘hard cases make bad law’ holds true. The Court decision to deny her husband immunity from prosecution if he were to assist her suicide is not only ‘consistent with legal precedent’ but is morally right. There are essentially three arguments in the debate about voluntary euthanasia and physician assisted suicide, which is only euthanasia one step back. Doyal and Doyal are explicit about the first – the autonomy argument of rights (we want it). They implicitly invoke the second – compassion (we need it), but gloss over the third – we can control it. The UK House of Lords Select Committee on Medical Ethics unanimously rejected legalising voluntary euthanasia in 1994 in the light of the Dr Nigel Cox and the Tony Bland cases, clearly rejecting the autonomy argument on the grounds that the prohibition of intentional killing is a fundamental cornerstone of society that protects us all. There is thus no right to be killed by a doctor, or by anyone else. This is BMA policy, regularly reaffirmed, and in March 2000 the BMA further rejected physician assisted suicide. The compassion argument stands or falls on the answer to the question: do we need to kill the patient in order to kill the symptoms? St Christopher’s Hospice has proved that even in the case of motor neuron disease, the compassion case falls. Yet the High Court was told by Mrs Pretty’s QC that ‘anticipating arguments that palliative care would do much to relieve the suffering which Mrs Pretty fears, he said simply that Mrs Pretty has not been offered any such care’ (Judgment handed down October 17 2001, Paragraph 6). Why ever not? Where’s the moral good in that omission? There is considerable evidence from the Netherlands that allowing (and now legalising) voluntary euthanasia leads to euthanasia which is not voluntary. Doyal and Doyal’s spin on the control argument is to acknowledge that ‘any coherent advocate of active euthanasia and physician assisted suicide must take seriously the problem of slippery slopes’. They go on to say ‘Though this may be difficult, it cannot be impossible’. Well, the Dutch have found it impossible. All three pro-euthanasia arguments have been tried and found wanting. Euthanasia is wrong, unnecessary, and uncontrollable. While I agree with some individual steps in the fancy philosophical footwork of Doyal and Doyal, their choreography is not coherent. Andrew Fergusson 9th November 2001
It is my right 10 November 2001
David Henshaw, retired none Send response to journal: Re: It is my right	An awful lot of moral and ethical clap-trap is being bandied about. The decision about dying is a personal one: I have no right to influence your decisions and you have no right to interfere with mine. Throughout my life I have freely made my decisions, and reaped the consequences of those decisions. To impliment many such decisions I have needed the active assistance of other people - and I am grateful for their help. I chose my profession, and strove to achieve my goals. I chose when to take my driving license. I choose what I wear, what I eat, what I do. I chose when to relinquish full-time employment and how to use my leisure. Having spent a life-time of decision-making why may I not choose how and when to draw my life to a conclusion?
Doctors do no harm 10 November 2001
D Mistry, SHO Gen Surgery Calderdale Royal Hospital, Halifax Send response to journal: Re: Doctors do no harm	Editor, I was interested to read Professors Len and Lesley Doyal’s thought- provoking article advocating euthanasia and physician assisted suicide.1 However, I feel that trying to parallel the scenario of withdrawal of treatment from a severely incompetent patient with active euthanasia as in Mrs. Pretty’s case, is wrong. Where a treatment is in place or being proposed, doctors ask themselves whether it is of clinical benefit in the short and/or long term. If the answer to the above question is no, then the treatment is futile. In the case of a patient on life-sustaining treatment, the probability that life will not survive independently following treatment is the reason why it may be withdrawn. It is not, as the authors suggest, that doctors have deemed that the life is not worth living. The withdrawal of futile treatment cannot be paralleled to the institution of damaging treatment purely on the grounds that both result in the acceleration of death: The reasoning for the first is very different to that of the second. It is also dangerous to suggest that a patient's right to autonomy should extend to the involvement of doctors doing harm at a patient's request. 1. Doyal L, Doyal L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001;323:1079-80
A precedent for euthanasia 10 November 2001
Santoch Rai, Specialist Registrar in Forensic Psychiatry St Luke's Hospital, Marton Road, Middlesbrough, TS4 3Af Send response to journal: Re: A precedent for euthanasia	In marshalling their evidence for the moral benefits of euthanasia1, the worthlessness of some lives and the value of death, I am surprised that the authors failed to include the most obvious precedent in their arguement: the termination of pregnancy. Dr Santoch Rai SpR in Forensic Psychiatry St Luke’s Hospital, Middlesbrough. 1Doyal L, Doyal L.Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001;323:1079-1080
Greater Good 10 November 2001
Louise Beckham, SHO in accident and emergency medicine Royal Berkshire Hospital, Reading. RG1 5AN Send response to journal: Re: Greater Good	In the present climate (eg Shipman) I do not believe we can debate this argument without seeking the opinion of the general public. Should the general public feel uncomfortable with legalised euthanasia / assisted suicide, I would argue with a Utalitarian hat on: it would be for the 'greater good' to promote trust in the medical profession at this time.
If autonomy is valuable, euthanasia should be permissible. 10 November 2001
Danny Sullivan, Honorary Research Associate, Monash University, Australia Maudsley Hospital, London SE5 8AZ Send response to journal: Re: If autonomy is valuable, euthanasia should be permissible.	The Doyals are to be commended for addressing uncomfortable topics. They rightly note that Diane Pretty can refuse treatment and die, but that this cannot be legally hastened. In a time of increasing support for patient autonomy, the legislative and common law barriers to euthanasia are increasingly out of touch with public opinion. Patients lacking capacity may be euthanased (qv Bland); but those who seek not to suffer must do so (qv Pretty). The medical profession is one geared towards the welfare of its charges, and this is not always served by keeping people alive against their wishes. When people make competent decisions that their life is no longer worth living, it is not for doctors to insist that they are wrong. If one's life is subjectively torrid, and capacity is present, why should not those who so choose be allowed to die in a humane fashion? And why should doctors be prevented from ensuring that this is indeed humane? The Doyals provide a robust framework for euthanasia. Those who wish not to avail themselves have nothing to fear; but there is no proper reason that others should be prevented from accessing legally-protected euthanasia. Doctors wish to ensure good lives, not to ensure existence at all costs. Thus the Doyals raise very good reasons that euthanasia and physician-assisted suicide should be addressed by legislation.
Confusion of Morals 10 November 2001
Edward E Rylander, Oklahoma State Medical Director VistaCare Hospice Tulsa Oklahoma 74132 Send response to journal: Re: Confusion of Morals	The fallacy of your arguments are crystallized in your 8th paragraph: ----On the other hand, if death is in the best interests of some patients if the withdrawal of life sustaining treatment can be said to be of benefit in this case then death constitutes a moral good for these patients. And if this is so, why is it wrong to intend to bring about this moral good.---- You confuse a Physician’s duty to provide the least harm with “Moral Good”, It is never good to end life, unfortunately some clinical situations in the real world force us to select between “the lesser of two evils”. The worst “slippery slope” in medicine (and life) is in thinking something “bad” we are forced to do becomes “good” by virtue of our having done it. We must make the difficult decisions in our patients best interest, however, we must never allow ourselves to confuse the “least bad” with “Good” and progress from there to the justification of further bad actions out of habit or a blunted sense of what is truly in our patient’s best interests. Through the correct application of the principals of Palliative Medicine we should work with Ms. Pretty to control all of the symptoms of her disease completely and to her satisfaction, physical and psychological alike. If in the process of this treatment we reach the point that the use of dangerous levels of medication become necessary, we again will decide between the “lesser of two evils” having acted in the most morally correct fashion available to us as Physicians having worked to maintain her comfort, dignity and quality of life. Edward E. Rylander, M.D. Diplomat American Board of Hospice and Palliative Medicine
Hypothetical moralisations 10 November 2001
Roger Woodruff, Director of Palliative Care Austin Repatriation Medical Centre, Melbourne 3084, Australia Send response to journal: Re: Hypothetical moralisations	The hypothetical moralisations of Professors Doyal have little relevance to end-of-life care in the real world. A patient who is dying and becomes incompetent would not normally be artificially kept alive by medical technology. And if such treatment is in use, to withdraw it is to allow death to occur naturally, not to hasten it.There is no "failure" associated with not prescribing futile therapies for the terminally ill. Their discussion about "saving lives" is not relevant to the treatment of the terminally ill. Their discussion of benefits and burdens smacks of paternalism. End- of-life care involves sensitive discussions with patients and their families, with an honest explanation of their situation and what therpy is or isn't available, to establish agreed and realistic goals of care. They (or their families in the case of incompetent patients) want care, they want comfort,they want to be allowed to die with dignity; they don't want to be killed. There is a huge moral difference between allowing a terminally ill patient to die, competent or otherwise, and actively killing them. Legalised voluntary euthanasia for the terminally ill leads to involuntary euthanasia, including those not terminally ill, people with treatable psychological disorders, and those who feel a burden. The Dutch have proved this beyond any doubt.
Observe what is happening elsewhere 10 November 2001
Michael H K Irwin, Retired United Nations Medical Director Retired Send response to journal: Re: Observe what is happening elsewhere	As I have campaigned for the legislation of voluntary euthanasia for several years, it was a great pleasure to read the editorial "Why active euthanasia and physician assisted suicide should be legalised". Quite rightly, this editorial notes that we "must take seriously the problem of slippery slopes - of deciding when a request for helping dying is appropriate". In this connection, the best I can say to the anti- choice lobby is that I hope it will observe carefully and very impartially what is happening in The Netherlands (where physician assisted suicide and voluntary euthanasia have been possible for the past twenty years), in Oregon (legalised physician assisted suicide since 1997), and in Belgium (where positive legislation is expected within a few months). Then, we should ask ourselves if we are so different from the Belgians, the Dutch and the residents of Oregon? If such legislation can work well there, then why not in the UK?
Desperate patients should be appropriately helped, not eliminated 10 November 2001
Michele Tringali Udine, Italy (Friuli Venezia Giulia) Send response to journal: Re: Desperate patients should be appropriately helped, not eliminated	Sir, just after World War II, Sir Winston Churchill was invited at a meeting in Boston, Mass. (USA) where the faculty dean spent half an hour exalting the marvellous promises of incoming machine-assisted, protocol- based health care delivery. At his turn, Winston Churchill thanked the dean and audience for the privilege that had been offered him to hear of such improvements, and added that his only hope with respect to the issue was that when all that wonder had to happen, he hoped to be dead since a long time. I suspect that, following Winston Churchill reasoning, even everyday people would be strongly reassured to have a chance to read in an authoritative BMJ editorial that although some “evidence-based logic building” suggests what can be seen as the best way of working for Parliaments, Courts and scientific bodies too for end-of-life decisions, then – bottom line – some more fundamental regulation hopefully stands on and prevent all that powerful logic to be potentially applied to frail people left alone to struggle with their pains and bad feelings, and so (actively) deprived of any hope. From a very logical point of view, since life could be described as a (poorly-preventable) lifelong mortal disease, there should be no questioning on why do not offer more and more pages (and occupy more reader’s time) with appropriate, evidence-based or (in the event of evidence lacking, say, not enough large RCTs existing) opinion-based consensus statements on how to best anticipate, in the (soon advertised by interested third parties?) “almost certain” occurrence of body and dignity disintegration in case of death, and then obtain a legally and morally “ISO-some number” certified death-pill (one-shot only, please). Being this treatment reserved to some convicted criminals even in “advanced” countries all around the globe, why do not offer the same opportunity to ordinary people with less than extraordinary reasons? I suspect this should be quickly accepted by managers in some (slippering?) geriatrics facility. Where use of logic fails, while appealing to be coherent, reason can (probably) succeed. If it is reasonable to act taking into account any and all the factors that underline experience, we should try to make some efforts in understanding how and why for some people it can sometimes become difficult to adhere to the simple fact that a life has been given to all of us, gratuitously (and, possibly, for some reason). Since human beings happens to be meaning-dependent devices (such that they can be even manipulated, for unforeseeable reasons, to the point where a suicidal plane hijack brings destruction to thousands on behalf of some authority that, for Good’s sake, has not yet succeded to become a law maker or a judge, let alone a doctor), any practical observation should point to the fact that, maybe, “severely incompetent patients” must be respected in their lifelong intended meaning for life, which obviously can be challenged during extremely distressing conditions. I assume that what makes meaningful to be alive is something that is naturally received and shared among human beings, without any fundamental need to “decide to be alive” in the first place, or at the end of the path. Doctors should not take care of body machines only, but of the whole human person. For doing so, it is sometimes useful to admit one’s own powerlessness and to assist people maybe in a less-than-scientific way but always with a determination to sustain and share the burden (and the meaning) of life. It is not a moral right to adhere to a (desperate) proposal of suicide just because one’s conscience is supposed to think that. In general, subjective moral opinions have no foundation other than in prejudice (this is not necessarily confined to religion or politically- oriented fundamentalists). I understand more on this could be written, but I suspect too much space has been reserved on BMJ in the last number on this subject (to err is human) and it is not worthwhile to offer other chances to advocates of what could become, out of one’s best intentions, market-based human-elimination medicine. Michele Tringali Knowledge Centre SOS di Dipartimento "Conoscenza e Ricerca" Staff della Direzione Strategica Azienda Ospedaliera S. Maria della Misericordia Piazza Santa Maria della Misericordia, 15 33100 Udine
No to euthanasia 10 November 2001
Paul McArdle, Consultant Child and Adolescent Psychiatrist Fleming Nuffield Unit, Burdon Tce., Jesmond, Newcastle upon Tyne NE2 3AE Send response to journal: Re: No to euthanasia	Doyal concludes that it is morally justified to actively bring about death under certain conditions. Although his arguments are difficult to counter, they do seem unreal. Perhaps it is not a coincidence that the authors are not apparently in clinical practice. If doctors can be allowed to end life, there two main consequences are likely. Patients with long term illnesses may find themselves under pressure to justify their lives when all around them, including their doctors, tell them that their quality of life is poor and likely to decline. Secondly, patients’ trust in doctors, the foundation of our profession, would inevitably decline. By publishing a polemic like this, the fear is that all of us have been tainted with the views it contains. It is absolutely critical to all doctors and their patients that the BMA holds fast to its current stand against ‘active euthanasia’.
I would want medical help to end my life if it became intolerable 10 November 2001
Diane Munday, retired Send response to journal: Re: I would want medical help to end my life if it became intolerable	Thank you for your courageous editorial on voluntary euthanasia As a 70 year old woman who nursed both a husband and a mother who ended their days in indignity and ill health, I would like to have the reassurance of knowing that, if I reached the state where my life was no longer of value to me, there would be a caring and kindly doctor who would not put his career and reputation on the line in order to help me leave this world with dignity. When my mother started developing Alzheimers and understood what was happening she begged me 'to get some tablets so I do not live to be a stupid old woman'. She survived for 5 years, an incontinent, shambling wreck of the strong and intelligent person she had been. My husband, following a physically disabling stroke at the age of 53 repeatedly stated that should he become any more disabled, he would not wish to live. Twelve years later having, for seven years, been unable to communicate or understand language he died in a psychiatric unit exhibiting such extreme bizarre behaviour I could no longer care for him at home. Others may decide they wish their lives to be sustained in these sort of circumstances. I know I would rather die with some dignity remaining at a time of my choosing. Let us hope your clear and logical editorial encourages the medical profession to back a change in the law to allow them to openly do what a number of them bravely already do.
Protection for those who wish to live 11 November 2001
Elisabeth Le Strange, SHO, Paediatrics Wycombe General Hospital HP11 9BA Send response to journal: Re: Protection for those who wish to live	I believe that all forms of active euthanasia (doing something positive as opposed to not doing, or stopping doing) should not be legalised. I have full sympathy for people who find themselves contemplating this option. However, it is not for their sake, but for the protection of those who do not wish to be "euthanased", that I feel legalisation would be wrong. We must protect those who are less able to protect their selves. The "slippery slope" is breached sooner than the more obvious point at which euthanasia is allowed on people who cannot ask on their own behalf. Interestingly, despite suggestions by those given the partial opportunity to prepare for when they will die, it is not a normal right possessed by all people to end their lives at a time of their own choosing. Let us focus on quality of life for all, and try to make the best decisions when faced with trying to save lives that hang in the balance.
Be guided by our humanity. 12 November 2001
M D Oliver, GP Browning Street Surgery, Stafford Send response to journal: Re: Be guided by our humanity.	Doyal and Doyal have done us a service by ventilating this issue on which our society and profession is so confused and hypocritical. I feel that as a doctor I have a moral duty to contribute to the reduction of suffering.I do not think it appropriate to deny a patient the right to pass away peacefully, at a time and place of their choosing, when they are terminally unwell and suffering.It is what I should want for myself or my family.I should not have killed them, merely altered the moment in time at which the inevitable occurs due to disease. On the other hand I am personally unable to accept the argument in favour of destroying a person at any time from conception to natural death, unless this is morally justified by a reduction in suffering of greater degree, for example during war or to prevent loss of life on a greater scale. I therefore find myself at odds with most of the profession in being prepared to help people in the terminally ill category should the law adopt a more humane course, and in declining to assist in termination of pregnancy for reasons of convenience.I hope I shall not feel out in the cold for many decades yet.
A blurring of distinctions 12 November 2001
Iain B Craighead, General Practice Principal Fern Hill Medical Practice, 26 Coxwell Road, Faringdon, Oxon, SN7 7EZ Send response to journal: Re: A blurring of distinctions	Dear Editor, I disagree with the assertion made by Professor Doyal that 'the moral and legal status of not saving life through failure to treat can be the same as actively taking life.' As a general practitioner it has been my priveledge to care for those approaching the end of their lives. In clinical practice the distinction has always appeared obvious to me. Death can never constitute a moral good. Great efforts need to be made in order to provide for the physical mental and spiritual needs of our patients, and especially for those whose concern for the future is so great that they anticipate that they may wish to end their lives prematurely. We often seem to expend a good deal of our resources on futile last courses of chemotherapy, whilst palliative care remains a specialty heavily dependent on charitable donation. It is time to embrace palliative care as a specialty, and to resource it adequately. It is also our duty in Primary Care to listen to our patients anxieties and fears for their future and to provide them with the care that they require to live life to the full until it draws to a natural close. Yours sincerely, Iain B Craighead
response to editorial 10th Nov 12 November 2001
Yolanda Holderness, General Practitioner Chiswick Healthcentre, Fishers Lane, London W4 1RX Send response to journal: Re: response to editorial 10th Nov	EDITOR- If the view expressed by Doyal and Doyal in this week’s editorial (1), that killing our patients is morally equivalent to allowing them to die of natural causes by withholding high-tech life support, is the official B.M.A. view, then as a Christian I will be compelled to resign my membership. A medical profession which would countenance finishing off our patients, rather than demanding the investment (both financial and emotional) necessary to nurse them with dignity right up to the end, will be one that has truly sold its soul. Yours truly, Yolanda Holderness General Practitioner 1. Doyal L. and Doyal L. editorial BMJ 2001 323:1079-80 “Why active euthanasia and physician assisted suicide should be legalised”
When does means justify the ends? 12 November 2001
Dilip Menon, Specialist Registrar Wrexham-Maelor Hospital LL13 7TX Send response to journal: Re: When does means justify the ends?	Editor, Professors Len and Lesley Doyal's opinions over euthanasia and physician assisted suicide (1) tread on more than a slippery slope of indecision. They walk in an ethical and moral minefield with potentially explosive consequences if accepted as an extension of a physician's duty of care in his patient's best interest. Yet, the opinions they express are ones we need seriously deliberate .The landmark case in Britain that comprehensively addressed the issue of withdrawing life support in a patient's best interest was that involving Mr Anthony Bland (2).Mr Bland suffered from posttraumatic persistent vegetative state with no foreseeable likelihood of recovery following the Hillsborough disaster in April 1989.In the House of Lords decision (2), permission was given to withdraw nutritional support to Mr Bland albeit with misgivings, expressed for example, by Lord Browne-Wilkinson ,over the irrationality of lawfully allowing foreseeable death by acts of omission(withdrawing nutritional support) yet recognising acts of commission(lethal injection) as unlawful. Anthony Bland was awake but not aware and needed others (his family,his physicians,the courts) to decide his best interests. The recognition that he was insensate and incapable of experiencing pain facilitated the act of withdrawing nutritional support, as it was felt he would not have suffered the pain of deprivation or starvation. Diane Pretty is awake and aware. Any act of lawfully permissible omission(refusing nutritional support) would be a painful and unacceptable suffering to her being , yet is one where she has legal recourse to pursue in her right to self determination of her best interest. Herein lies a legal and moral paradox that we as a society have to reconcile while constantly upholding the sanctity of human life as a beacon transcending race and religion. Death can never be in anyone's best interest but if its inevitable as all death invariably is over time, its morally good if the process is made as pain free and dignified as possible. If death results in the process of relieving suffering it must always be as a secondary rather than primary endpoint of intent. Anything less would be the decimation of a civil society and should be morally and legally unacceptable. Dilip Menon Specialist Registrar in Emergency Medicine Wrexham-Maelor Hospital, Wrexham LL13 7TX 1.Len Doyal, Lesley Doyal. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001;323:1079-80 2.Airedale NHS Trust v Bland [1993] 1 All ER 821(HL); [1993] AC 789;[1993] 2WLR 316;
Medicine as dictated by ethicists 12 November 2001
Andrew Farkas, Consultant Obstetrician and Gynaecologist Jessop Wing, Sheffield S10 2SF Send response to journal: Re: Medicine as dictated by ethicists	It is a sad sign of the times that the British Medical Journal has chosen to give pride of place to an editorial by two social scientists advocating the practice of legalised euthanasia and physician assisted suicide which they can only theorise upon. Does this constitute a personal view, article for debate or does it carry the weight of the BMJ behind it? We must not be lulled down the path of '...if death is in the best interest of the patient...'. The history of the 20th century has taught us that there is a thin line between this philosophy and State determination of such matters. A clear distinction exists between what is best for the patient and what is best for the State, and for that matter a patient's relatives. This editorial undermines the stance that the BMJ has taken against physician assisted State execution in the USA. Such an article calls into question the value of medical ethicists in the undergraduate medical curriculum. Our students may be better served learning about the pharmacology of medicines used in palliative care. The medical profession must take advice from all interested parties and work with the public in making difficult decisions. However, it is we who carry the burden, moral and practical, of these decisions which must not be thrust unwilling on us.
Specious arguments do not assist informed debate. 12 November 2001
Timothy J Fetherston, Consultant Ophthalmologist Sunderland Eye Infirmary, Queen Alexandra Road, Sunderland, SR2 7UZ. Send response to journal: Re: Specious arguments do not assist informed debate.	Dear Sir, Specious arguments do not assist informed debate The poet, Arthur Hugh Clough famously wrote that “Thou shalt not kill; but needst not strive / Officiously to keep alive.”(1) I am amazed, and saddened, that Professors Len and Lesley Doyal, clearly cannot see the difference.(2) I read the leading article several times, because I simply couldn’t believe that it contained so many fallacious arguments and flabby reasoning, nor that the BMJ would publish it in its present form, unless the intention was – as so often in the printed media - merely to incite heated debate. Surely the profession has not reached the stage of such moral and ethical bankruptcy that death is regarded as a “moral good” and “… in the best interests of some patients”. What justification is there for these statements? If one accepts them, then the deliberate extinction of human life is reduced to the level of putting a wounded pet animal to sleep. Many paragraphs start with an unsubstantiated assertion - and then embark on a circular argument which (unsurprisingly) proceeds eventually to support the original assertion. Twice, in the article, active euthanasia is proposed as the “next step” following the cessation of life saving treatments, as if this should be a natural and desirable progression. What kind of reasoning is this? If one holds a firearm then the “next step” may be to aim it and pull the trigger. It may be a small step, but the implications are profound. Our profession remains noble only so long as it acts as the guardian and protector of human life. If we repudiate that principle, we lose everything. Timothy J Fetherston Consultant Ophthalmologist Sunderland Eye Infirmary, Queen Alexandra Road, SUNDERLAND SR2 7UZ 1 Clough, Arthur Hugh (1819 - 1861) The Latest Decalogue, 11, 1862 2 1. Doyal L, Doyal L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001;323:1079-80
“…in the face of so much moral right, where is the wrong?”1 12 November 2001
H van Woerden, SpR Public Health Bro Taf Health Authority Send response to journal: Re: “…in the face of so much moral right, where is the wrong?”1	Christianity rejects a moral right to “choose the circumstances of one’s own death” as asserted by Professors Len and Lesley Doyal1. In the Bible, Job lost his children, his wealth and his health. His wife suggested he curse God and take his own life. He replied, “Shall we accept good from God and not trouble?”2 I believe that we can experience tremendous spiritual growth as human beings even when we experience the physical deterioration associated with a terminal illness. Professors Doyal ask, “In the face of so much moral right, where is the wrong?”1 There are two aspects to a Christian reply. Firstly, God says, “From each man I will demand an accounting for [taking] the life of his fellow man.”3 Secondly, the Bible clearly asserts that death is not “the end of life.”1 It states that, “We must all appear before the judgment seat of Christ, that each one may receive what is due to him for the things done while in the body, whether good or bad.”4 and that life continues beyond physical death in heaven or hell. 1 Doyal L, Doyal L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001;323:1079-80. 2 The Bible. Job 2:10. 3 The Bible. 2 Corinthians 5:10. 4 The Bible. Genesis 9:5.
Why not legalize assited suicide? 12 November 2001
Michael Loren, assistant professor of pediatrics, University of Kansas 17500 Medical Center Parkway, Independence, MO 64057 Send response to journal: Re: Why not legalize assited suicide?	If there is no moral source other than ourselves, why worry about this issue of how much pain or irreversible brain damage is present in a patient? With the proper planning and using majority rule we will be able to humanely put away all those aggrevating conditions that are straining our health system. Just think, we will never have to suffer endlessly or worry about suffering. Even the idea of worry is enough suffering and for those worrying souls, we can properly plan their early demise. Consider the issue of overworked physicians who are not interested in calming an anxious patient in pain. The physican's more important work can be made easier with wholesale assisted suicide.
Evidence and euthanasia 12 November 2001
Peter Barratt Send response to journal: Re: Evidence and euthanasia	In recent years we have become much more aware that medicine is an inexact science. Up to 10% of all admissions are associated with an adverse event. Harm is caused to patients as a result of incomplete knowledge, human errors and system failures. In a climate of increased accountability and a frank acknowledgement of the limitations of medical science it seems foolish to be promoting the increased usage of a treatment as final as euthanasia or assisted suicide without a strong evidence base. An individual case such as that of Mrs Pretty cannot inform the development of legislation which needs to account for a broad range of scenarios. The first question which must be answered in a variety of scenarios from teaching hospitals to rural general practice is "how reliable are doctor's predictions of the timing and the inevitability of death". This may seem burdensome to those eager to commence using the "treatment" but is consistent with the rigour applied to all other interventions.
The last right? 12 November 2001
Simon Chapman, Professor of Public Health University of Sydney Send response to journal: Re: The last right?	On February 10 1984, my mother Margaret died in bed at her home. About a year before she been diagnosed as having breast cancer. She had a mastectomy soon after, followed by radiotherapy. For the next nine months she seemed mostly her usual optimistic self. She looked forward to coming to Sydney every three months to see her oncologist. At her November 1983 visit, it was discovered that the cancer had metastasised into her lungs. She came from the hospital straight to my office, where looking at my face for the slightest sign of hope, she told me that she had made up her mind to fight it. After I started university in 1970, mum would sometimes come and have dinner with me and my student friends. She threw herself into every conversation about politics, sex and all the big topics. Then, as at home, I recall her many times saying things like "heavens, when my time's up, I don't want to linger around in pain and misery ... I'd like to just go off at a time of my own choosing." If someone had knocked on the door with a survey about voluntary euthanasia, she would have told them the same. But from the moment she was told the news about her lungs, all this changed. There was not a moment when even a crack appeared in her resolve to "fight it". She dredged up all that fighting spirit stuff -- the sort that had been with her during the London blitz, which had allowed her to live in the drab back room of her first business after migrating to Australia, knowing she would work her way out of it. From that morning on, her life became focussed on how she was going to beat this thing. Two days later she went back into hospital and was knocked sideways with chemo- and radiotherapy. I visited her every day in a huge barn of a public ward and sat with her as she lay almost motionless, screened off by a thin white curtain. I had never seen anyone looking so sick. Still through this, she would cling to the smallest fragment of hope passed to her by the doctors and nursing staff trying to give her comfort. "The doctor said it had all gone well ... he said I'd be feeling much better in a week or two, and then it will be wait and see." "The way I see it, if I don't give it a go, then I'd never give myself a chance, would I?" After two weeks she came home and was so exhausted she could barely bother to walk a few yards into the back garden to get some sun. She insisted on cooking us what would be her last Christmas dinner. As the cancer grew, her breathing became increasingly shallow and rapid. Three weeks before she died an oxygen cylinder was brought in beside her bed. When you can't breathe properly, every moment of your life becomes preoccupied with getting the next breath. Lack of oxygen -- hypoxia -- causes disorientation and confusion. My sister and I had been taking it in turns to go down to her house in a small town and help. In the evenings we would sit with her and feed her junket through a straw. When we left the room, we left a bell near her hand so she could ring it if she needed anything. I was sleeping on the floor in the next room the night she died. Dad woke me at 4am and asked me to come and see if mum was alright. I could see straight away that she was dead. The bell had fallen to the floor. Her body was still warm. Dad felt it right that the local doctor should be phoned right away so she could come down and tell us what was obvious. I pretended to phone and then sat with dad drinking scotch, every now and then going back in with him to hold mum. The last thing she said to me was about how the next day she was going to tell the doctor that she wanted to go back into hospital for another try with "the treatment". When the news about her lungs came through, we knew mum was going to die. We didn't know when, but we knew it could be soon. All we wanted to do was comfort her, give our love and hope that it would happen with minimal suffering. Both my sister and I stifled the impulse to talk with her as we would have normally. We said to each other "She's going to die. The only thing she has to look forward to is this crazy hope she clings to. Who are we to try to take that away from her?" Dad has always been frightened and appalled by talk of death, regarding it as profane and unseemly. This made us keep him away from our often angry discussions about the way medicine conspired with the fear of death to build these optimistic artifices that were deceitfully called "treatment". So the option that she take no further therapy was never really discussed. I fell upon the phrase that the treatment she received after her November lung cancer diagnosis was in fact a form of medically sanctified torture. I said this to everyone I met when they asked how things were going. I did literature searches in oncology journals, confirming my understanding that the probability of the treatment she was getting giving any decent remission was practically zero. The last weeks of her life were appallingly wretched. She existed in total exhaustion between the kingdoms of fear and anger, whipped along by what we sensed was an unflagging burden of virtuous stoicism. There seemed no respite from this tyranny of false hope. Our temptation to ease the subject into the open with her retreated beneath the force of the plea behind her often terrified eyes that we didn't. One night as I stroked her arm, she angrily brushed my hand away. Where does this false hope, this "break my bones, but don't dare take away even the tiny chance I have" thing come from? Partly it must come from our culture's denial and sanitization of all things to do with death. Expressions like "brave", "battle with cancer" and "never stopped trying" say much about the way we spurn any resignation about imminent death. Yet how needless much of her suffering all seemed. I tried to put myself in her consultant's shoes. Here was a warm, articulate woman only 64 years old, begging for hope ... pleading with them to do something, jumping at any nuance of a chance, stoically prepared to weather any misery involved. Was it fair of me to expect him to deny her any chance, no matter how remote or at what suffering? If her two children, with a lifetime of talking with her, were not prepared to raise the subject of putting up the white flag and accepting death, why should I expect him to do it on the basis of having known her for a cumulative total of perhaps a few hours? It seems to me that above everything else, many in medicine feel the need to do something in the face of threatened death. It is almost as if it is sacrilegious to do nothing, particularly in circumstances when death may be still months away. If it can muck in with technochemical heroics which signify the defiance of all odds, there will be plenty of people there to cheer it along, and very few who will feel it reasonable to be angry if these attempts fail as they almost invariably do in cases like my mother's. Culturally, medical heroics dovetail with the arrogance of our collective belief in our earthly immortality. They represent the institutional expression of the cultural denial of death. For doctors trained and expected to rescue, revive and restore, the open recognition of the limits to medicine can come close to an admission of failure. And if the decision to be frank about doing nothing is difficult, what of hurrying things along - what of the attitude that says "if I am honest with this person, I will not seek to hide that it is nearly certain they will die within weeks. These weeks are likely to become progressively miserable and will become more devoid of hope for any reprieve. Is part of my duty of care at such times to offer to end this suffering if it is requested?" In my mother's case this misery did not mean pain that could be relieved with drugs, giving the doctor a valued and sanctioned palliative care role. It meant instead that she would slowly suffocate to death over several weeks while becoming increasingly disoriented. She would have never wanted that. Who in their right mind would? And what sort of medical ethics says that she should just have to put up with it? If her doctor had not tempted her with treatment, she would have developed hypoxia but avoided the weeks of nausea and misery brought on by the treatment. The local GP who attended her in her last weeks did not offer and mum did not ask if her life might end with a sedative injection or drink. Each day she visited I would ask as mum lay gasping in the next room "how much longer do you think she has?" The answer was always indeterminate. Medicine devoid of any vocation to actively assist in the right to die, has no answer to such pointless suffering. There are those who argue that there is some point to such suffering. I say let them feel free to exercise that option with their own deaths if it brings them a higher comfort. But I have only contempt for ethics that insist such degrading suffering should be compulsory for those whose fates select such paths. Any laws or codes of conduct which institutionalise a denial of the dying's right to determine their time of death do not reflect a civilised view of the end of life. The hastening of death in such circumstances, when the dying who have requested it are often incapable of taking action themselves, will require assistance. It follows for me that doctors and others should be able to assist such deaths with impunity where it is beyond any doubt that the dying person has consented. Would my mother's experience have been any different if she had lived her life knowing that as well as tending you all through your life when you are sick, doctors could be there, like priests, to come at your call and give you the medical equivalent of the last rights? To supply you with a way of choosing your own time to go? If she had grown up in a culture when it might be as natural as day and night to say "my time is near, let's have the doctor help me avoid the worst of the suffering" ... would she have felt to impelled to put herself through so much wretchedness for what was really no chance at all? And how different might her death have been if her doctor had decades of a medical tradition behind him which better enabled him to be frank rather than surreptitious about what lay ahead; about the futility of aggressive chemicals and radiation in prolonging her life; and who could instead offer options of assisted, painless death at a time of her choosing. [This reflection was first published in Chapman S, Leeder S (eds) The Last Right? Australians take sides on the right to die. Sydney: Reed Books,1995:39-44
A Response to Dr. Andrew Fergusson 12 November 2001
Michael H K Irwin, Retired United Nations Medical Director Send response to journal: Re: A Response to Dr. Andrew Fergusson	In his response of November 10th (see above), Dr. Fergusson mentions a popular belief of the anti-choice lobby that "there is considerable evidence from The Netherlands that allowing (and now legalising) voluntary euthanasia leads to euthanasia which is not voluntary". Involuntary and non-voluntary euthanasia happens around the world. In The Netherlands, one detailed report in 1990 indicated this represented 0.8% of all deaths in that country; and another similar report in 1996 showed this figure to be 0.7% (a reduction!). However, from an article in The Lancet in 2000, it was noted that in Australia, in a 1995 survey, 3.5% of all deaths were "without the patient's explicit request"; and in Flanders, Belgium, in 1998, the figure was 3.2%. We have not yet had any accurate survey in the UK on how patients die. But, I am willing to make a reasonable bet with Dr. Fergusson that the percentage of involuntary and non-voluntary euthanasia cases here is closer to the Australian and Belgian figures than that of The Netherlands. If one needs to be critical of the Dutch, it is that they are open and honest about end-of-life issues (unlike us in the UK). (1) Deliens L, Mortier F, Bilsen J, et al. End-of-life decisions in medical practice in Flanders, Belgium: a nationwide survey. Lancet 2000;356:1806-11.
The Evil of Ignorance 12 November 2001
Antony Tobin, Intensivist Queen Mary Hospital, Pok Fu Lam, Hong Kong Send response to journal: Re: The Evil of Ignorance	When I withdraw medical support such as mechanical ventilation from a dying patient, I do this because I see the patient as a human being to whom I have a duty of care. Part of that duty is a responsibility to give that patient only those treatments that I believe are or may be beneficial. When it is clear that my treatments are not effecting a cure or enhancing life (the two reasons for initiating any treatment) but merely prolonging biological life, I withdraw those ineffective treatments. The action is not one of killing but of choosing not continue ineffective treatments for my patient. The unqualified prolongation of human life is not and never has been a moral or ethical duty of the doctor. If a medical ethicist is unable to differentiate between medicine practiced in this context and actions whose only purpose is to kill another human being then we have a lot to fear if such ethicists are allowed to influence medical and public opinion or to shape legislation. Albert Camus in The Plague1 wrote “evil in this world always comes of ignorance, and good intentions may do as much harm as malevolence, if they lack understanding”. He continues “the most incorrigible vice” is “that of an ignorance which fancies it knows everything and therefore claims for itself the right to kill”. It is my belief that such ignorance is commonplace in the euthanasia debate and that some good intentioned people are about to add another sanctioned evil to society. References 1. Albert Camus. The Plague. p 127 Penguin Books September 1998 ISBN 0140278516
How do you influence legislation? 12 November 2001
Anders Nordentoft, pensioned, non-medical Denmark Send response to journal: Re: How do you influence legislation?	I fully share your viewpoints to legalise volontary death, and I have been promoting the case in Denmark via newspapers, television and letters to members of the government. Is the discussion in UK merely internal or do you make efforts to have legislation altered? Best regards, Anders Nordentoft
Legalising Euthanasia would be a bad move 12 November 2001
Huw Morgan, GP tutor Bristol Send response to journal: Re: Legalising Euthanasia would be a bad move	Sir, I was very concerned to read the Doyal's editorial advocating a change in law on euthanasia. My understanding was that the BMA remained opposed to this. Whilst there are aspects of the Diane Petty case that appropriately call for an examination of the issues, it is not good to make law by forcing decisions on individual cases through the courts. Practising clinicians should all be aware of the minefield that leagalised euthanasia would be, and its potential destruction of trust between doctor and patient. Slippery slopes and thin ends of wedges are approptiate metaphors here. Surely our responsibility as doctors is to maintain respect and humilty in the face of all human suffering, doing our utmost to relieve but not deliberately and actively ending lives that are judged to be not worth living. It is but a short step to Auschwitz from such a stance.
Too simple by far 12 November 2001
Margaret Whipp, consultant in palliative medicine and communication skills co-ordinator University of Durham, Old Shire Hall, Durham. DH1 3HP. Send response to journal: Re: Too simple by far	EDITOR – I applaud the decision of the editors to give pride of place to the Diane Pretty debate1, but I am dismayed that they should offer such a one-sided and ill-informed argument. The Doyals rightly use the Pretty case to emphasise the limits to autonomy placed by current legal and professional boundaries. A young, determined, articulate patient seeks maximum control in the context of a massively distressing illness. Euthanasia or assisted suicide seems a simple solution in such an obvious case. Yet the Doyals’ argument is too simple by far. It is not a simple matter to argue that one individual’s autonomy may override the need for legal and professional protection of hundreds of other more vulnerable patients. They admit that it would be difficult to ‘take seriously the problem of slippery slopes’, presumably by drafting legislation which is sufficiently scrupulous to prevent widespread abuse. Sadly, all evidence from the Netherlands2 shows that this is not possible, and that the consequent level of carelessness and complacency puts disabled and elderly patients in fear for their lives. After the Shipman scandal in our own country, it is naïve and dangerous to ask ‘in the face of so much moral right, where is the wrong?’1 The Doyals must also recognise that the exercise of autonomy is a far from simple matter. Patients who want to die very often change their minds3, many of them when they are met with careful attention to the social, physical and existential dimensions of their distress4, and others – ironically like Diane Pretty – when they find a meaningful focus for living until death comes. Autonomy ceases at the moment of death. It is then too late for the individual (but not for those left with uneasy questions) to wonder whether there might have been a change of mind. Death as a ‘solution’ is uniquely final, and as a way of dealing with human distress it is a solution which is too simple by far. The weakness in the Doyals’ position is not a lack of compassion for the individual, but a lack of appreciation for the moral complexities of living as an individual within society. Each individual owes to society a respect for boundaries that are established to protect the weak. And each individual deserves from society the best that skilled and compassionate care can deliver to eradicate distress without eliminating the patient. 1 Doyal R and Doyal L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001; 323:1079-80. 2 Keown J (ed). Euthanasia Examined: Ethical, Clinical and Legal Perspectives. Cambridge University Press, 1995. 3 Bayliss, R. More on pre-mortal provision. BMJ 2001; 323:731. 4 Submission from the Ethics Group of the Association for Palliative Medicine of Great Britain and Ireland to the Select Committee of the House of Lords on Medical Ethics. May 199
Don't be mislead! 13 November 2001
Karen Sanders, Senior Lecturer in Health Care Ethics South Bank University Send response to journal: Re: Don't be mislead!	One of the weapons used by those who cannot support their side of the argument with correct facts is to use emotive words in an incorrect manner contrary to their definition. Recent contributions have included the concept of doctors "murdering" (unlawfully killing someone against their will) and "executing" (killing someone as a form of punishment, usually based within some form of legal framework). To discuss the subject of voluntary euthanasia properly and objectively, it is necessary to adhere to the facts and to use words within their correct meaning. It is "voluntary" and therefore cannot be "murder" or "execution". A much more accurate description is "assisted suicide". It is important to remember that those who are physically able may kill (or attempt to kill) themselves at any time, without fear of legal sanction. There are those who are too ill to be able to physically perform this act. The decriminalisation of Voluntary Euthanasia would enable the removal of this form of discrimination against the physically frail.
Who decides? Empowering patients 13 November 2001
Roger M Goss, Director Patient Concern Send response to journal: Re: Who decides? Empowering patients	Editor – Professor Doyal’s argument is logically and morally impeccable. (1) It has the support of the majority of the general public. (2) So why the opposition from the medical establishment and the judiciary? Medical practitioners “manage” patients rather than care for and treat them. They decide whether those in their care would no longer benefit from life prolonging treatment. If patients were allowed to decide for themselves, this would undermine the power of medical professionals. Human nature rules. Unacceptable. QED. The judiciary live and think like members of the professions rather than ordinary citizens. They include their share of Catholics, Jews and others opposed to euthanasia – a good death – for religious or philosophical reasons. So the responsibility for change falls on Parliament. It is, after all, supposed to represent the will of the electorate. But it has yet to overcome its fear of the furore that change would produce from an influential, vociferous minority. Roger M. Goss Director – Patient Concern (1) Doyal L. Why active euthanasia and physician assisted suicide should be legalised: If death is in a patient’s best interest then death constitutes a moral good BMJ 2001; 323: 1079-1080 (10 November) (2) The Times ePoll. Should euthanasia be legal in Britain? (20 August 2001)
"Active euthanasia" 13 November 2001
C M Gaston, GP Principal Cambridge CB1 8BA Send response to journal: Re: "Active euthanasia"	I hope very much that the views expressed in this article are not shared by a majority of doctors caring for terminally ill patients. All of us must have deep sympathy for the plight of Diane Pretty and others like her. However, contrary to Doyal and Doyal, I feel there must remain an important distinction between the withholding of treatment (including, in certain cases, artificial feeding) and the deliberate killing of a patient. Omissision and commission are different in everyday life- for example, not to intervene when a child is being beaten might be seen as heartless, but would not be equated legally or morally with actually doing the beating. motor neurone disease is somewhat atypical in that mental faulties are entirely preserved while physical capability is lost: in most terminal conditions, there is loss of both, either from the disease process itself or from its therapy. Who is to give informed consent in these circumstances? And what of requests from the severely depressed or vulnerable? Sadly, fewer doctors may profess traditional faith than in former times, but we abandon further the Christian principles which have shaped medical practice at our peril.
Active euthanasia and physician assisted suicide:where is the wrong? 13 November 2001
David Jeffrey, Macmillan Consultant Palliative Care Cheltenham General Hospital, Cheltenham GL53 7AN Send response to journal: Re: Active euthanasia and physician assisted suicide:where is the wrong?	Dear Sir, Active euthanasia and physician assisted suicide: where is the wrong? Doyal and Doyal argue for the legalisation of euthanasia and ask,”where is the wrong”? (1). We must acknowledge that both the authors and those of us opposed to active euthanasia share a common goal: the relief of suffering and preservation of patient dignity. However, the means of achieving this goal are morally relevant. In the case cited of the patient with motor neurone disease, the authors argue that the legal judgement is “morally wrong” and so the law should be changed.(1) However sound law is rarely derived from ‘hard case ‘ judgements. Professional ethicists can be depended upon to describe philosophical examples which support their arguments. Although “ the moral and legal status of not saving a life through failure to treat can be the same as taking that life”, it certainly is not necessarily the case. The authors also suggest that because the competent adult ,and those “who know and love her” , perceive that death is the best outcome, that this somehow creates a right to euthanasia. The scope for patient abuse in this situation is all too clear. Some ethical issues are ignored by the authors; the consequences of an action are morally important. The consequences of legalising euthanasia, for other patients and for society, are considerable. Not least would be the loss of trust in the medical profession, a trust which has already been threatened in recent years. The authors dismiss the moral status of the intentions of the doctor . These are of critical concern in end of life care. Intentions influence notions of the virtue of the doctor which are relevant and guide the continuing development of tomorrow’s clinicians. Although the authors are not clinicians, they concede that deciding when a request for active euthanasia is appropriate may be difficult. However they assert “it cannot be impossible”. But such decisions can indeed be impossible ,due to a combination circumstances: difficulties in diagnosing depression, prognostic uncertainty, an overwhelming workload, lack of time and the vagaries of patient decision-making . “Helping dying” is not about active euthanasia, it is about acknowledging the value of each individual, about giving doctors the opportunity to develop the wisdom to reject futile treatments , and about working with colleagues in differing professions , to allow patients to die with dignity and without suffering. Such care is possible with proper resources; patients ,healthcare professionals and society should be striving to achieve this standard of care rather than seeking to legalise active euthanasia. Yours sincerely, David Jeffrey Macmillan Consultant in Palliative Care 1 Doyal L, Doyal L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001;323:1079-80.
Doctor assisted suicide 13 November 2001
Tarra , college student city grill 85715 Send response to journal: Re: Doctor assisted suicide	I am a student at Pima Community College in Arizona and was assigned to compose an argumentative essay on doctor assisted suicide. I visited your site in hopes of finding some reason this maddness might possibly serve a purpose in our society and after reading your article I was very dissapointed. There is absolutely no reason to even consider allowing people to help kill others. Suicide in any form is awful. Humans were not placed on this earth to hurt eachother. Especially not doctors, they are supposed to heal people, not serve as an easy out for someone that doesn't like the life they have been given. In studies it shows that most of the people that do want to end their life this way are only suffering from depression, not actual physical pain. We have wonderful scientists and doctors that have developed this wonderful stuff called pain medicine. In 1991, a study was published in Archives of Neurology that found that 58% of patients that have a "firm diagnosis" of being in a life long veggitative state have regained conciousness with in three years! This means that there is hope for everyone, instead of giving up on people and helping them end their life, maybe you should devote a little more time to making their life here a little easier and maybe a little less painfull. You need to have more faith in people and then maybe you would understand that life isn't something you can choose from a hat and hope you get a good one, you should cherish the one that you have and live it to the fullest(no matter what) Thank You and Good Luck in your life!Hope it's the one that you wnated!
Re: The last right? 13 November 2001
Peter Bradley, GP 25yrs Springwood, Brisbane, Qld, Australia Send response to journal: Re: Re: The last right?	I agree with the sentiments so well expressed. Let's be clear - this is not a condemnation of palliative care, this is just a realistic appraisal of a set of circumstances where sometimes an earlier departure is better. Especially one settled on by the sufferer. We do not allow our pets to suffer do we? Are we to continue to inflict unnecessary suffering on our loved ones, only to have them die a lonely death in spite of our efforts to be with them? In this day and age, with the technology we have, this is unacceptable. In fact,The issue of euthanasia is always guaranteed to be emotive. Opposition often seems strongest from, on the one hand, palliative carers, who seem to feel the desire for this as somehow a criticism of their art and efforts, and on the other, from people who have had little first-hand contact with anyone in the position of being likely to want this service, or from those doubters in the community who have no faith in their fellow man (doctor) to continue to do what we have always strived to do in good faith, and that is to do what is best for our patients. Let us be clear about this. It is not a criticism of palliative care. They do a great job. It is for reasons such as expressed in Dr Chapman's and other letters, and illustrated in my own experience, which I would also like to share to further the debate. It is also something which would not actually be wanted by many in the end, but that option should exist in a modern, humane society. We are actually sensible and enlightened enough to handle this issue - let's give ourselves that credit. I guess I might once have also felt reservations about taking this last step in delivering that final care until my own mother died in 1994 of bowel cancer. I would like to share this, as it affected me deeply, and bannished any last reservations I personally had regarding the subject. I remember clearly the feeling of grief and despair, after having flown 3000 kms to be at her bedside, she was so wasted away I could not even recognise her, my own mother, and she had lapsed into a coma as well, so we could not converse even. I remember I kept thinking about funny things like, if maybe I put her glasses back on her face, it might somehow help her to look like I remembered her. I was crying at the bedside of a stranger! My brother, driving his heart out to be there in time, did not make it. As we were exhausted from the trip, a senior nurse assured us she had been like this on and off for days and would still be so in the morning, so, against my better judgement, but as there was nowhere nearby to rest, we went away for some sleep, and she died all alone at about 0300, after all our efforts to be there. How often this happens. The early hours seem the most common time to die - di-urnal rhythms no doubt? It came to me then - surely there is a basic 'rightness' about being able to choose the time of out departure. We have no choice about our birthday, or how, when, or where we enter this earth, but surely we should be able to choose our 'deathday'. So that if one is in a state of pain and/or irretrievable decline, and before we lose the dignity of control of our bladder and bowels, or ability to eat, - or more importantly, speak, - we can summon our loved ones from wherever they are, to rally round so we can say those last things we all want to say, - then hit the button, so to speak, and off we go, with their good-byes the last thing we hear. The funeral is then logically follows soon after, and all can be there, then return to the many scattered places from whence they came - a modern phenomenon, but one which will not change. Now why would anyone want to deny someone a good death like that? Few will want this option in the end. But it should be there. Few doctors will want to do it. I'll be honest and say I would probably not want to. It should be done by 'experts', and there are these people around,who even now, risk falling foul of the law to help in this way. For example Drs Kavorkian (excuse spelling if incorrect), in the US, and here in Australia, our own Dr Phillip Nitscke (ditto). I felt immensely proud, when for a short few months, we here in Australia, in the Northern Territory, took the step of doing what no other country, (including Holland), had until then had the courage to do, and enshrine voluntary euthanasia in LAW. How disappointing to have the federal politicians lose courage, (fearing loss of votes, no doubt), use extraordinary legislation to overthrow the NT's legislation, and render it illegal once more, - before it had even had a chance of a reasonable trial, - surely the logical thing to do, and one rather unique advantage, (and there aren't many), of a Federal State system. What a lost opportunity? Now at least Holland and Belgium have taken the step - how long does it take? Peter Bradley
Thanks to the Doyals 13 November 2001
Jeremy Holford-Miettinen, Writer (freelance) Cambridge Send response to journal: Re: Thanks to the Doyals	I would like to thank the Professors Doyal for their clear and concise article and the editor of the BMJ for publishing it. All parties have shown a clear-headed and courageous approach to the subject, which it is to be hoped fellow professionals will emulate. Yours faithfully, Jeremy Holford-Miettinen (I am a member of VES)
If only pro-choice doctors felt able to speak out more!" 14 November 2001
Don Aston, Member of Executive Comittee, Voluntray Euthanasia Society London Send response to journal: Re: If only pro-choice doctors felt able to speak out more!"	As a campaigner for patient choice this e-correspondent was naturally thrilled that the BMJ had been prepared to commission such a major editorial article. Its authors are of course distinguished medical ethicists/social scientists rather than the practising doctors who might have been expected to write it. This is in spite of ( necessarily anonymous ) survey evidence that some two-thirds of GPs in the UK for instance favour voluntary euthanasia/physician assisted suicide ( VE/PSAS ) in some circumstances. This assertion is based on the Taylor Nelson Sofres Omnimed survey published in October 1999. The relatively small but nevertheless statistically valid sample size enabled repondents to be questioned in some detail on both their own and colleagues attitudes. However pro-choice GPs will not publicly express their support for patients choice and almost half of all respondents have not even discussed VE/PAS with their colleagues. For instance the writer knows of only one practising doctor willing to speak out in favour in the whole of the West Midlands Region of the UK and she is a locum in her 70s. As usual all the practising doctors ( usually palliative care specialists ) who have so far e-mailed are anti-choice but perhaps they should also bear in mind that their final role in this life will be as terminally-ill patients very likely under present law and medical practice to suffer a lingering death with inadequately controlled physical pain and mental distress.
Outlaw medical killing 14 November 2001
John Scotson, retired general practitioner Send response to journal: Re: Outlaw medical killing	The authors of the editorial “ Why active euthanasia and physician assisted suicide should be legalised” appear to argue that because medical treatment can on occasions, such as when a patient becomes permanently and severely incompetent as a result of brain damage, legitimately be withdrawn knowing that this will result in the death of the patient, then legalised voluntary euthanasia should be acceptable, which means that doctors, in similar circumstances, should be empowered to kill their patients. The ethical consideration is that the patient must not be deliberately killed as a result of an act of commission or omission on the part of the medical attendant, or any other person, but from the underlying disease or injury from which the patient is suffering. Hence it can never be right to do something or to omit to do something with the intention of causing death by that act: it is however reasonable, under certain circumstances, to withhold or withdraw extraordinary medical interventions ( which does not include ordinary means of life support such as nutrition and basic care) even though this has the unintended effect of hastening death. The Hippocratic prohibition against the killing of patients by their doctors and the commandment “ thou shalt not kill” will always remain guiding principles in the practice of civilised medicine. John Scotson Retired General Practitioner
? 14 November 2001
Mark Blackwell, Consultant Psychiatrist Sutton SM2 5NF Send response to journal: Re: ?	Crucial to Doyal & Doyal's (BMJ 10th Nov) argument in favour of euthanasia is their misunderstanding of the use of the terms "burdensome" and "of no benefit" applied, by those who oppose euthanasia, to treatments which can be legitimately withdrawn. A treatment could be burdensome because it is bankrupting a patients' family and "of no benefit" because the patients illness cannot be cured and the suffering caused by the treatment itself outweighs a slim prospect of extending life. Neither of these judgements imply that `the clinician must already have have decided that the life of the incompetent patient in question is not worth living and therefore not worth prolonging.' That two professors should misunderstand this so completely would be laughable if the intent were not so deadly. Yours truly, Dr MJ Blackwell
A confused argument for legalised euthanasia 14 November 2001
Stuart M White, Specialist Registrar, Anaesthesia Guy's and st Thomas' Hospital, St Thomas Street, London, SE1 9RT. Send response to journal: Re: A confused argument for legalised euthanasia	Dear Sir, The Professors Doyal have presented an eloquent argument in support of physician assisted suicide and active euthanasia1. Nevertheless, I wholly reject their position. Their editorial uses the emotive case of Diane Pretty to advocate physician assisted suicide, by equating the active withdrawal of medical treatment to active euthanasia. There are two subtle problems with this comparison. Firstly, it confuses two commissive acts: the act of withdrawing medical treatment with the act of administering a substance designed to kill. Both acts lead to death. However, medical treatment is administered with the intention of preserving life. The withdrawal of treatment does not cause death: medical treatment merely delays the natural inevitability of death. Administration of a lethal substance, however, is never intended other than to cause death. Secondly, the examples used to evidence medical collusion in active euthanasia identify decisions concerning incompetent patients. Disregarding the fact that such collusion is morally wrong (and therefore cannot be used to justify the remainder of their argument), these decisions are restricted to cases of PVS, a condition in which patients are not conscious of their condition and not aware of their death.However, Diane Pretty is a competent adult. Ethical medical practice dictates that the autonomy of competent patients is always respected. I agree, therefore, that Diane Pretty has every right to choose the circumstances of her own death. However, I would contend her right to ask another person, even a loving member of her family, to commit an act which is morally wrong (ie intentional killing). This may result in an undignified and painful death (though with appropriate palliative care, there is no reason why it should), but then death is often undignified and painful - no absolute right to a comfortable demise exists. The assertion that it must be decided “when a request for helping dying is appropriate” is problematic. It requires a decision concerning who is right and who is wrong to want to die. This decision will inevitably overrule the patient’s autonomous determination to die. Also, who decides ? A doctor’s decision would always be open to judicial reproach. Common law or statutory provision would be unable to decide who should die, because to do so could potentially force doctors to intentionally kill a patient. Active voluntary and active involuntary euthanasia remain uncomfortably close. Doctors should not support a paradigm shift towards active euthanasia and physician assisted suicide. We are not executioners, Yours faithfully, Dr. Stuart M. White, FRCA, BSc Department of Anaesthesia, Guys and St Thomas’ Hospital St Thomas Street, London, SE1 9RT. Reference. 1. Doyal L, Doyal L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001;323:1079- 1080.
Euthanasie in Europe - the dilemma of differnt national laws concerning legalisation 14 November 2001
Wolfgang Sohn, The dilemma of patients right to self dertermination and doctors obligation to provide treatment GP and paintherapy, Dorfstr. 5-7, 41366 Schwalmtal, Germany Send response to journal: Re: Euthanasie in Europe - the dilemma of differnt national laws concerning legalisation	Under the aspect of patients right to self determination and doctors obligation to provide treatment the article of Doyal&Doyal is very helpful. BMJ has shown already in the past it's engagement to give "the discussion on Euthanasia" an open platform. The dilemma of differnt national laws concerning legalisation of euthansia, medical guidelines so far they exsist and the ethical aspects is shown in the just published book: Sohn W, Zenz M (eds.) "Euthanasia in Europe", Schattauer Verlag, Stuttgart 2001. emailinfo@Schattauer.de or http://www.schattauer.de With chapters of all countries of the EU added by Norway and Switzerland we have tried to show the present level of decision making.It becomes clear that not only The Netherlands but Belgium,Danmark and Finland have a long running process of dicussion and in the end concret steps of legislation (see Belgium two weeks ago). Germany is not able to discuss present questions but still has to do with the trauma of Nazi-Euthanasia, what is shown in the chapter of our country.
The nature of editorials 14 November 2001
Francis H Sansbury, Student, Cambridge Graduate Medicine Course 25 Mill Street, Cambridge CB1 2HP Send response to journal: Re: The nature of editorials	Editor - Although you do not appear to publish criteria for the various different types of article either within the printed BMJ or on the website, one expects editorials in any journal to give a balanced view and discuss both sides of relevant arguments. Whatever one thinks of the quality and validity of their reasoning, the editorial by Doyal and Doyal ("Why active euthanasia and physician assisted suicide should be legalised; BMJ, 2001; 323: 1079-80) is one of the most partisan that I have ever read, particularly for a situation where opinions are known to differ. Views differing from their own are mentioned only very briefly for the purpose of saying that such arguments are unacceptable, and that there are rational arguments against their proposal (held by a large sector of the public and of the medical profession) does not seem to come into their consideration. Their article sits uncomfortably in the Editorials section. It would seem to fit more easily within the "Education and Debate" section of the journal, especially as given its nature it would seem to make sense to tie it with an article giving the opposing view. It could also form part of an "Ethical Debate" such as the recent one on the MMR vaccine by Heller et al. (BMJ, 2001; 323: 838-840). Given such a one sided view appearing as an editorial, would it not be reasonable for the readers of your journal to hear the other side of the coin? I suggest that it would only be equitable to invite another medical ethicist or other appropriate author, known to hold opposing views to theirs, to write an article replying to their ideas and giving the alternative response to the Diane Pretty case. It would also seem only fair to give it the same prominence as Doyal and Doyal's article, i.e. lead editorial, and for it to appear very soon: in the next issue if possible. There have been and will doubtless continue to be many responses to Doyal and Doyal, of all hues, but they will only appear in the printed letters page in some weeks' time, if at all. It would be more impartial to let your readers, many of whom will not be accessing www.bmj.com, hear the other side of the argument now. If you do not plan to do this, are we to conclude that you wish to align the journal with Doyal and Doyal?
Should we add killing too? 15 November 2001
Atsu Seake-Kwawu, Senior Medical Officer North Tongu, Ghana Send response to journal: Re: Should we add killing too?	I have read with interest the article of the Doyals on physician- assisted suicide. I have a different view though. I suggest the role of doctors to safe life and relieve suffering should not get doctors mixed up in controversies like ending lives of patients. Induced abortions have already done so much damage to the standing of the profession and adding assisted killings will be one too much. Why should it be the doctor? Relatives who feel they should end the loved one´s suffering should go ahead and face the consequences. We can serve the cause of society better by intensifying research for cure or relief instead of arbitrating over who should live and who should die. If we fail to control what we offer society, it will not take long before specialties develop for euthanasia or assisted killing. It will certainly be unenviable. As a doctor, I will not forgive myself if I kill a patient suffering from an incurable disease today only to discover that a cure for the disease has been found the next day.
Two points to make in response. 15 November 2001
Martin Hughes, G.P. White House Surgery Weston. SO10 9HJ Send response to journal: Re: Two points to make in response.	Anyone out there believe in the sixth commandment,"thou shalt not murder",( and generally embraced by all the major world religions),or is that too untrendy to adhere to these days? And anyone recall the passing of the 1967 Abortion Act - the slippery slope - turned out to be very slippery and downward all the way - connect?
After death? 15 November 2001
Julian Kennedy, Staff Grade,Emergency medicine Royal Bournemouth BH7 7DW Send response to journal: Re: After death?	The professors Doyal in their editorial argue for voluntary euthanasia and physician assisted suicide starting from the widespread practice of withdrawal of life support from incompetent patients . They seem to think it is a small step from one to the other. The major errors in their thinking are these-firstly competent people have no right to kill themselves under law and are morally wrong in their aim at self-murder. Secondly-any doctor willing to assist such a person, however ill the patient is abetting a crime. There is no reason anyone should necessarily suffer in this day and age of potent analgesics. Finally they completely overlook some spiritually-deduced points of fact(my conviction). Death itself is a moral evil brought in as judgement at the time of the fall of man in the garden of Eden-it is the ushering-in of an eternal moral soul into eternity-of either heaven or hell depending on the predestinating purpose of God. So when the professors ask ‘where is the wrong?’ it lies in the fact that the Creator of each one of us has given us an allotted span in which to repent and turn to Him-shortening this time in any competent person whether they are willing subjects or not is wrong.And the slippery slope is a misnomer-sacrificing our children to the god Moloch is the truth and it started legally in 1967 and 'terminations' (what a disgraceful euphemism) continue unabated.Anyone wanting chapter and verse can e-mail me. Dr Julian Kennedy, Staff grade, Emergency medicine, Bournemouth
Legalisation of euthanasia? Not from this argument 15 November 2001
Richard Hayward, Consultant Paediatric Neurosurgeon Send response to journal: Re: Legalisation of euthanasia? Not from this argument	Editor – In their editorial, the Professors Doyal argue strongly for the equivalence of omission and commission (active versus passive) in the management of severely incompetent patients but can this argument be carried over to cases like that of Mrs. Pretty (whose case provoked their editorial), where competence has not been disputed? Should she be able both to ask her doctors to “actively end her life” and expect them to do so? They propose that our response to the second question should be yes but have they proved their case? I think not. Their argument is complex but its thread may, if my interpretation is correct, be summarised as follows:- a. As Mrs. Pretty is competent she can request for herself (and expect to have that request granted) a passive life-terminating option (the withholding of particular treatments). b. There’s no technical difference between what would end life for a competent Mrs. Pretty and an incompetent (perhaps ventilated and brain- dead) patient. In both it would be the withholding of one treatment or another – artificial respiration in the latter case. c. What is nowadays accepted management for an incompetent patient removes the distinction between active and passive decisions which are acknowledged will lead to death (and are indeed so intended). d. As there is no difference between active and passive in this context, there is no logical case for denying Mrs. Pretty an option (assisted suicide or euthanasia) that appears more active than “merely” withholding treatment when a life-threatening crisis occurs. But does this argument hold up to close examination? Can we accept, for example, that the interests of competent and incompetent patients – the sentient and the insentient – can be equated? And is it right to equate active and passive in our dealings with the competent and the incompetent? Would not the Professors Doyal admit that our decisions in these difficult situations exist on a spectrum that has active at one end and passive at the other – with fusion between the two being most apparent when it comes to dealing with the severely incompetent patient. Acceding to a plea not to treat, for example, a chest infection with antibiotics and physiotherapy would clearly fulfil their definition of actively hastening Mrs. Pretty’s death by an act of omission but can we really accept the moral equivalence of such a policy with the administration of, say, a lethal dose of opiate? Richard Hayward MBBS FRCS Consultant Paediatric Neurosurgeon, Great Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH e-mail:- haywar@gosh.nhs.uk 1. Doyal L. & Doyal L.. Why active and physician assisted suicide should be legalised. BMJ 2001;323: 107901080 (10 November)
The Judge is right in his decision. 16 November 2001
M S Basharuthulla, Consultant Physician & Cardiologist/Clinical Tutor Adan Hospital Kuwait Send response to journal: Re: The Judge is right in his decision.	Sir, The situation anent Diane Pretty is understandable, and is certainly miserable with poor outlook. But the Judge is absolutely right in his decision in her case,as we do not want to open door for future conflicts pertaining to such cases.Indeed any depressed patient would ask legally to terminate his or her life at any stage or ask doctors to decide about it.We all know that as doctors we are suppose to save life ,not deliberately take it. Ofcourse we may with hold treatment at certain stage if the out come is futile,but certainly not hasten death by giving deliberataly some thing knowing well it would do harm.Unless we are clear about these rules ,things will go out of hand and then every one will blame the doctors and the legal system. Sincerely yours MS Basharuthulla MD,FACP,FRCP.Gl ,FRCP.Ire,
Legal right to assisted suicide is an insurance against suicides 16 November 2001
Anders Nordentoft, Royal Pensionnaire (non-medical) Denmark Send response to journal: Re: Legal right to assisted suicide is an insurance against suicides	In Denmark the only number of suicides not decreasing is the figure for elderly people. In Denmark you can make a "liwing will" asking not to have treatment to prolong your life when you have reached a certain very well defined state of physical and/or mental conditions. In spite of the "living will" decision and of good professional care we all see a number of elderly relatives slowly rotten or dissolve for years before they die with all the mental pain this period involves. A number of suicides "before time" could be avoided if the living will was allowed to include physician assisted suicide. We would not have the fear of going through a painful period as our relatives if we had an "insurance": when you want to die, and when it is judged (on the basis of your will read by a doctor and a lawyer and a relative?) to be the right thing to do, we will help you.
Nothing to with best interest 16 November 2001
Kalman Kafetz, Consultant Physician Department of Medicine for Elderly People Whipps Cross Hospital London E11 1NR UK Send response to journal: Re: Nothing to with best interest	Doyal and Doyal base their support of euthanasia on a false premise. They consider that doctors stop life sustaining treatments when they believe that this is in the best interests of severely incompetent patients. From this premise they argue that euthanasia is acceptable. However this is not the reason why many doctors withdraw treatment. They do this because it is clear that the treatment is not working. A debate about euthanasia and physician assisted suicide is important. However Doyal and Doyal have made an unhelpful contribution beacause they do not understand the realities of clinical practice.
Deadly compassion. 16 November 2001
Gregory Gardner, Non-Principal GP Swanpool Medical Centre, St. Marks Rd., Tipton DY4 OUB Send response to journal: Re: Deadly compassion.	Len and Lesley Doyal's editorial on Euthanasia/Physician-Assisted Suicide[1]centres around the scope of autonomy. Is autonomy absolute? Clearly the answer is no. Society and the law places limits around individual autonomy in order to protect the most vulnerable. The Doyals ask, why it would be wrong to stop life sustaining treatment when the life of the incompetent patient in question is not worth living and therefore not worth prolonging. The answer is that a clear distinction must be made between the worth of a particular treatment and the value of the patient's life. To confuse these two can be fatal. Decisions should be made on the objective medical needs of the patient, not a subjective value judgement about whether their life is dignified, meaningful or burdensome.[2] They say that 'if death is in the best interests of patients....then death constitutes a moral good for these patients.' The logical extension of this argument would be that if death is a moral good for some patients who are asking for euthanasia, why should that moral good be denied to patients who are not asking for it? Opinion polls in Holland support this with almost the same percentage of people saying yes to both voluntary euthanasia for themselves in the future and involuntary euthanasia for disabled patients in the present. The Doyals rightly point out that omissions in which the intention to kill is present are in the same moral category as commissions which have the same intention. Even focusing narrowly on active intervention, there was an increase in euthanasia deaths in Holland from 1990 to 1995 of 3.7% of all deaths to 4.7%.[3] In the same surveys at least 50% of Dutch doctors report the appropriateness of suggesting the possibility of euthanasia not recognising how much patient autonomy is compromised in so doing. About a quarter admit to ending patient's lives without their consent and babies in Holland with easily correctable congenital heart defects have been refused surgery. Now the Dutch health minister has proposed that elderly people who are 'tired of life' should be offered a suicide pill.[4] There is an inseparable connection between voluntary euthanasia and involuntary and non voluntary euthanasia both philosophically and practically which the authors of the editorial have not dealt with. Finally, when BMA policy is opposed to Euthanasia and Physician Assisted Suicide why is such editorial prominence given to only one side of the debate? Yours sincerely, Gregory Gardner. 1 Doyal L, Doyal L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001;323:1079-80. 2 Smith W. Culture of Death. The assault on Medical Ethics in America. San Francisco, Encounter Books 2000:92. 3 Hendin H. Physician-Assisted Suicide and Euthanasia in the Netherlands. Lessons from the Dutch. JAMA 1997;277:1720-22. 4 CNN 14 April 2001.
Not enough for "good chaps" to agree 16 November 2001
Gervase Vernon, General Practitioner, John Tasker House, 56 new St, Dunmow, Essex CM6 1BH Send response to journal: Re: Not enough for "good chaps" to agree	Dear Editor, you have published an editorial in favour of active euthanasia(Doyal & Doyal 2001). The authors fairly address and summarise the arguments for both sides. Yet the article fills me, as a GP, and inevitably a future NHS patient, with dismay. They speak of a doctor who disagrees with the decision to withdraw life support "when the clinical team agree it is appropriate." Recent events, the Bristol case and that of Dr. Shipman in particular, have forced society to look more closely at medical fallibility. Much research shows the error rate to be high(BMJ special issue, 2000). It is no longer enough to depend on the decisions of "good chaps"(Gillon 1985), Yours sincerely, Dr. Gervase Vernon References BMJ special issue 2000, "Facing up to medical error", BMJ, vol. 320,no. 7237, p. 0. Doyal, L. & Doyal, L. 2001, "Why active euthanasia and physician assisted suicide should be legalised", BMJ, vol. 323, pp. 1079-1080. Gillon, R. 1985, "Conscience, good character, integrity, and to hell with philosophical medical ethics?," in Philosophical medical ethics, John Wiley & Sons, Chichester, pp. 28-33.
Francis H Sansbury can be gratified at once 16 November 2001
Richard Smith, Editor BMJ Send response to journal: Re: Francis H Sansbury can be gratified at once	Francis H Sansbury need not wait for an editorial arguing against euthanasia but can be gratified at once. The BMJ published one just a couple of months ago--by Ezekiel J Emanuael.(1) This is the beauty of signed editorials. If the BMJ were to publish unsigned editorials arguing opposite positions it might seem strange, but the BMJ is not a sentient creature. It is looked after by a collection of individuals who have different views. "All sentences that begin with 'we' are lies," said Simone Weill. My predecessor, Stephen Lock, who taught me most of what I know, told me that "editorials must be within two standard deviations of the norm." Twenty, even 10 years, ago an editorial arguing the case for euthanasia would not have met his criterion. Now it does. Richard Smith Editor, BMJ (1) Emanuel EJ. Euthanasia: where the Netherlands leads will the world follow? BMJ 2001; 322: 1376-7.
Re: Who decides? Empowering patients 16 November 2001
Timothy James, Senior Lecturer University of Central England Send response to journal: Re: Re: Who decides? Empowering patients	Mr Goss's arguments are equally powerful as a case for the reintroduction of the death penalty for mrder. This, too, "has the support of the majority of the general public. It is "the opposition from [among others] the medical establishment and the judiciary" which has prevented it. The curious thing is that here, too, Parliament listens to the vocal minority, not the voting majority. Whenever the issue comes before Parliament, the Government allows a conscience vote, and abolition is upheld. This, too, is hardly "represent[ing] the will of the electorate." My own opinion is that the minority is, in each case, right and the majority wrong. We are better off without both hanging and euthanasia. But if I am mistaken, Mr Goss and those who agree with him must accept their own logic and campaign equally powerfully to bring back capital punishment.
Dead wrong 16 November 2001
Paul Keeley, Research Fellow Department of Palliative Medicine, Beatson Oncology Centre, Glasgow, G11 6NT Send response to journal: Re: Dead wrong	The Professors Doyal have started a vigorous debate and should be thanked for that, but their thinking is profoundly and deeply wrong. The plain fact is that intentional killing is wrong, plain wrong. The Dutch experience has demonstrated the slippery slope argument as true (how else could you justify the killing of a woman in her 50s with depression alone?; voluntary pretty soon becomes involuntary euthanasia). The Shipman case showed that in the wrong hands medical power over life and death, even when legal sanctions are in place, is easily abused. The debate is fraught with euphemism: euthanasia simply means good death - since when did killing someone constitute moral goodness? Caution should be expressed about philosophers and academics exhorting us to euthanasia - has anyone ever heard a call for philosopher- or politician-assisted suicide? Plenty of societies have asked doctors to do their morally dubious work for them in the past (cf psychiatrists in the USSR) The dying are vulnerable and their protection should be akin to the protection accorded other voiceless and vulnerable groups. I do not doubt that those who favour active euthanasia are sincere people who wish to see an end to suffering, so do we all. Part of the answer is the proper provision of pain and palliative care services rather than the patchwork of inequitable service that the NHS gets on the cheap - pain & symptom control, palliative care education and care at the end of life, not abandoning the dying are not optional extras: they should be core care. A note of caution however: while most pain is treatable with increasingly sophisticated techniques and drugs, not all pain is controllable. Here we need to reassure those in pain that we will not walk away from them. Spiritual and existential suffering in the face of death is as old as humankind - doctors it strikes me are good at treating sickness and physical pain but are do not have the skills to try to soothe mankind's deepest fears in the face of death.
Kakothanasia 16 November 2001
Marinopulos Ioannis, Consultant Paediatric Surgeon Interbalcanic Medical European Center Thessaloniki Greece Send response to journal: Re: Kakothanasia	Eu + Thanatos are two words practically impossible to join. From the linguistic point of view the word euthanasia should have never been builded. There is good and miserable life but only one kind of death. Courts may legalize death at will, propably by extending patients chart but doctors should not consent as this will mean that we accept our inability to comfort patients and look for new ways to improve their lives. It sounds absurd with so many advances in painrelief and artificial feeding that a patient will be offered the option of having his life taken away. Treating children with congenital abnormalities is a life's commitment that we cannot always fullfill.Many times life cannot be saved but we should always comfort.
A view from the slippery slope 16 November 2001
Daniel Munday, Acting Consultant in Palliative Medicine Myton Hospice, Warwick, CV34 5JH Send response to journal: Re: A view from the slippery slope	The editorial by Professors Doyal “Why active euthanasia and physician assisted suicide should be legalised” covers very familiar ground and has provoke the expect debate. However, since the editorial is based on the implicit assumption, that the overriding ethical principle is personal autonomy, with its relativistic implications, I was surprised to find a reference to the “slippery slope” in the last paragraph. Surely any meaningful discussion of “slippery slopes” must be based on the premise that we can define the nature of the slope. Without external reference points allowing us to determine “up” and down” on the “y” axis, (we can all agree on the “x” being “time”) how can we define the direction in which the slope travels? “Pro-lifers” will argue that we are already on that slippery slope and some way down it. Legalised abortion in 1967, “Tony Bland” in 1994 take us to this point, one further small slide and we have physician assisted suicide (we must not forget that the “Diane Pretty” case was not about euthanasia as her counsel reassured us). The next slide will then be voluntary euthanasia and where after this? “Pro-choicers” will see this as a slope for which they have campaigned and struggled to climb. But when will they reach the summit, after which the slope starts to slip downwards? How will we know that we have arrived? Where is the limit of the freedom to choose? External reference points, such as the “sanctity of life”, even within the moral maze of clinical practice at least provide us with some hope of knowing where we are. Maybe it is time to re-examine this principle which we have so readily discarded. It might provide a beacon for those of us floundering in “a sea of relativity”.
Poor Reasoning 16 November 2001
Roger Albin, Professor of Neurology University of Michigan Send response to journal: Re: Poor Reasoning	This editorial is an effective piece of rhetoric but the conclusions are based on poor reasoning and straw man arguments. The basic argument is the pursuit of analogy with withdrawal of life support from a hopelessly ill and incompetent patient. Analogy is a useful method of illustrating arguments but is a notoriously weak form of reasoning. To paraphrase Walter Benjamin, analogy is in the realm of thought what ruins are in the realm of buildings. You have to make your case on the basis of the situation at hand, not some analogous construct that provides you with more favorable ground. The straw man arguments include statements such as the one about how the most eloquent opponents of physician assisted suicide or physician directed euthanasia accept that there is no difference between active participation in these activities and passive withdrawal of life support. This is simply not true. Whether or not one accepts them, there are reasonable arguments about real differences between active participation in death and withdrawal of life sustaining support. These arguments have been made by some notably eloquent and well know figures in the field of medical ethics. It is important to not also that this is not simply a debate about an individual moral issue, but also a debate about acceptable public policy. In that context, both the negative and positive social consequences of approving physician assisted suicide and/or physician assisted euthanasia have to be examined. This editorial ignores this crucial dimension. Interested readers would do well to consult the relevant chapter of James Bernat's Ethicial Issues in Neurology for an evenhanded discussion of this difficult issue.
The Law is an Ass 17 November 2001
Andrew Thornton, GP Northlands Surgery, Calne, Wilts SN11 0HH, UK Send response to journal: Re: The Law is an Ass	If Diane Pretty were to tell her GP that she is in a lot of pain, he/she could legally kill her with morphine. He would not need to collude with her in this, but even if he did, he would only be prosecuted if this became known. If he admitted to the collusion, he could be prosecuted, as Nigel Cox was a few years ago. A doctor can legally starve or asphyxiate a patient who is on life support, but not kill them humanely. The Law forbids us to use on humans the humane methods we are allowed to use on animals, and would, rightly, prosecute us for starving or asphyxiating a dog. If a patient wishes to die, the Law forbids us to ease them out with dignity and without suffering. But, in a few cases, the Law allows us to kill them using barbaric or inappropriate methods. If the British public wants euthanasia or assisted suicide, then the Government should set up a proper system of monitored killing that is not hidden from the safeguards of public view, and that is not at the whim of both the physician and the loopholes in the law. We should be grateful to the Doyals for setting in motion what is already a very heated debate, and hope that the Government will grasp the nettle and no longer turn a blind and uncaring eye to the problem.
The Doyals do not refute their opponents 17 November 2001
Andrew Warsop, GP principal Jubilee St Practice, 368 Commercial Rd, London E1 0LS Send response to journal: Re: The Doyals do not refute their opponents	Doyal and Doyal do not establish that active euthanasia is morally permissible. As they admit, their most articulate opponents state that notions of 'benefit' and 'burden' must not be linked to any claim that life is no longer worth living. This is quite correct; notions of 'benefit' are logically distinct from whatever intrinsic worth human life may have. One may quite legitimately claim that the value of a human life is not commensurable with notions of benefit or burden. If one is to advance the thesis that the value of a life can be measured wholly in terms of 'benefit' then the Doyals owe us some argument in support of this claim. Sadly, none is provided. The authors suggest that death can be in the best interests of some patients and that therefore it constitutes a moral good. If human life has some intrinsic value incommensurable with notions of burden and benefit, then death cannot constitute a moral good. Also, there is a prima facie case for claiming that taking a life is always morally wrong. If one construes 'care' as meaning care of the life of one's patient (as opposed to, say, avoidance of suffering)- active euthanasia always constitutes a failure in a doctor's duty of care.
Other things to consider 17 November 2001
Martin Jackson, General Practitioner Braintree CM7 9BY Send response to journal: Re: Other things to consider	The article is a very articulate on the moral good of this difficult and emotive area. One area which should be looked at in Mrs Pretty's case and in similar ones is what does the patient want? In her case it mentions the indignity and suffering she feels, in other people they mention their physical, mental and emotional anguish, the intolerable burden they are putting their caring friend or relative through, avoiding what they saw in another ill person or something similar. If these are the main things that trouble the patient then surely we should be looking at how these could be improved. The hospice movement has made many strides to address these issues for many patients and their carers. Other areas to look at are, is the patient depressed which may improve with medication or psychological treatment. Another area to consider is more spiritual, like is there life after death? Though people have many views on this subject, the strenght of our views will not alter whether life does continue after death and this is not addressed in the article. Other difficult questions to face are, what methods of assisted suicide are acceptable, how long between the recquest and being allowed to die, who assesses the genuineness of their recquest, what criteria do they use, how do we avoid relatives coaxing ill people to recquest assisted suicide. Though the article is very persuasive I think it is morally better not to allow euthanasia or assisted suicide. Martin Jackson General Practitioner Braintree Essex
Only God the Sir of Life, physician the servant of Life 17 November 2001
Matias Diaz Sanchez, Hematology Service Complejo Hospitalario Dononosti. San Sebastian. Spain. Send response to journal: Re: Only God the Sir of Life, physician the servant of Life	As a physicianI am compromised to make my best to take care of my patiens under all circumstacies they are, but just not to kill them. And if a disperate or terminal of my patients would demand me his dead I just must remember to myself such a compromise that a day I promised to mankind -remember the Hypocrates's jurement. When a physician cut the problem of a desperate patient in such a way -tout simplement killing him -, he is far of solving the problem his patient have. More, he forgot a duty of medecine -let remember the hypocratic imprecation!-: if medecine are not capable of healing a patient from his illness at least the practionner has the duty of make less penible and more confortable if possible his patient's end of life not only with the potent therapies and the collaboration of others colleagues more expert in technical remedies the modern medicine have, but in exerciting the ancient art of medecine wich consist in hearing his patient complaints and to understand him, in such a way that he can assume the natural end of his life with peace, and if his patient have confidence in God, as a God's appel to another true Life.
Re: Doctors as killers 18 November 2001
Mohan Chawla, Consultant Psychiatrist Kettering General Hospital, UK. NN15 7EU. Send response to journal: Re: Re: Doctors as killers	We have recently been told in UK that we do not have right to dignified death : ( Law Lords have ruled that a terminal patient Diane Pretty cannot ask her husband to help her kill herself and she should continue to be what has found to be subjected to torture and inhuman treatment.) In Europe, right to life is first human right but not a right to dignified death if there is any thing like that which I strongly believe there is. The matter is extremely complicated in a health system like UK where NHS is a monopoly employer for doctors and if you don't agree with managers, there are risks to your professional life and success. I believe that any such debate should first clarify that the physician is an independant practitioner or a state employee ?
Re: It is my right 18 November 2001
Mohan Chawla, Consultant Psychiatrist Kettering General Hospital, UK. NN15 7EU. Send response to journal: Re: Re: It is my right	I strongly believe that we can take matters forward if we were to agree to the question ? Whom does the body belong to ? Is it the individual or soul in the body or the state has authority over people's bodies?
Caution is the word 18 November 2001
Manvikar Purushottam, Resedent Departmetn of Anatomy St.Johns Medical College Send response to journal: Re: Caution is the word	Legalisation of euthanasia is acceptable but caution need to be exercised.In a country like India, it is very easy to convert a murder in to euthunasia.Doctor may become accomplice crime.However we seems to have forgotten Hypocratic oath.We have pledged to save lives of suffering and allevaite sufering.It is ironical that we are forced to alleviate suffering by killing the sufferer! Secondly , l;igically thinking, why law needs a doctor to kill a patient?Any designated person other than a doctor can pullout endotracheal tube of a patient on ventillator or a trained personnel can push a toxic drug? The role of the doctor needs to be limited to certification of an incurable disease.
No justification for killing anyone for any reason 19 November 2001
Sahar Jameel Kalyal, Graduate student Dept. of Community health Memorial university of Newfoundland A1B3X5 Send response to journal: Re: No justification for killing anyone for any reason	Behind my motivation for choosing to be a physician was something my father who was a Colonel in the army once said to me. " A soldier has the unfortunate job of killing people when ordered to do so, in contrast a doctor must save lives under all circumstances,so maybe your life as a doctor can balance mine, that of a soldier". There can be no justification for killing anyone for any reason, least of all Doctors killing patients. I cannot envision doctors in the role of an executioner, it's frightening.
Why active euthansia and physician assisted should be legalised - the arguments are flawed 19 November 2001
Michael Jarmulowicz, Master - The Guild of Catholic Doctors Royal Free Hospital, London, NW3 2QG Send response to journal: Re: Why active euthansia and physician assisted should be legalised - the arguments are flawed	Sir, Professors Doyal and Doyal present a progression of arguments to justify legalisation of euthanasia.1 However their approach is flawed for several reasons. They misunderstand the difference between the “sanctity of life” principle, which argues for the moral equivalence of acts of commission and omission, and the realistic acceptance of our ultimate 100% mortality, which leads to the justification of the withdrawal of treatment in appropriate settings. In essence the “sanctity of life” principle argues that life is a gift (from God) which we are to cherish and which we do not have dominion over. In consequence we are duty-bound to take reasonable steps to preserve it and do nothing (and here omission is included) to bring about its end. At the same time we know that death will come to us all, and as doctors we need to recognise when that time is approaching with the concomitant acceptance of the futility of trying to oppose it. It is at this time that medicine needs to concentrate on the relief of suffering and not prolong the dying process - a philosophy epitomised by good palliative care. It is in such circumstances that withdrawal or withholding of treatment is not bringing about the death of the patient; rather, it is the recognition of its inevitability. The principle is straightforward to state, but its application frequently requires fine judgment, which is the domain of conscience. Intention is likely to form a significant part in the assessment of the morality of a proposed action/omission, but in the assessment of intention we have to rely on the integrity of the individual concerned. That is why it is imperative to have a profession of honest individuals of the highest integrity. The Doyals’ approach is also flawed as they mix moral argument with legal precedent as if they were equivalent. But Lord Justice Ward, in his summary relating to the Manchester conjoined twins judgement, stated in response to the Archbishop of Westminster's submission on the ethical issues involved - "This is not a court of morals but a court of law...." It is sad that judicial rulings on what is legal or illegal may no longer coincide on what is morally right or wrong. As an example, the Bland judgement is one which many have criticised as morally wrong. The final difficulty in Doyals’ arguments is their use of the term “best interests” of the patient. Although this phrase is being used increasingly to justify doctors’ actions, it appears never to have been defined and without a clear and universally acceptable definition, its use in moral and legal arguments is meaningless. A good doctor-patient relationship relies on trust; trust both that the physician is competent and that his or her intentions are honourable. Sadly much of the bureaucracy now being imposed on the medical profession is because that trust has been undermined by a small minority of doctors with flawed integrity. I believe that any relaxation of the prohibition of euthanasia will not only be a morally retrograde step but also lead rapidly to the total distrust of the medical profession by the general public. Yours sincerely Dr Michael Jarmulowicz FRCPath, MBBS., BSc. Master - The Guild of Catholic Doctors 1.Doyal L, Doyal L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001;323:1079-1080
Medical Ethics Alliance intervene tooppose Mrs Pretty 19 November 2001
Anthony Cole, consultant paediatrician WR5 2BT Send response to journal: Re: Medical Ethics Alliance intervene tooppose Mrs Pretty	sir, The Medical Ethics Alliance joined the DPP and the Home Office in opposing Mrs. Pretty in her High Cout application that her husband could assist her suicide without fear of prosecution We would have placed before the court medical evidence concerning palliative care available for end stage motor neuron disease in order to challenge the assertion that the manner of her last weeks would necessarily amount to "degrading" or "inhuman treatment" under the meaning of the Human Rights Act 1998. The court however declined to hear medical evidence even on appeal, and proceeded on the basis of an unquestioned assertion made by her lawyers. The judges noted that the court had not been told what was proposed to bring about Mrs. Prett`s death and agreed that the DPP was right to contend that he had no statutory or other powers to give an undertaking not to prosecute, or grant a pardon in advance of any proposed criminal conduct under Section 2(1) of the suicide Act 1961. Nor did he have any powers or resources to investigate her death. We are now endeavouring to bring the conclusion of the BMA`s consensus conference opposing assisted suicide to the appeal before the Law Lords. We contend that doctors will inevitably become involved in such suicides. Further such a far reaching change in the law would have wide moral, ethical and social consequences. This must preeminently be a matter for Parliament alone. On the human rights argument the judges said;"This case concerns the conflict between two of the fundamental rights possesed by all human beings ths right to life and the right to decide what will and will not be done with one`s own body. English law gives priority to the first, as does the Convention Englishlaw curtails a persons right to bodily autonomy in the interests of protecting that persons life even against her own wishes". Elsewhere in the judgement they refer and agree with the Assembly of the Council of Europe document "On the protection of the human rights and the dignity of the terminally ill and dying,1999". "Inour view the right to human dignity which is enshrined in article 3[of the European Convention of Human Rights] id not the right to die with dignity, but the right to live with as much dignity as can possibly be afforded, untill that life reaches its natural end". Unlike Len and Lesley Doyal who write "Once it is accepted that doctors could be allowed to make clinical decisions to end life passively on the basis of such claims, active euthanasia in the best interests of such paients would be the next logical step". (Leading article the BMJ 10th November), The judges quoted from the report of the House of Lords Select Committee on Medical Ethics 1994; "The right to refuse medical treatment is far removed from the right to request assistance in dying. They did not believe that the aruguments were sufficient reason to weaken society`s prohibition of intentional killing. They could identify no circumstances in which assisted suicide should be permitted, nor did they see any reason to distinguish between the act of a doctor or any other person in this connection". Despite the reasoning in favour of voluntary and involuntary euthanasia in the BMJ leader, members of the association have already expressed themselves in two Annual Representative Meetings in 1998 and 1999 by voting overwhelmingly against assisted suicide and euthanasia. We trust the lesdership still own this policy. The judgement itself is worth further study(1). (1) Case no CO/3321/2001 Dianne Pretty v the DPP and Home Office and Others The Royal Courts of Justice, Strand, London. WC2A 2LL Yours sincerely Dr.Anthony Cole Chairman the Medical Ethics Alliance
Doctors rights, patients wronged. 19 November 2001
Edward Hanlon, CONSULTANT PSYCHIATRIST GENERAL HOSPITAL, LETTERKENNY, CO.DONEGAL, ROI Send response to journal: Re: Doctors rights, patients wronged.	The purpose of euthanasia is to relieve distress i.e. to put the patient out of his/her misery.But killing has nothing to do with doctoring.Why should a physician have a right to terminate someones life as opposed to, say, a teacher, bank manager, or even your local friendly milkman?
What is wrong today will be legal tomorrow 19 November 2001
Graham Todd, Obs & Gynae SHO North Hampshire Hospital, Aldermaston Road, Basingstoke, Hampshire. RG24 9NA Send response to journal: Re: What is wrong today will be legal tomorrow	Dear Sir Reading Len & Lesley Doyal’s editorial about euthanasia[1] was like watching a card trick, only the Professors used words. Two phrases that I thought I understood were shuffled together and came out meaning the same thing. Apparently active euthanasia is the same as passive euthanasia and therefore they are morally equivalent. Using the same logic and semantic skills I wonder if they could prove that Hippopotami (lit. River Horses) would be good at show jumping. Allowing people to die by removing treatment is an example of passive euthanasia. Injecting them with potassium is an example of active euthanasia. There is a huge difference and the Professors are dishonest to smudge that difference to make their point. Professors Doyal speak of the need for clinical agreement about when active euthanasia would ‘benefit’ a patient, but say nothing of the difficulties obtaining this agreement would entail. However, they do admit that there is a problem with ‘deciding when a request for helping dying is appropriate’. ‘Though this may be difficult it cannot be impossible’ they propose. I disagree. It will be impossible to correctly decide all the time and therefore those doctors who are prepared to ‘assist suicide’ may in truth be executing the unwanted. I am disappointed but not surprised by this article. Whilst the tinsel and fairy lights of modern thought are full of altruism and ‘spirituality’, the foundations of Britain’s dominant philosophy are based on materialistic atheism. Human beings are a product of chance, we are told, and it appears to be widely accepted. The Christian ethic, through creation and the cross, gave all people value but the current Western worldview cannot. Consequently, our morality prioritises the reduction of visible suffering, rather than upholding the value of the individual. Social termination of pregnancy was once illegal but is now common practice and although active euthanasia is illegal currently, I suspect it will be permissible by the time I am an old man. If the BMJ is still in print in 40 years time, I may live to read an article re the value of cloning humans, no doubt eloquently articulated by a professor in medical ethics or health and social care. We are already on the ‘slippery slope’. Graham Todd Obs & Gynae SHO North Hants Hospital, Basingstoke Todds@doctors.org.uk 1. Doyal L & Doyal L. “Why active euthanasia and physician assisted suicide should be legalised.” BMJ 2001;323:1079-8. (10 November).
The last enemy 19 November 2001
M Trimble, Specialist Registrar in Clinical Pharmacology Belfast City Hospital, Belfast BT9 7AB Send response to journal: Re: The last enemy	Sir, In reply to the recent editorial by Doyal and Doyal. Death has been called the "last enemy". When we withdraw treatment from a patient it is because we have lost the battle with our enemy, and we realise that our interventions are of no use. In these cases the patient dies of their disease. It is not accepted practice to intervene to end the lives of people in physiologically stable conditions. As to the claim that the court's decision, preventing Mrs Pretty's husband assisting her suicide, is morally wrong, I must disagree. Regardless or the patient's wishes, the view of society, (or even of the ruling of the courts) we do not have the God given right to end a person's life.
Euthanesia and Physician Assisted Suicide 19 November 2001
W Eric Scott, Attending Intensivist Cooper Hospita/University Medical Center Send response to journal: Re: Euthanesia and Physician Assisted Suicide	Editor It was both refreshing and encouraging to read the closely reasoned argument expounded in the editorial on active euthanasia and physician assisted suicide in the BMJ.1 However reason and rational discussion often have little to do with the formulation and adoption of an individual's moral code and value system. Generally it is the early upbringing and environment of the individual that determines fundamental beliefs and only a minority subsequently subject these to rational analysis In a pluralistic society however we should respect all of the varied beliefs of societal members and tolerate the behavior dictated by those beliefs. The only justifiable reason for restricting individual behavior should be a clear demonstration that such behaviour will have a damaging effect on society and upon its ability to achieve its goals of maximizing the happiness and fulfillment of its members. Viewed in this light it is indeed difficult to understand why a caring physician should not be legally permitted to acquiesce to a reasonable request from a competent patient to assist in terminating their life in a manner and at a time of their choosing. Assuredly there will be many who will regard the termination of a human life under these circumstances as wrong, and that view should be accepted and understood as deriving from their fundamental belief system. For many of us however,such an action is morally good, and that view too should be accepted and understood as deriving from a different belief system. Such differing philosophies are to be anticipated and tolerated in a pluralistic society. As stated above however, legal embargos on actions driven by such beliefs can only be justified if such actions can be shown to be detrimental to society. I would submit that no evidence exists to demonstrate that society will be harmed by a caring physician agreeing to assist the few competent patients who find living conditions so intolerable that they do not wish to continue their lives. W. Eric Scott MD FCCM Attending Intensivist Cooper Hospital/ University Med. Cent. 1 BMJ 2001;323:1079-80
Re: The Law is INDEED an Ass 20 November 2001
Peter Bradley, GP 25 yrs Brisbane Qld Australia Send response to journal: Re: Re: The Law is INDEED an Ass	Thank heavens for such a sensible letter well put. I tried to do likewise by citing personal experience (see letter above "The last right?"), however, a feature of the nay-sayers in a debate like this is they ignore the harsh realities - the lack of comfortable black and white - and resort to lofty argument whilst at the same time giving meaning to the old saying, "there are none so blind as those who will not see." They denigrate our profession by implying dastardly deeds would be done if legallised, overlooking the fact anyone wanting to do something illegal, does so - eg Dr Harold Shipman, whom some even mention, as if that is supporting evidence. No wonder, as you point out, we are still in the dark ages with respect to this issue which will not go away. With respect, I suggest it is hypocritical and gutless, to suggest it is wrong to assist someone requesting termination of their life for good reson, yet we can hide behind this sham of it being ok to just withdraw treatment, and let them die a lingering miserable death by slow suffocation or dehydration, when as pointed out, if you did it to your dog you could be prosecuted. What is wrong with these people?
Why euthanasia should not be legalised 20 November 2001
Liz Croton, SHO A&E City Hospitals NHS Trust, Dudley Road, Birmingham B18 7QH Send response to journal: Re: Why euthanasia should not be legalised	Why euthanasia should not be legalised In response to the editorial regarding the legalisation of active euthanasia and physician-assisted suicide,1 I present the following arguments against the legalisation of active euthanasia. Active euthanasia is unnecessary because alternative treatments exist It is widely believed that there are only two options for patients with terminal illness: either they die suffering or receive euthanasia. Recent research in palliative medicine has shown that virtually all unpleasant symptoms experienced in terminal illness can be relieved or alleviated by existing techniques. Requests for active euthanasia are rarely free and active. A person with terminal illness is vulnerable, lacking the skills and knowledge to alleviate their symptoms. It is very difficult for him to be entirely objective about his own situation. Their capacity for decision-making may equally be affected by confusion, dementia or symptoms, which could be relieved with appropriate treatment. Patients who on admission say "let me die" usually after effective treatment are grateful that their request was not acceded to. Active euthanasia gives too much power to doctors Ironically, active euthanasia legislation makes doctors less accountable and gives them more power. Patients generally decide in favour of euthanasia on the basis of information given to them by doctors. If a doctor confidently suggests a certain course of action, it can be difficult for a patient to resist. However, diagnoses may be mistaken and prognoses may be widely misjudged. Active euthanasia gives the medical practitioner power, which in turn can be abused. Active euthanasia leads inevitably to involuntary euthanasia When active euthanasia has been previously accepted and legalised, it has led inevitably to inactive euthanasia. Holland is moving rapidly down the slippery slope with the public conscience changing quickly to accept such action as acceptable. The Royal Dutch Medical Association has recommended that the termination of the lives of patients suffering from dementia is acceptable under certain conditions. Case reports include a woman killed at her own request for reasons of "mental suffering".[2] Such a progression requires only four accelerating factors: favourable public opinion, willing doctors, economic pressure and a law allowing it. In most Western countries the first three ingredients are present already. When legislation comes into effect and political and economic interests are brought to bear, the generated momentum inevitably follows. Dr Liz Croton SHO A&E City Hospital NHS Trust, Dudley Rd,Birmingham B18 7QH elizabethcroton@hotmail.com 1. Doyle L, Doyle L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001:323;1079-80. 2. Sheldon T. Judges make historic ruling on euthanasia. BMJ 1994;309:7-8
Blurred ethical arguments should not be used to justify killing 21 November 2001
Adrian Treloar, Consultant and Senior Lecturer in Old Age Psychiatry Memorial Hospital, London SE18 3RZ Send response to journal: Re: Blurred ethical arguments should not be used to justify killing	The suggestion that there is no difference between killing someone and not imposing onerous treatment that will not help them is utterly extraordinary, and shows how sophisticated arguments can come to bizarre conclusions. To claim, as the Doyals have done, that the moral status of an act is determined by its outcome rather than by its purpose or intention , results in arguments so blurred that they can deceive. Patients such as Mrs Pretty require the absolute assurance that good quality care will be afforded to them when they are in need and that symptom control will be of paramount importance. Justifying killing using the arguments presented in their editorial, would also lead to the conclusion that running someone over with the intent of killing them is morally the same as the most unavoidable of road traffic accidents. If the courts were to accept such arguments, then the defence of our most vulnerable and sick patients would be very severely compromised.
Upon what morality can euthanasia be based? 21 November 2001
Gareth Payne, PRHO Queen Elizabeth Hospital, Edgabston, Birmingham, B15 2TT Send response to journal: Re: Upon what morality can euthanasia be based?	EDITOR-Doyal and Doyal's1 editorial states that the real basis for allowing euthanasia to occur is that there is no moral difference between acts of omission and commission. As someone opposed to euthanasia, I would state that I believe that there is a significant difference between allowing someone to die, and making sure that they do so. We all ultimately answer for our own actions. If someone refuses a treatment, that is their responsibility, but if we act to actively end their life, we have become the agent of death. I would like to know what the basis of their decisions that certain actions represent a 'moral good' or are 'morally' wrong, particularly in relation to questions of life and death. I I am also concerned that they feel that it is the doctor's duty to 'protect life and health.' I do not believe that it is part of my duty to protect life at all costs. Surely a doctor's role is to aid, advise, offer treatment and support as required and needed. In this technological age we have lost sight of what our predecessors knew of allowing the disease to take its course, whilst providing good care and support for the patient. Doctors are qualified best to make value of treatment decisions. No one is qualified to make value of life decisions. 1 Doyal L, Doyal L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001;323:1079-80. (10 Nov) Gareth Payne PRHO in Medicine Queen Elizabeth Hospital, Birmingham, B15 2TT garethpayne@bigbluespot.com
Active euthanasia and physician-assisted suicide 21 November 2001
Andrew Rivett, Senior Clinical Medical Officer Communicable Disease Control, Southampton & South-West Hants Health Authority Send response to journal: Re: Active euthanasia and physician-assisted suicide	EDITOR – Doyal and Doyal make a cogent case for legalising assisted suicide . They argue that what is important is the justifiability of the outcome. Given that death is at times in the best interest of the patient, they assert that it is therefore a moral good to bring about this end. First, I would agree with the authors that the point is not whether death is caused by action or inaction. However, the difference of intention remains important. If you decide that it is time to switch off my ventilator, and, against all expectation, I continue to breathe spontaneously, I hope you would be glad - even if it only delays the inevitable. Your intention was not to kill me: you felt that such extraordinary means were no longer justified in view of what you believed was an unavoidable death. However, if you inject me with a large dose of diamorphine, my not being in pain, your intention is to end my life. Here the principle of dual effect is an essential divider: while your intention remains the relief of pain, appropriate intervention is justified even if it also shortens life. When you move on to seeking my demise, you move also onto very different moral ground. Death may at times constitute a moral good. But how are we to decide? Are we sure that we have the patient’s interests at heart, and are not influenced by other considerations? Is even the patient able to decide in the emotional turmoil of a serious illness? Even when we may believe that death is a moral good, it is a unique one if only for the reason that no- one knows what it is like. It is, to borrow a word from the cosmologists, a singularity; and we cannot look beyond it. How are we to weigh the benefits of this unknown entity? I would suggest that for this unique sometimes presumed moral good, uniquely is it immoral to seek it. It may at times be welcomed – even embraced. But we have neither the wisdom nor the moral clarity to use medicine to achieve it. Andrew G Rivett Senior Clinical Medical Officer Communicable Disease Control, Southampton & South-West Hants Health Authority, Oakley Road, Southampton SO16 4GX andrew.rivett@sswh-ha.swest.nhs.uk
The end does not justify the means 22 November 2001
Andrew Perrett, GP Beijing United Family Hospital Send response to journal: Re: The end does not justify the means	Doyal and Doyal’s article (1) (10 November) is both sad and worrying, if its publication as a leader in the BMJ means that it reflects medical opinion in the UK. The reaction of colleagues to the article suggests that this is far from the case. It is never appropriate that a doctor, whose first principle is to do no harm, should intend death, as opposed to accepting or allowing it. Shortening of life may be an acceptable ‘side effect’ of treatments in difficult circumstances. Treatment may also be omitted or removed (for example turning off life-support machines) with the intention of reducing distress and suffering, perhaps for the family as well as the patient, despite knowing that it will shorten life. These are different from a clinical decision to kill, whether active or passive. Secondly, in contrast to Doyal and Doyal’s assertion, an intention to relieve suffering and an intention to accelerate death are always morally distinguishable. An understanding of intent is fundamental to our interpretation of the right or wrong of human behaviour (“morals”). For example, a man who pushes a child into the path of a car is viewed differently (morally and legally) on the basis of his intention (to save, to kill, or accidental), even though the result may be the same. The patient (or their family) is not the only participant in this moral maze. There is also the medical team. Decisions to use or withhold medical treatments are never exclusively made by the patient. (A doctor could not responsibly prescribe a dangerous and inappropriate drug simply because a competent patient requested it.) If doctors become agents not only of comfort and healing but also of death, there are implications for their relationship of trust with all other patients. Autonomy must be balanced with non-maleficience (as well as beneficience and justice). Working in palliative care, I was struck by the extent to which a patient’s attitude towards death affected their approach to life as they approached the end. The patients who most warmly embraced the prospect of death (as a move to a ‘better place’), were also strongly of the opinion that the timing of their death was rightly removed from their own hands, or the hands of their doctors or relatives. Inspired by the lives (and deaths) of those patients, I’m inclined to think they were right about the timing of their death already being in the best hands. Notwithstanding the above, the pragmatic arguments against legalisation are substantial. Firstly, the slippery slope appears indeed to be slippery, judging from Dutch data (2). Secondly, who has the right and ability to decide that a life is not worth living? This is not conferred by medical qualification or by the closeness of a relationship. Nor is it necessarily wise or fair to place this decision in a patient’s hands. Many people endure sustained periods in their lives during which they would choose or request to die, for reasons with which we can empathise, but they subsequently change their mind (3). Thirdly, policing our profession for individuals such as Shipman and Allitt is difficult enough when the law is clear cut; the present law protects both patients and doctors (4). Fortunately, the provision of good palliative care should render this debate purely academic, because we do have the means to relieve suffering without intending the death of a patient. Given the unfortunate amount of anecdotal evidence that suggests the contrary, we should perhaps follow the Californian model of introducing palliative care training as part of continuing medical education for all doctors (5). 1 Doyal L, Doyal L. Why active euthanasia and physician assisted suicide should be legalized BMJ 2001;323:1079-80 2 Van der Mass PJ, van Delden WM, Pijnenborg L, Looman CWN. Euthanasia and other medical decisions concerning the end of life. Lancet 1991;338:669- 74. 3 H A Thiadens. A message from Holland BMJ 2000; 320: 1655 4 A M Smith, R Twycross, P Madeley, J Gilbert, V Ventafridda, H J Thomson, A Fergusson, P Saunders, I G Finlay, P Norris, B Ward, and P Tate. Euthanasia: Present law protects doctors and patients BMJ 1994; 309: 471. 5 F Charatan. New law requires doctors to learn care of the dying. BMJ 2001;323:1088.
Flawed arguments against active euthanasia 22 November 2001
Martin Klein, Neurologist 97070 Wuerzburg, Germany Send response to journal: Re: Flawed arguments against active euthanasia	Dear editor: I share the view of Doyal and Doyal that active euthanasia should be legalized under well-defined conditions. But there is a difference in active and passive euthanasia which preclude it`s equation: To refuse my wish to perform an action is not a threat to my autonomy but to refuse my wish to omit an action is (e.g if I want help to have a machine repaired, it is not against my autonomy if my neighbour refuses to help, but it is if the neighbour obtrudes on me. If a patient does not wish to be put on a respirator, I must not intubate him; if he wishes that I kill him, he cannot force me, but if I comply this should be legal (under well-defined conditions not discussed here). It is very simple: Advocates of euthanasia do not intend others to be forced to it ; but opponents seem to ignore the autonomy of free individuals. It is sad to read flawed arguments against active euthanasia again and again , especially when words like "executioners" or "eliminating patients" are used. The reason is that it is wrong to maintain that only "if we actively end life, we have become the agent of death" (Payne). If we do not intubate a severely ill patient who is hypoxemic than the cause of death will be his disease AND our failure to act (with the disease AND our treatment he can live longer). Our non- tratment is therefore a cause to his death. Otherwise a mother is not guilty of murder if she fails to provide fluids and food to her one-year old infant. What makes the difference is not doing or omitting, but the fact that one is a guarantee (as is a mother to her infant and a doctor to his helpless patient). Doctors who really maintain that any suffering can be treated do not have seen enough patients, e.g with ALS or tetraplegia. If it were true that no one "is qualified to make value of life decisions" than passive (and indirect) euthanasia should to be bent. There is no escape from potential slippery slopes in medicine as in our life. This is the reason why the slippery slope argument is not one unless it is proved. In the Netherlands there is no evidence for slippery slopes concerning euthanasia but a more open-minded debate than in other countries:Comparisons between the Netherlands and other countries who do not allow active euthanasia show that in the former doctors perform less often actions with the intent to end the life of patients(1). 1 Kuhse H. From Intention to content. In: Battin MP, Rhodes R and Sivers A. Physician assisted suicide. Routledge New York and London 1998, 252-266. I have no competing interests. M. Klein
Compassion and rationality 22 November 2001
Nigel Phillips, retired teacher Send response to journal: Re: Compassion and rationality	I support the views expressed by the Doyals in their editorial. It is plainly wrong that Mrs Pretty's rational perception of her own best interests should have been judicially overruled. In the name of both rationality and compassion it must be right to make it legal for doctors to fulfil requests from mentally competent patients to assist their release from unbearable suffering. As Andrew Thornton points out in his response, the law that obliges us to treat animals more humanely than humans is indeed
Patient autonomy requires information 22 November 2001
David Oliver, Consultant in Palliative Medicine Wisdom Hospice, St Williams's Way, Rochester,ME1 2NU, J Fisher Send response to journal: Re: Patient autonomy requires information	The recent Court case involving the application by Diane Pretty to allow her husband to assist her suicide has raised many issues about physician assisted suicide. Doyal and Doyal argue that Mr and Mrs Pretty should be allowed to take this course of action and that there is no difference between assisted suicide and the withdrawal of life sustaining treatments (1). However there are many complex issues to be considered. Firstly there is a need to consider how patients come to make an informed autonomous decision. Is all the relevant information available to the patient and their family? Many patients with motor neurone disease (amyotrophic lateral sclerosis) fear a distressing death but several studies have shown that this is rare, particularly with good palliative care (2). Moreover there is evidence that assisted suicide is not always as easy and peaceful as is often suggested – a Dutch study reported complications, such as nausea and vomiting in 7% of cases, problems of completion, with longer times to death than expected, in 15%. There were 114 people in the study and doctors intervened and performed euthanasia by giving of an injection for 21 (18%) (3). A decision for assisted suicide can only be made clearly and autonomously if such issues have been fully discussed. Secondly it is important to consider the reasons as to why people may request their lives to be ended prematurely. Zylicz and Finlay (4) suggest that in 80% of cases the reason is fear of the future (either of a distressing death or of being kept alive), depression may be responsible for 14%, in 4% patients are very near to death and they and their families suffer from “burnout”, the need for some people to control their lives is responsible for 1% and severe pain is the main factor for less than 1%. All these issues need to be addressed, particularly for a person with MND who may have read of the possibility of a distressing death, often from the discussion of cases such as that of Mrs Pretty in the media. There may not always be an easy answer to these concerns but they should be openly discussed, and if possible the anxiety relieved. There is also the need to look at the effects on all involved – the family and close carers, the health and social care professionals and society itself. Many families find the discussion of assisted suicide very difficult and if there are complications the memories are far from positive – there can be long lasting questions left for family members. There have been occasions when to ensure that death occurs the family or friends have resorted to putting a plastic bag over the person’s head. (5). Many professionals find assisting in the death of a patient very difficult and one study showed that 24% of the physicians who had been involved in a case of assisted suicide regretted their decision (6). These professionals may be left with many questions about their own actions. Although there is much discussion about the ethical and moral differences between the active killing of a patient and the withdrawal of life sustaining treatment there can never be any clear and consistent view for society. For the patient, the family and the professional it often only too clear that there is a distinction and if physician assisted suicide was legalised there is a high risk of undermining the care of all dying patients. Society needs to be clear of the size of this step before the Legislature and Courts make any decision to legalise the taking of life, opposed to the withdrawal of inappropriate treatment to allow life to take its natural course and death occur. Dr David Oliver BSc FRCGP Medical Director and Consultant Physician Honorary Senior Lecturer at the Kent Institute of Medicine and Health Sciences at the University of Kent at Canterbury Dr Jackie Fisher BSc MRCGP Consultant Physician REFERENCES 1.Doyal,L.,Doyal,L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001; 323:1079-80. 2. Neudert,C., Oliver,D., Wasner,M., Borasio,G.D. The course of the terminal phase in patients with amyotrophic lateral sclerosis. J Neurol 2001; 248: 612-616. 3. Groenewoud,J.H., vander Heide,A., Onwuteaku-Philipsen,B.D., Willems,D.L.,van der Maas,P.J., van der Wall,G. Clinical problems with the performance of euthanasia and physician –assisted suicide in the Netherlands. N Eng J Med 2000; 342: 551-556. 4. Zylicz,Z., Finlay,I. Euthanasia and palliative care: reflections from the Netherlands and the UK. J Roy Soc Med 1999; 92: 370-3 5. Jamison,S. Final Acts of Love, New york, Jeremy Tarcher/Putnam, 1995. 6. Emanuel,E.J., Daniels,E.R., Fairclough,D.L., Clarridge,B.R. The Practice of Euthanasia and Physician-Assisted Suicide in the United States: Adherence to Proposed Safeguards and Effects on Physicians JAMA 1998; 280: 507-513
Slippery slope arguments 22 November 2001
Colin Ferguson, Head of Curriculum Development Edinburgh's Telford College EH4 2NZ Send response to journal: Re: Slippery slope arguments	I entirely agree with this carefully thought out and argued case. Opponents of euthanasia even in carefully defined and controlled circumstances are entitled to their views, but not to impose them on others; some primacy should be given to the expressed wish of the person involved when this is clearly rational,considered and in line with an overwhelming majority of public opinion. The present interpretation of the law is inhumane, not respectful of the individual, and, as the article argues inconsistent. The "slippery slope" argument is unconvincing; of course without appropriate safeguards and checks there would be dangers, as in most tricky ethical areas where principles conflict. But we have already slipped down a much steeper slope on the other side of unnecessary and undignified suffering.
Euthanasia - an Overview and a Balanced Approach 22 November 2001
Dayantha Fernando, General Practitioner Principal and Student of Medical Ethics Camberley, Surrey Send response to journal: Re: Euthanasia - an Overview and a Balanced Approach	I would like to thank the Doyals for opening a fresh debate on this vexed subject and the BMJ editorial team for picking two non-medical ethicists to deliver the first salvo (pace Drs McArdle, Fetherston, Farkas and others). Perhaps intentionally and as reflected in the title, the Doyals have set out the pro-euthanasia case and the responses show that the bait has been well and truly taken with a large majority taking the opposing view. Yet, the case against euthanasia must be argued for and I believe that there is scope for the balanced view which I present here. The subject area is hardly new, Epicurus (342 BC) observed that "death is of no concern to us; for while we exist death is not present, and when death is present we no longer exist". St. Thomas Aquinas wrote that suicide is always morally wrong for it transgresses our duty to God, to others and to ourselves. David Hume in 1784 had answers for Aquinas arguing that God has given us free will to shape our lives (and death) and that sometimes death of an individual can be good for the community (eg Hitler) and sometimes good for ourselves. Voluntary euthanasia, an "easy, gentle death" desired by the individual and in practice procured by the physician is perennially in the news. Interest is heightened from time to time by fresh developments: the de facto (now de jure) Dutch practice of euthanasia, the Tony Bland case of 1993 in which the Law Lords permitted withdrawal of treatment in persistent vegetative state (PVS) thus allowing his death, the Nigel Cox case of 1994 in which a Rheumatologist was successfully prosecuted for administering a lethal injection to a woman in intractable severe pain and most recently the case of Diane Pretty, competent but physically incapacitated by Motor Neurone Disease, who wishes to have immunity from prosecution for her husband were he to assist in her suicide. Individuals reduced to contemplating death by suicide, euthanasia or assisted suicide in preference to continued life merit our universal sympathy and compassion. The Doyals invite us to imagine Diane Pretty rendered severely and permanently incompetent: would we not let her die? If she were in PVS, probably yes, but further hypothetical discussion on these lines seems pointless for she is not incompetent. Failure to treat they then claim can be tantamont to killing and they cite the unlikely example of a patient allowed to bleed to death in the Emergency Room. They argue that it is justification of outcome that matters, not whether the end is achieved by omission or commission (granted in this context). The Doyals then claim that action and inaction are moral and legal equivalents in the context of deliberate failure to save lives that should be saved. Using this analogy, we are then invited to agree the moral equivalence of action and inaction with respect to lives that should not be saved and to agree that somehow this is an argument for euthanasia. This writer is among those baffled by their reasoning. What are the goals of medicine? Most would agree with a duty to care, to give comfort, promote health, cure and to relieve suffering. But to relieve suffering by putting to death? Under what circumstances may it be morally permissible to kill our (guiltless) patients? The prohibition on killing is universal and strong albeit prima facie whereas our attitude to letting die, morally and legally, is far more equivocal (1). The pro-euthanasia lobby would argue that killing is permissible when continued life has become so burdensome that death is preferable. It goes unsaid that there should be a settled disposition to end one's life. Many and perhaps most of us have fleeting thoughts of "ending it all" in moments of despair. Some do go on to commit suicide in the face of overwhelming illness or injury. Consider the case of a young man rendered paraplegic in a hang gliding accident who kills himself (2) but contrast his account with that of the actor Christopher Reeve who suffered quadriplegia in a riding accident and continues to campaign vigorously for sufferers of spinal injury. These examples illustrate the dangers inherent in evaluating what constitutes "a life not worth living" in the face of physical impairment. How much more difficult then must the assessment of mental illness be and yet, Dr Chabot of Holland, having consulted seven "experts", assisted in 1991 in the suicide of his patient Mrs Boomsma, a sufferer of depression (3) However beneficent the underlying intention, killing to relieve suffering continues to prove inimical to the aspirations of a large majority of the public in general and to the medical and legal professions in particular. The prohibition on killing is just too great. I am not persuaded by the claim that a majority "support euthanasia" (4). These figures, replicated everywhere, merely represent the liberal outlook - "if people want it (whatever "it" may be) let them do it so long as others aren't harmed in the process" - of contemporary society. There is a sharp drop off in numbers when individuals are asked if they would want euthanasia for themselves and only a tiny residue of patients (and indeed physicians) actively seek this exit route. Perhaps then, physicians and not patients are best placed to assess whether a patient's request for euthanasia or assisted suicide should be acted upon. Experienced doctors could I suppose on clinical grounds (unreliably) identify patients in severe pain, distress and despair but what next? There are large individual variations in thresholds for entertaining thoughts of being killed as a means of escape from suffering, not to mention the day-to-day mood fluctuations we all undergo. Or should we perhaps have euthanasia by committee decision (one is tempted to ask whether these should be unanimous or by majority vote) and appoint (medically) qualified panels of experts to adjudicate? For the Dutch this appears to have become routine practice but elsewhere we may yet ask "What sort of physician would want to serve on euthanasia committees? Would they not attract those of a pro-euthanasia bent? Physicians who sincerely believe, exceptionally, that it is in a patient's best interests to be killed should consider some further issues also: The "right" to die doesn't imply a duty to kill (5) The trust that patients place in their doctors may be eroded by the knowledge that they may now have a dual role - to preserve and protect life on the one hand and to kill on the other. There are some signs that in Holland some fearful individuals are consulting pharmacists in the first instance in preference to doctors. How should patients of marginal and impaired competence be assigned when considering life and death issues? In conclusion, I submit that these are and will continue to be difficult questions which defy categorical solutions. Within the last generation, severely malformed and ill neonates were being "put out of misery" by lethal injection. Many physicians quietly admit on occasion to having administered excessive doses of morphine (sufficient sometimes to arrest respiration) to ease the passing of a terminally ill patient nearing the point of death. In this post-Shipman era few will openly acknowledge such acts. Nonetheless, I have yet to see a convincing case made for euthanasia and conclude with St. Augustine: "Never do evil that good may come". 1. Gillon R. Euthanasia, witholding life prolonging treatment and moral differences between killing and letting die. Journal of Medical Ethics, 1988, 14, 115-117 2. Hill C. The Note in Kuhse H (ed.), Willing to Listen: Wanting to Die (Ringwood, Victoria: Penguin Books, 1994) 3. Griffiths J. (1995) Assisted Suicide in the Netherlands: The Chabot Case. The Modern Law Review, 58, 232-248 4. The Times ePoll: Should Euthanasia be legal in Britain? 20th August 2001 5. Callahan D. (1995) Setting Limits: Medical Goals in an Ageing Society Washington DC: Georgetown University Press, 1995 2nd Edition.
Compassion and Common Sense 22 November 2001
V E W Ball, Retired Send response to journal: Re: Compassion and Common Sense	It is illegal for me to allow my dog to suffer needlessly and equally illegal for me to relieve my wife from a greater degree of suffering. It is legal for me to refuse treatment and thus die aslow death but illegal for my Doctor to afford me a quick and painful one. In the days when the prohibition aginst physician assisted suicide was logical, nature was allowed to take its course and pneumonia was called "The old persons' friend", ending, as it did, the suffering of many people. Now, technology keeps alive many people who would otherwise have died. I would wish to be one such IF I can return to a reasonable life for a reasonable time. But, to prolong life merely to aviod dying is ridiculous and cruel. A friend of mine, intelligent, active and compassionate spent the last three months of life able to do nothing but stare at the ceiling and contemplate, endlessly the longed for, inevitable end. No one deserves to die such a death. I pray that such a fate does not come to me and that some couageous physician will do as I would wish and send me on my way V.W. Ball
Autonomy not absolute 22 November 2001
Malcolm Savage, Christian Medical Fellowship Staffworker Sheffield Send response to journal: Re: Autonomy not absolute	Dear Editor, Professors Len and Lesley Doyal ask 'should she (Dianne Pretty) not be able to invite them (her doctors) actively to end her life?' (1) The right to total personal autonomy is a cornerstone of the pro-euthanasia case. However there is a fundamental problem with this approach. It pictures us as being individual individuals, rather like bricks strewn across a builders yard, with no relationships, so what ever one brick does doesn't effect any others. We're not like this. We are more like bricks in a house where we have close relationships and responsibilities to those around us, friends and family, and we are connected to society as a whole. Our autonomy is balanced by our responsibilities. I don't exert my right to drive to Tescos at 150mph because I accept my responsibility to not endanger others. It has already been argued that euthanasia is unnecessary (2), but let us say that one person still wanted it. For that to happen, the law would have to be changed from where it protected everyone's life absolutely, to where it left vulnerable people unprotected. In this case the one person ought to wave their right to autonomy because of their responsibility to others. There is another problem with autonomy, for a choice to be valid, it has to be free. Sadly our society doesn't value old people, they are often made to feel as if they're in the way and not useful. Sometimes familles make their older members feel the same way. Tragically this is often how the older generation feel about themselves. They knew about the NHS's limited resources, and can feel guilty about using them up. If euthanasia were legal they would inevitably feel pressured to do the decent thing, and die, to stop using up others resources, be it a hospital bed or the children's inheritance. Euthanasia is not the answer. Rather we need to provide meticulous palliative care and by so doing demonstrate that people are valued, by our profession and our society. 1Doyal L, Doyal L.Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001;323:1079-1080 2 Dr Fergusson A Fancy philosophical footwork but choreography is not coherent (10 November 2001)
The stories I have heard 22 November 2001
Simon Allen, Humanist Ceremonies Officiant Hertfordshire HP4 1PX Send response to journal: Re: The stories I have heard	I have been taking secular ceremonies for over ten years, mainly funerals. I have lost count of the sad stories heard from people who have listened to their family and friends make requests for release in vain. The debate is stuck in a rut of, "Legalisation is a slippery slope" I can only wonder how the following statement: This act should only be granted to those that have consistently expressed their wish over a period of years AND who has signed legally binding instructions AND where multiple medical opinion agrees on their fatal condition. Is changed into a 'free for all' where medical people can kill anyone they want. It is ludicrous! If we legalise what often happens in practise (and I have witnessed it in my own family) then we will be protecting lives. Openess and honesty must replace covert practise.
End the suffering 22 November 2001
Stephanie Bacon, Retired Send response to journal: Re: End the suffering	It is time the law was changed for Diane Pretty along with many other people facing long undignified suffering before they finally die very badly. Today's modern medicine is able to extend life for thousands of people in Britain today and they are therefore dying more slowly and miserably than ever before. Diseases are so well documented that these patients know well in advance what the extent of their final suffering will be. It is now legal for a doctor to help his patient in these circumstances if you happen to be lucky enough to live in the Netherlands, why is it so different here in England? Having watched my daughter suffer until she died from a congenital heart defect at the age of thirteen, my overriding feeling was - thank goodness her suffering is over. By legalising voluntary Euthanasia, we are asking that the terrible suffering of terminally sick patients could and should be lessened. This compassionate act should only be offered after repeated requests from the patient. This cannot be evil, it cannot be bad and it cannot be wrong. It can only be kind, compassionate, sensible and right. Stephanie Bacon Warren Lodge, Fowlmere Road, Melbourn, Cambridgeshire SG8 6EZ
COMPASSION AND CHOICE 22 November 2001
D Hardy, headteacher Triangle Nursery School SW4 7JQ Send response to journal: Re: COMPASSION AND CHOICE	I want to register my support for the contribution made by Dr Andrew Thornton entitled "the Law is an Ass". I feel that in a compassionate society we should respect all the wishes of mentally competent, terminally ill patients including their right to ask for assistance to die.
The state's power over our bodies should be ended 23 November 2001
Amorey Gethin, retired teacher Send response to journal: Re: The state's power over our bodies should be ended	The opponents of euthanasia or assisted suicide often resort to the "slippery slope" argument. They warn, for instance, that we will end up, as in Nazi Germany, with mass killings of people considered defective in some way, or a burden to the community. In fact, if there is any slippery slope that leads towards that sort of atrocity, it lies in continuing to allow decisions like that of the high court against Diane Pretty. Its judges, agents of the state, have condemned her to torture, although they have neither a legal nor a moral right to do so. It is irrelevant to the argument whether or not palliative care can lessen Diane Pretty's physical suffering. She is already suffering mental torture because of her condition, and that torture is made worse by her anticipation of what the court has condemned her to, and will increase as she comes closer to her end. The precise implications of the current laws on the subject are also irrelevant. It is time to bring to an end the powers of an arrogant state to decide matters in which it has no right to interfere.
"one more voice" 24 November 2001
Val Martin, retired SRN nil Send response to journal: Re: "one more voice"	I respect the feelings of the self styled 'pro-lifers' for themselves and their families; but how can they be so certain that they know what is right for every person regarding end of life decisions. How can they be so confident that voluntary euthanasia carried out within carefully planned legislation would be wrong for those that desire it. Many people have religious beliefs regarding the sanctity of life, but others, of many faiths, and of none have come to feel that there are occasions when it is indeed "time to die". Many of us do not fear death but do fear a slow and degrading dying. I am asking to be given a choice, so that if I become severly incapacitated I can be given medication to end my life. I believe the 'Pro -life' campaigners are trying to deny me that choice while I am denying them nothing. It is surely time to press the medical profession and the government to admit that the laws on voluntary euthanasia/assisted suicide need to be changed.
patients need medical care not legalised euthanasia 25 November 2001
M D D Bell, consultant in intensive care The General Infirmary at Leeds LS1 3EX Send response to journal: Re: patients need medical care not legalised euthanasia	Editor - With the emotive statement ‘Diane Pretty was refused the legal right to choose the circumstances of her own death’ Doyal and Doyal claim that the law is an impediment to moral good. In calling for change, the editorial relies heavily on misplaced rhetoric rather than reasoned argument and thereby fails to achieve any moral or ethical validity for such a crusade. The civil courts were clearly unable to prospectively legalize a criminal act and were correct furthermore in not jeopardizing the role of law designed to protect the vulnerable rather than restrict an individual’s rights. Diane Pretty has every right to access treatment for pain, discomfort and distress and such care can be escalated in the home, hospital or hospice when her life becomes irreversibly burdened by one or more of these debilitating factors. With the appropriate input from GP, hospital consultant or palliative care team, elements amenable to improvement should not be overlooked, contrary to this possibility if patient and spouse were to become the determinants of ending life rather than seeking to alleviate burden. In the absence of specific treatment options, practitioners could justifiably increase symptomatic treatment for the distress of living with such a condition, even though this process could predictably foreshorten life. Just as presumably the patient’s husband takes responsibility for providing aspects of care currently, his contribution to this process could be considered a continuum of overall care, rather than construed as a new active act. Thus, the moral good of a dignified death in such unfortunate circumstance can be achieved and accommodated within the existing ethical and legal framework directing care in terminal conditions. The impediment, if such exists, is not the law but the confidence and commitment of practitioners in these clinical areas, and this cannot be legislated for. The subsequent debate on the moral equivalence of commission and omission and the rightfulness of withdrawing life sustaining treatment from the severely incompetent is therefore irrelevant. The flaws inherent in using a dissimilar class of patient to develop an argument are compounded by the unsubstantiated claims that euthanasia in the best interests of such patients would be the next logical step, that death constitutes a moral good and that clinicians intend to accelerate death. The declaration, that it being morally right to kill some competent patients at their request justifies provision of the medical wherewithal to kill themselves, finally exposes ignorance of what medical care can and should be towards the end of life. The Pretty family were ill-advised to consider that the moral good of a death with dignity could only be achieved via the courts or that an individual’s unfortunate circumstances could by an appeal for sympathy create legal precedent whereby law designed to protect the vulnerable could be overturned. By duplicating this stance of emotion overtaking reason, the arguments of Doyal and Doyal similarly carry little justification for a change in the law. It is unfortunate that the authors have not used the opportunity of an editorial to identify the true shortfalls highlighted by the family having to consider turning to the law in the first place. The medical profession needs to ascribe as much importance to compassionate terminal care as it does to heroic measures to maintain life. To suggest that this can only be accommodated by a change in the law will not assist that process. With the potential to jeopardize the capacity to end life with dignity, contrary to the stated aims, the editorial should simply be considered a provocative contribution to debate.
Euthanasia and physician assisted suicide 26 November 2001
Robert Twycross, emeritus Clinical Reader, Oxford University Sir Michael Sobell House, Churchill Hospital, Oxford, OX3 7LJ Send response to journal: Re: Euthanasia and physician assisted suicide	Dear Sir Euthanasia and physician assisted suicide Doyal and Doyal ask, ‘In the face of so much moral right, where is the wrong?’ I would suggest, first and foremost, in the failure to take into account the experience of the Netherlands and the state of Oregon. Once physician assisted suicide (or euthanasia) is allowed, it unfortunately becomes politically incorrect to oppose it, official data are ‘massaged’, possible abuses are surrounded by a cloak of silence and Orwellian-type officialese tends to be adopted. Most clinicians appreciate that an autonomous voluntary decision by a patient is essentially impossible and that, in most cases, the request for assistance in dying is a cry for help which needs to be evaluated by a doctor who understands human ambivalence. Equally important, is the knowledge that such requests are often a symptom of treatable depressive illness – and that most doctors are not good at diagnosing depression in patients with advanced physical disease. Giving doctors a licence to kill, even in very restricted circumstances, will undermine the trust of many more patients than will be benefited. In my opinion, it also would have a corrupting effect on the medical profession. As someone said, the risk of legalising physician assisted suicide (or euthanasia) is too great because, as the history of the Twentieth Century shows, killing is a contagious disease, not easy to stop once unleashed into the community. Yours consequently Robert Twycross emeritus Clinical Reader in Palliative Medicine, Oxford University
The implications could have grave consequences 27 November 2001
G Barr, Staff Grade in Otolaryngology Monklands Hospital , Airdrie,ML6 OJS Send response to journal: Re: The implications could have grave consequences	Editor- Arguing that commission and omission are equivalent when the outcome is the same is not correct. If one flies around the world the or stays at home the outcome is the same but the experience is totally different. If taking a life is equivalent to not saving a life through failure to treat this will only be so when negligence is involved. It is true that if a patient refuses lifesaving treatment and dies then omission has led to death but the direct connection between the physician and patient has been lost. It should be made clear, therefore, that the case put forward in the article (1) does not apply to the mentally competent because they have the ability to refuse treatment. The situation with the mentally incompetent is much more complex unless a living will or prior wishes have been intimated . However, the decision to stop treatment would be better considered as making a decision to refuse treatment on behalf of a patient who does not have the ability to make that decision , rather than comparing it to active euthanasia. In the article Professors Doyal mention the slippery slope but their proposals are more of a precipice which the medical profession is invited to jump over and cling on to the edge.How many medical practitioners would be happy giving a patient informed consent along the lines of ,‘ you can have treatment A, or B, or no treatment , or we can kill you’ ? The implications of such proposals being legalised could have grave consequences for large groups of sufferers and their relatives. Who would be covered and who or their legal guardians would be at risk of feeling pressured into taking advantage of such legislation? Only terminally ill patients or patients with chronic illness that will die sooner or later, patients with severe arthritis, MS, dementia early or late , the housebound, the elderly in nursing homes with a limited quality of life who do not want their estates dissipated to pay for care ? Once the premise of active euthanasia and assisted suicide is established what future influences ,unthinkable now,could come to bear ? With the cost of medical treatment especially for prolonged illness , death is no doubt the cheaper option. In a culture where we have abortion on demand is death on demand not the next ‘logical step’ from active euthanasia and assisted suicide ? 1. Len Doyal,Lesley Doyal. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001:323:1079-1080
On not arguing the case 28 November 2001
Luke Gormally, Senior Research Fellow The Linacre Centre for Healthcare Ethics, 60 Grove End Road, London, NW8 9NH. Send response to journal: Re: On not arguing the case	As Professors Len and Lesley Doyal refer to me as one of those who is to be counted among "the most articulate opponents" of the position they advance I hope I may be permitted to comment on the defence of their position. The Doyals' position rests on three propositions,each of which is controversial and for none of which they provide an adequate defence: (1) That it is the duty of doctors to act in the 'best interests' of their patients, where the notion of 'best interests' is an umbrella concept covering whatever a competent patient's preferences might be and whatever a 'responsible body of medical opinion' might think to be in the 'best interests' of an incompetent patient. (2) That it is acceptable to aim to end a patient's life by the withdrawal or withholding of life-prolonging medical treatment. (3) That the traditional justifications for the withdrawal of life- prolonging treatment - that it is 'futile' or 'excessively burdensome' - covertly rely on a judgement that the patient's life is no longer 'worth living'. (The Doyals seem readily to recognise that the belief that death is a 'benefit' for a patient, on which justifications of euthanasia rely, itself assumes the truth of the judgement that the patient's life is no longer worthwhile.) If (1) were true we might as well say goodbye to the claim that medicine is a profession, for a profession involves not merely a knowledge -base and a range of technical skills, but knowledge and skills devoted to serving what everyone can recognise to be a human good. The central human good which medicine has traditionally been held to serve is human health: its restoration and maintenance. The prolongation of life is a related aim, in the sense that doctors seek to prolong life, by medical means, where some measure of functional ability to enjoy other goods remains, even if seriously impaired. The prolongation of life is not an unqualified goal of medical practice; the inevitability of death is sufficient to show that it could not be. When death is imminent, however, and quite generally when cures cannot be achieved, medicine has the continuing role of controlling patients' symptoms to reduce the impact of their conditions on their ability to continue to share in some other human goods. This substantive understanding of the goals of medicine adequately represents the proper good that medical knowledge and skills exist to serve. Doctors are not trained merely to have a set of technical skills which can be employed for just any technically feasible end (such as satisfying patients' preferences). If they do not hold on to a substantive understanding of the goals of the profession, then doctors expose themselves to extensive manipulation, and move from indiscriminately satisfying patients' preferences to indiscriminately satisfying politicians' preferences, which are likely to be for the disposing of patients no longer capable of articulating preferences. The Doyals' unargued assertion (3), that traditional justifications for the withdrawal of life-prolonging treatment - that it is futile or excessively burdensome - must covertly rely on a judgement that the patient's life is no longer worth living, is in part a consequence of the umbrella concept of 'best interests' they invoke in defining a doctor's duty. But it is in relation to a limited, substantive understanding of the goals of medicine that any treatment may be described as 'futile' (i.e. as failing to secure the therapeutic or palliative aims of treatment), and it is because patients are under no quite general obligation to pursue those goals irrespective of the costs (physical, psychological or social) they may incur, that it is said that 'excessively burdensome' treatment may be declined by a patient. And if a patient is entitled to decline it for that reason a doctor is entitled to withhold it. And since we can make judgements about what is likely to be excessively costly to incompetent patients, in the way of pain, stress and social dislocation, doctors can withhold treatment on those grounds from such patients, as well as from competent ones. An elderly woman who declines to undergo chemotherapy, which may offer her an extra 12 to 18 months of life, because she prefers to spend the remaining 6 months otherwise predicted for her with her daughter, son- in-law and grandchildren, is not committed to the proposition that any such additional life would simply not be worthwhile. Her position is that she prefers to spend her remaining days undisturbed in the bosom of her family, rather than suffering the stress of regular hospitalization and the side-effects of chemotherapy. The Doyals' assumption (2) that it is acceptable to aim to end a patient's life by the withdrawal or withholding of life-prolonging medical treatment perhaps relies on the judgement in the Bland case, when three of the Law Lords subscribed to precisely that proposition. But the Doyals must know that the proposition remains controversial; the Law Lords themselves in subscribing to it agreed that they had reduced the law of homicide to a "misshapen" and "almost irrational" condition, for they remained opposed to active euthanasia. No one claiming to be a medical ethicist can simply assume the truth of such a controverted proposition in order to advance the case for active euthanasia. That case (as also the case for aiming to end patients' lives by withholding or withdrawing treatment) assumes, as the Doyals recognise, that it is possible and appropriate to make judgements on the worthwhileness of patients' lives in order to determine whether death is to be deemed a benefit to them. But the overall worth of a patient's life at any given time is not a proper subject for medical judgement and is something about which a doctor ought to remain at least agnostic. The Doyals, though evidently familiar with what I have written, nowhere face the basic objection I have advanced to making judgements on the worthwhileness of people's lives the basis of legalised killing. Justice in society (in the sense of recognition of basic human rights) relies on a defensible assumption of the basic equality in worth and dignity of every human being. To recognise worth and dignity in the lives of only a select body of human beings is to make an arbitrary determination of which human beings possess basic human rights. Arbitrariness of that kind is contrary to our most basic intuitions about justice. The Doyals' confidence that it must be possible to contain descents down slippery slopes displays a remarkable insouciance over the political potential of legalizing killing on the grounds that human beings may be judged to lack lives not worth living.
A patient's view 29 November 2001
M van Ments, Retired lecturer Send response to journal: Re: A patient's view	When all the arguments and counter-arguments have been rehearsed, there are surely at least three fundamental reasons why I should expect to have the freedom to end my life if I wish, and moreover to have the understanding and support of my doctor if I chose to do so. Firstly, life is not an object which can be passed from one person to another. It is a state or condition of my body in just the same way that my being hot or cold, healthy or diseased is a state or condition of my body. Therefore I should be the only person who judges whether I want that state to continue or cease unless by so doing I am endangering the life of others. Secondly, I cannot see on what grounds the option of 'being put to sleep' should be the prerogative of animals who are suffering, but not humans. Thirdly, if doctors, for perfectly good reasons, insist on their unique right to dispense 'dangerous' drugs, and ensure that I cannot purchase the drugs I require for painless voluntary euthanasia then I am forced to look to them for help.
Criticism of Editor 29 November 2001
Andrew Cooper, GP Principal Health Centre Lerwick ZE10QA Send response to journal: Re: Criticism of Editor	BMJ editorials are still regarded as authoritative statements in the various fields of medicine. The Doyals editorial would surely have been better published as a Personal View or in the For Debate series. It is merely a vehicle for their legitimate opinion but in no way presents any sort of balance and barely acknowledges that there is a wide range of equally valid opinions. BMJ readers expect a much higher intellectual standard from an editorial.
Withholding and withdrawing medical treatments towards the end of life 2 December 2001
Sanjay Shah, Specialist Registrar, Palliative Medicine & Honorary Senior Lecturer/Consultant, Palliative Medicine Leicestershire Hospice, Groby Road, Leicester, LE3 9QE, Mari Lloyd-Williams Send response to journal: Re: Withholding and withdrawing medical treatments towards the end of life	EDITOR - We read with interest an editorial by Professors Doyal in BMJ1. We here describe our views about thorny issues of withdrawal and withholding of “life-prolonging” or “life-sustaining” treatments. It is not morally right to use medical interventions or decisions to kill or to help someone die, whether competent or incompetent. Hence it should not be morally right for a health professional to withhold or withdraw treatment with a view to bring death forward. Withholding or withdrawing treatments should be clinical decisions based upon best available evidence, and in accordance with existing ethical guidelines, and not the acts of omissions or commissions to facilitate death. Withholding a treatment is not a “passive” management. Treatments should be withheld only if they are likely to be unsuccessful or risks outweigh the benefits. Treatments should be withdrawn only if they are ineffective. Before embarking upon any treatment, clinician and a patient or next of kin for an incompetent patient need to set the realistic aims after honest discussion. Professors Doyal1 rightly comment the most important point is justifiability of an act. Aims of various medical interventions have been to try to correct aberrations in the anatomy and/or physiology of a human being. When correction is not possible, aim would be to mitigate the consequences of such abnormalities. We seem to have achieved these aims successfully for quite a few conditions resulting in prolonged survival. Still, we cannot deny the fact that sooner or later nature takes its own course. Advances in medical sciences have also been accompanied by changing attitudes of health professionals, patients and public about meaning of life, quality of life and death and dying. Realistic aim in patients with progressive, incurable disease with short life expectancy would be to put one back to where one was at time of an acute event which is potentially reversible, to ensure maximum comfort in remaining time and dignity in death. Let us consider our index case of advanced motor neuron disease (MND). Natural course would be relentless progression culminating into death. What could happen if this patient was to develop a potentially life threatening but reversible illness, say pneumonia. Patient may not wish to be treated with antibiotics after detailed explanation of the nature of illness and the need for proposed treatment. Should this be considered allowing a suicide? Perhaps not. At other extreme, scenario could be a patient wanting everything possible done. to restore the life to pre-pneumonia state. It will be wrong not to give appropriate antibiotics. But the ethical dilemma would arise on failure of conventional treatment of pneumonia leading to severe respiratory failure. Should the patient be mechanically ventilated to allow antibiotics time to work? If weaning from ventilator appeared unlikely, reinstatement of pre-pneumonia state, too, would be unlikely. A clinician may withhold mechanical ventilation, which will inevitably result in death. Should this be considered “an act of omission to help patient die”? A clinician has not acted passively, nor is there any inaction. Clinician has made efforts to weigh the pros and cons of an intervention and has utilized knowledge and wisdom gained by years of training and experience. Palliative care at end of the life is an active management to ensure comfort and dignified death. Third scenario would be that the patient goes on the ventilator. After an adequate trial failure of such a treatment becomes apparent. Common sense and practice demand withdrawal of an ineffective treatment. No alternative is available. Patient dies. Should this be considered “an act of commission to bring death forward”? Patient has died not because an ineffective treatment has been stopped, but because no effective treatment was available. Withholding and withdrawing of treatments by health professionals and refusal of treatment by a patient should not support the case for euthanasia or physician assisted suicide, and clinicians should make sure that such decisions are based on available evidence and that the principles of patient autonomy, beneficence and nonmaleficence are respected. References 1. Prof Doyal L, Prof Doyal L. Why active euthanasia and physician assisted suicide should be legalized. British Medical Journal 2001; 323:1079-80.
Consequences of the editor's choice 4 December 2001
Mark Houghton, GP locum and clinical assistant Sheffield Send response to journal: Re: Consequences of the editor's choice	Dear Sir, The editor and writers of the B M J are free (at present) to promote the killing of patients. (B M J, 10.11.01, page 1079). But as the good physician advises the smoker so it is the duty of doctors of faith to advise of the consequences of the editor's choice. While the patient may not understand all the reasoning behind why we say, don't smoke; yet they can still get the message. We may not fully understand why a kindly Creator said, don't kill people, but we can follow his message if we choose to the benefit of all. And what if we choose not to? Like the smoker, we shall become vulnerable to destructive forces. For instance we might lose professional independence, suffer the ridicule of the media and plummeting morale? We found it easy to build, on our privileged God given status, the twin towers of modern medicine: arrogance and unbelief. But those towers can fall. When they fall the smoking ruins will be the memorial to the crematorium fires of our unlawful medical killings. Unlawful to the Creator -who also inspired state laws to protect our patients. As the B M J undermines these laws so the whole profession suffers. The time has come when we are no longer free. We are tossed forwards and back by society and state. Its our fault. Yours sincerely Dr. Mark Houghton
Re: Consequences of the editor's choice 5 December 2001
Wayne Lewis, GP Blaenavon, Gwent Send response to journal: Re: Re: Consequences of the editor's choice	With the events of Sept 11th in mind, Dr. Houghton might like consider if using the metaphor of collapsing twin towers and smoking ruins is really a useful contribution to this debate. This indefensible lack of sensitivity only adds to the inadequacy of your argument. Language is important, Dr. Houghton. Use it carefully.
Circumstances Alter Cases 6 December 2001
Hugh Wynne Eur Ing, Former President, World Federation of Right to Die Societies UK Glasgow G4 9JX Send response to journal: Re: Circumstances Alter Cases	I was glad to see this brave editorial. As a long-standing proponent of the right to choose an easeful death, I am reminded of the adage 'circumstances alter cases'. These can be too much dogma, & not enough humanity & realism in the face of facts. For those choosing euthanasia for themselves, we should ask 'Why not?' Individual freedom may over-ride wider considerations, especially if harm does not ensue. What are the ulterior motives of our oppontents? We are not told, lest we accommodate them. It is time to balance the individual against the public good & bow to the inevitable. Civilisation has a price.
Denying us voluntary euthanasia causes unnecessary human suffering 7 December 2001
Jean Davies, Retired teacher 56 Marlborough Road, Oxford OX1 4LR Send response to journal: Re: Denying us voluntary euthanasia causes unnecessary human suffering	There is plenty of unavoidable human suffering. We should welcome an opportunity to mitigate the misery of a lingering death, a death that the dying person now longs for. Legalising voluntary euthanasia by a well- crafted law will provide such an opportunity. One would think that all reasonable people would agree and most do, as the opinion polls on the subject clearly demonstrate. But there is a vociferous minority intent on raising all possible objections. One of their responses is "Since 1961 it hasn't been a crime to commit suicide. They can do that." The case of Diane Pretty illustrates the shallowness of such a response. And while her case has its own unique features, I have known many other people near the end of their lives who needed our help to achieve a good death - and were denied it. Five years ago one of my closest friends, also a retired teacher, also with a large family of supportive adult children, spent the summer, from June to September, committing suicide. Despite every available medical investigation and offered treatment nothing had helped her rapid loss of short term memory. She could not read or watch television; by the end of a sentence she had forgotten the beginning of it. It was clear that she was soon going to be able to do nothing for herself, and she decided such a life was unacceptable. She persuaded her children that this was the right decision for her. While alone she swallowed all the medication she could lay hands on, but recovered consciousness, so she decided on starvation as the only remaining non-violent means of ending her own life. She didn't eat, but could not bear the discomfort of doing entirely without water; people dying of physical illness usually achieve their end in about 12 days, I believe. She began her abstinence on 22 June and died on 20 September. Imposing this sort of death on a non-human animal is illegal because it is so cruel. When a human animal is being denied the right to choose for themselves to forego the unacceptable closing phase of his/her life it is much more cruel. Legalising voluntary euthanasia will be one step nearer having a truly civilised society. Jean Davies. Editorial note We have permission to publish the details of this case from the family concerned.
"Patients want to know where we stand" 14 December 2001
Mark Houghton, GP non-principal Sheffield Send response to journal: Re: "Patients want to know where we stand"	Was it insensitive or was it vital, for a practising GP (Dr Wayne Lewis, eletters 5/12/01), to imply in a semi public website that he supports doctor killing? His patients could answer that. The anguished fears, disclosed by various of my patients (while under the protection of the present law and before Shipman), indicate that they wish to know which doctors can be trusted not to end their lives artificially. They have a right to know and the right to avoid such doctors. They have spotted the gravity of our professional state while some of us have missed it. So Dr Lewis has suggested, if unconsciously, how to move this debate on: in today's climate of transparency, should we consider an open register of doctors who favour the taking of life? Yours sincerely Mark Houghton
The law is there to protect both patients and doctors 26 December 2001
Sally E Bashford, SpR Geriatrics and General Medicine St Mary's Hospital, Paddington, London, W2 1NY Send response to journal: Re: The law is there to protect both patients and doctors	EDITOR- Professors Doyal and Doyal argue very thoroughly the case for legalising voluntary euthanasia and physician assisted suicide and show compassion for Diane Pretty, who suffers from motor neurone disease.1 However I have grave concerns over the legalisation of physician assisted suicide and voluntary euthanasia. I agree with the authors that there is no moral distinction in principle between the withdrawal of life sustaining treatment and withholding of life sustaining treatment. Doctors do though have a duty to protect vulnerable people, not to kill them however much it is felt their life is not worth living (is such a judgement on their worth dignified?). I would have no moral objection to withholding or withdrawing treatment from a patient who has no hope of recovery and is dying - but this is not because they are so disabled that they are perceived as having no benefit from life. In such a situation a doctor’s moral duty would be to palliate symptoms. If Mrs Pretty develops a condition that could result in imminent death, then it is also the physician’s moral duty to respect the terms of any pre-expressed wish to withhold treatment and this is a legal way that she has control over such circumstances. Mrs Pretty perhaps would commit suicide if she were able. As she is physically unable to commit suicide, some argue that she should therefore be granted help to perform this. If this course of action were legalised, many such requests would inevitably come before doctors. If a patient’s request for physician assisted suicide or voluntary euthanasia were to be granted then it is also likely that this request would have come up before one of a growing number of clinical ethics committees CEC). I am a member of a CEC in a large teaching hospital. This would be a huge responsibility and raises more issues, especially around training and the composition of such committees (should the public be more widely represented on such committees?). The perception of the CEC within a Trust would change and CECs would need a clearer mandate. Doctors and CECs will find themselves at the forefront of these situations. Patients look to us for guidance – and protection. The Law is there to protect us both. Sally Bashford specialist registrar in geriatric and general medicine Department of Medicine for the Elderly, St Mary’s Hospital, London W2 1NY Sally@csbashford.demon.co.uk 1 Doyal L, Doyal L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001;323:1079-1080.
Debate on active euthanasia and physician assisted suicide 15 January 2002
David T Shakespeare, SpR in Rehabilitation Medicine The Walton Centre for Neurology & Neurosurgery, Liverpool L9 7LJ, Peter Szlosarek Send response to journal: Re: Debate on active euthanasia and physician assisted suicide	Sir, In the wake of Shipman and Bristol, the character of doctors is publicly questioned as never before. In attempting to show that a contravention of the traditional law of murder can be considered to be morally right, the Professors Doyal are proposing a radical redefinition of concepts of morality and rights[1]. Traditional law and morality, upholding the right not to be killed unjustly (murder), is based on respect for the equality of persons, regardless of ability, usefulness or the subjective perception of the quality of that life at a particular time. Such values are also necessary to ensure consistent, high quality care for the most disadvantaged members of our society, as witnessed by the lessons of history where these values have broken down[2]. The Doyals base their ethical debate on a number of rights, such as the right to choose the circumstances of one’s own death, the right to fulfilment of one’s own perception of one’s best interests, the right to achievement of an identified good. The validity of basing a debate on these rights needs to be properly worked out within a societal framework that includes other rights, before this is accepted uncritically. The traditional prohibition of murder does not equate to a vitalist position of preserving life at all costs. Likewise, accepting the non- provision of excessively burdensome life-sustaining treatment does not have to rely on an implicit or subconscious judgement that certain persons are incapable of benefiting from further life - only that such treatment cannot preserve this life, even in its current form. Before proposing a change to the current system, it must be clear that an at least equally suitable alternative system is in place, tried and tested. Concerns about a slippery slope will not be placated by simple reassurances that construction of such a system “cannot be impossible”, as the failures of other attempts have shown[3]. Promoting the culture of a society which respects and values all persons, regardless of their ability or usefulness, remains paramount[4] and focusing on the character of those who are entrusted with healthcare deserves higher priority in ethical debate. The roles (and thus responsibilities) of medical educators and medical journalists in this debate are clearly very significant. Timing of this editorial in relation to the recent House of Lords hearing, preventing equality in the timing of the publication of differing opinions, goes contrary to previous BMJ practice[5, 6]. The Doyals’ final question could also be turned on its head: in the face of so much wrong, where is the right? Yours sincerely, David Shakespeare, SpR in Rehabilitation Medicine, Walton Centre for Neurology & Neurosurgery, Liverpool Peter Szlosarek, Honorary SpR in Medical Oncology, St Bartholomew’s Hospital, London 1. Doyal L and Doyal L. Why active euthanasia and physican-assisted suicide should be legalised. British Medical Journal, 2001. 323: p. 1079- 80. 2. Alexander L. Medical practice under dictatorship. New England Journal of Medicine, 1949. (Jul 14): p. 39-46. 3. van der Maas P, et al. Euthanasia, physican-assisted suicide, other practices involving the end of life in the Netherlands, 1990-5. New England Journal of Medicine, 1996. 335: p. 1699-1705. 4. Weatherall DJ. Palliative care for non-cancer patients. Journal of the Royal Society of Medicine, 2001. 94: p. 600-1. 5. Gillon R. Forseeing is not necessarily the same as intending. British Medical Journal, 1999. 318: p. 1431-2. 6. Doyal L. The moral character of clinicians or the best interests of patients? British Medical Journal, 1999. 318: p. 1432-3.
Re: Francis H Sansbury can be gratified at once 17 January 2002
Francis H Sansbury, Student, Cambridge Graduate Medicine Course 25 Mill Street, Cambridge CB1 2HP Send response to journal: Re: Re: Francis H Sansbury can be gratified at once	The Editor argues that my proposal for a article of equal prominence giving the other side of the argument to that of Doyal and Doyal (1) was met by Emanuel's editorial published earlier in the year (2). While accepting that Emanuel argued against euthanasia, his grounds for doing so were that euthanasia and physician assisted suicide play no part in the dying process for the vast majority of patients, and so "Focusing on euthanasia and physician assisted suicide means diverting effort away from the more mundane but consequential activities necessary to improve end of life care for the 90% or more of dying patients who will never even vaguely desire euthanasia." Emanuel did not discuss the moral questions raised by Doyal and Doyal (it is interesting to see that rapid responses to his editorial comment on his avoidance of those issues), and could not comment on the Diane Pretty judgement given that it had not then happened. His editorial was also much less highly charged and partisan, and this is possibly reflected that there have been far fewer rapid-responses than to Doyal and Doyal (which measured by file size, has generated nearly 10 times as much correspondence to date). I am afraid that Richard Smith's assertion that I could "be gratified at once" is therefore incorrect. No one would disagree that it is reasonable to discuss the issues involved in euthanasia and physician-assisted suicide. A very one-sided article like Doyal's and Doyal's appears without any corresponding article in print raising the alternative arguments does not suggest a balanced debate - and Emanuel's article does not raise those arguments, so does not counterbalance Doyal's and Doyal's. In spite of the accessibility of rapid responses at www.bmj.com, most subscribers will only see the printed BMJ where a small fraction of the correspondence raised will appear some months after the original editorial, when most readers will be hard put to remember just what Doyal and Doyal actually said. I agree that signed editorials do mean that opposite positions can be argued in different articles, and that the arguments can be considered to be the opinion of the author but not necessarily that of the Editor. One would expect an editorial to be an authoritative statement of a situation, compared to for example an article in "Education and debate," and even if Doyal's and Doyal's article is in the Editor's opinion "within two standard deviations of the norm," he must agree that it is still very partisan. Without any clear disclaimer to the contrary and in the absence of any balancing article since the 10th November, people could be forgiven for assuming that the journal is taking a particular view, something not helped by the web edition during the following week having "Legalise euthanasia!" (complete with exclamation mark) on its cover. 1. Why active euthanasia and physician assisted suicide should be legalised. Doyal L. and Doyal L. BMJ, 2001; 323: 1079-80. 2. Euthanasia: where the Netherlands leads will the world follow? Emanuel, E.J. BMJ 2001; 322: 1376-7.
Ethical Diversity, Consistent Law 29 January 2002
Daniel L Johnson, internist Menomonie, WI, 54751 USA Send response to journal: Re: Ethical Diversity, Consistent Law	A point not mentioned by the Doyals' editorial and prior respondents is that -- as is made obvious by the aggregate of replies to their editorial -- there are several moral systems among us, with disparate fundamental principles. The disagreement is occurring at a presuppositional level, and in the end, we can only disagree to disagree -- or change and unify our moral systems, not likely given human nature. The law, however, must take an unequivocal and uniform stance, which for efficiency and peace must come as close as possible to cultural and moral consensus and also minimize the opportunity for mischief. Administratively, the law also seeks to cloture disputes rather than to foster them. While there is not a consensus, most of the moral systems in world cultures mitigate against murder, defined as deliberate abbreviation of life. More pragmatically, to permit physician-assisted suicide provides ample opportunity for mischief. Consider, for example, our own (USA) Dr. Kevorkian, who did not bother to check the veracity of the medical histories given to him. One patient he assisted with suicide claimed to have metastatic terminal ovarian cancer but on autopsy was found to have no disease. Hypothetically, it would not be difficult to conspire against someone. In my town there lived for years a troublesome and vindictive attorney; if his body had been floating in the river, nearly every prominent citizen would have had motive, including several physicians; when he moved away, he had a collection of medical conditions that could have served any of his care-givers as a suitable cover for (socially) therapeutic termination of his life. Administratively, it is efficient to prohibit physician suicide. To permit it in specific instances will result in a rash of court cases testing its limits. Pragmatically, end-of-life hastening of death occurs regularly and quietly, with the acquiescence of relatives, the assistance of the physician and nurses, and the permission of the patient. There are two situations in which this does not occur: One, when someone involved wishes to create publicity in favor of legalized suicide; two, when the physicians or nurses caring for the patient hold to a moral code that prohibits hastening death, such as an orthodox Jew or a Catholic. For the patient, the pragmatic solution is, as always, choose your doctor intelligently and talk to your family ahead of the need. In any case, self-inflicted suicide is always an option, and many take it. This response, I should say clearly, should not be thought by any reader to represent my personal moral values.
Denying our humanity 7 April 2002
Guido G Geutjens, Consultant Orthopaedic Surgeon Derbyshire Royal Infirmary, London Road, Derby DE1 2QY Send response to journal: Re: Denying our humanity	Dear Sir, The euthanasia debate is not just a legal issue; it is a spiritual debate for our entire society. In the last few years, an increasing number of patients have insisted that avoidance of suffering at the expense of a rapid death should be their choice, and that more specifically, they should be able to determine the exact time and manner of their death. Perhaps some of these people are stuck in the anger phase described by Elisabeth Kubler-Ross (1). If euthanasia were to be fully legalised, it would give an a- spiritual message to society. It would encourage us NOT to face the natural existential suffering of life and thereby deny our soul the opportunity to learn a little more (even in our dying moments)(2). I fully agree that physical suffering must be relieved as much as possible, even at the expense of unnecessarily prolonging life, and in our society, we have the pharmaceutical and technological means to ensure that patients do not have to suffer agonising physical pain. What we should not have is the means to avoid the spiritual struggle associated with chronic debilitating illness or terminal disease. It is here that we as a society must learn to help patients deal with their spiritual struggle. It is argued that we help animals to die “humanely”, yet cannot legally assist patients in their suicide. However, this is precisely the point. We as humans are capable of growing as a person, even in our final hours, and denying us that opportunity would be denying our very humanity. 1 Doyal L, Doyal L. Why active euthanasia and physician assisted suicide should be legalised. BMJ 2001 ;323:1079-80 (10 November) 2 Kubler-Ross E. On death and dying. Tavistock publications 1978 (out of print) 3 Scott-Peck M. Denial of the soul. Harmony books, Crown Publishers, New York 1997
Re: Specious arguments do not assist informed debate. 28 May 2002
Agnes Wood, GP Send response to journal: Re: Re: Specious arguments do not assist informed debate.	If death is never a moral good then why do we live and die in the first place. Surely we would be immortal? If one never died then the world would become overcrowded and unable to support the life of our children. Perhaps you mean premature death? And if so, at what age and what stage, 50, 70 100, paralysed, insensate?
Re: Re: Specious arguments do not assist informed debate. 29 May 2002
Michele Tringali, Knowledge Centre Ospedale Santa Maria della Misericordia, 33100 Udine Send response to journal: Re: Re: Re: Specious arguments do not assist informed debate.	Life and death are something that we can't give to ourselves, we just receive them (we can rob ourselves our life with suicide, but definitively we can not earn our death, at least if we use our reason; can we "earn" ourselves a definitive damage?). Life has a moral value only because it is given; by Nature? by God? by whatever you like, if this answer can satisfy someone. Sometimes it can be a painful job to accept one's own life, but this is part of the journey, not the whole fact. I recognise it's difficult to accept dependence from someone outside of us, mainly for a culture that glorifies subjectivity and opinion in spite of evidence of our being creatures (given); but this is a decision (or a pre- judice), that brings about undesired consequences like a supposed right to dispose about one's own body (actually, the latter can't be named a "right", maybe it can be a claim, but an irrational one).