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Rapid Responses: Rapid Responses published:
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Fear of legalised assisted suicide
- Alison Davis (23 September 2005)
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Definitions and Medical Euphemisms
- Mick Tarry (25 September 2005)
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So much of the debate has not been needed
- Gareth C Payne (25 September 2005)
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Why not a team of specialists?
- Raj K Mohindra (25 September 2005)
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Assisted dying: What autonomy really means
- Charles A Foster (27 September 2005)
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It is not as simple as Mr Braithwaite believes
- Graham H. Charkham (27 September 2005)
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Fudging the distinction
- A. Joseph R. Shaw (27 September 2005)
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Couldn't we all agree that frail, dependent people usually consider themselves 'a burden'?
- John D Holden (28 September 2005)
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Legalizing euthanasia/assisted suicide decreases incentive to care for symptoms
- Kenneth R. Stevens, Jr., M.D. (28 September 2005)
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Euthanasia will destroy trust in doctors
- Michael R Jarmulowicz (29 September 2005)
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Society's role in assisted dying debate
- Jane E Seymour (29 September 2005)
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Euthanasia- no change in legislation required
- Joseph M O'Neill, Dr. Averil Fountain, Consultant in Palliative Care, North Cheshire (30 September 2005)
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Opposition to change
- william r primrose (30 September 2005)
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We must also listen to patients when considering the issue of assisted death
- Alison B. Chapple (30 September 2005)
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The lesson of history from Shipman and German psychiatry should warn society and doctors against euthanasia
- James D M Douglas (3 October 2005)
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Re: We must also listen to patients when considering the issue of assisted death
- Colin Brewer (4 October 2005)
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Physicians beware - this legislation will affect your practice
- Susan P Closs (4 October 2005)
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Patient autonomy and assisted death are unrelated
- John C Chambers (7 October 2005)
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Yes, time for change.
- Donal Martin (7 October 2005)
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no need for a change in the law
- Bernard Choi (11 October 2005)
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Educate the Young about Dying
- Renate P. Wright (13 October 2005)
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Alison Davis, Patient Home DT11 0LE
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I find the articles favouring assisted suicide in this week's BMJ profoundly worrying. Had assisted suicide been legal 20 years ago, I would not now be writing this message. I have spina bifida, hydrocephalus, emphysema and osteoporosis. My spine is collapsing, causing extreme pain as it traps nerves. Even morphine does not always control it, and when it is at its worst I cannot move, speak or think. It can go on for hours and there is no prospect of relief. In fact it is inevitable that it will get worse. It is "unbearable" but for the fact that I have to bear it. 20 years ago, when I also had a similar degree of pain, I decided I wanted to die, a settled wish that lasted about 10 years. Doctors thought at that time (wrongly as it turned out) that I was terminally ill. I attempted suicide seriously several times and was saved only because friends got me to the hospital, where I was treated against my will. If assisted suicide or euthanasia had been a legal option then I would have requested it. Under the terms of the Joffe Bill I would have qualified for it. Now, 20 years on, I have the same incurable disabling conditions, and the same pain. What has changed is my outlook on life. Assisted suicide and euthanasia allow no such change of outlook. Had this form of death been available to me I would have missed the best years of my life, but no one would ever have known that better things lay ahead. Assisted death may seem like a "compassionate" way out for suffering people, but in fact it allows doctors to turn their backs on helping people like me re-establish a sense of the value of our lives. I urge doctors not to do this. Doctors can be wrong (I was not terminally ill, though they thought I was), and life can be good even when lived with severe pain. What suffering people like me really need is help to live with dignity, until we die naturally. Yours faithfully, Alison Davis Competing interests: None declared |
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Mick Tarry, General Practitioner New Zealand
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Suicide is defined as "the act or instance of killing oneself intentionally". "Physician Assisted Suicide" is a dangerous medical euphemism as the act of death then does not become one of killing oneself. We are colluding to misrepresent what is happening when its proper definition is Physician Assisted Death. Doctors are trying to collude by creating a distinction between what we would like to think is a kindly act done by a hospice doctor and that done by a medically qualified executioner in an oppressive regime. There is something greater here than the issue of Physician Assisted Death and that is that where society blurs the line to become "Thou Shalt Not Kill - Although We Will Let You In Certain Circumstances" , it will do so at its peril. By all means legislate to acknowledge palliative treatment that reduces suffering but is also expected to foreshorten life , legislate even that every citizen should have a living directive, but do not legislate for Physician Assisted Death. As for allowing ourselves to being swayed by arguments about not letting dogs die like this - well reflect - most animals are "euthanased" because they have become incontinent/smelly/aggressive/inconvenient/ expensive/ have the wrong pedigree /or their owners have separated. With whom shall we start? Competing interests: None declared |
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Gareth C Payne, SpR Clinical Neurophysiology University Hospital Wales, Cardiff, CF14 4XW
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One of the main reasons that Euthanasia has come to the forefront is the case of Diane Pretty, as mentioned in MA Bratithwaite's article. With the encouragement of the Voluntary Euthanasia Society she wished to have permission for others to end her life as she feared the terrible way in which she was like to progress and finally die. Sadly she was perhaps manipulated and mis-informed as to what her outcome could be with good medical management. The experience of St Christopher's Hospice has shown that with good care it is possible to successfully palliate and comfort the dying motor neurone disease patient.(1) If the government would ensure good universal access to the dying and terminally ill, the need for palliative care would be so negligible as to not need to be legalised. 1. O'Brien T, Kelly M, Saunders C.Motor neurone disease: a hospice perspective. BMJ. 1992 Feb 22;304(6825):471-3. Competing interests: None declared |
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Raj K Mohindra, SpR Cardiology James Cook University Hospital, Middlesbrough
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Patient autonomy is not the sole driving ethical force in modern medical practice. This was made clear by the opinion of the Court of Appeal expressed by Lord Phillips MR in Burke v GMC.1 I believe that the reason for this is to ensure that some objective assessment of clinical benefit is integral to the delivery of medical care. Indeed without this element it is unclear that the service that is being delivered can be called medical care. The distinction between an act that causes death and a failure to act that results in death is fine indeed. In this debate the key function appears to be to identify a group of patients whose suffering makes them desire to die at an earlier time than would occur if nature was permitted to take its course. It does not otherwise appear to be a strong moral distinction. The fact that a doctor perceives the death of a patient flows from failing to do an act that is deemed futile or at the patient's request is irrelevant to this debate. Futility by definition means the act carries no power to change the outcome and if the heart of the pro argument is respect for patient autonomy then respect for it cannot be wrong here. There is a clear distinction between a desire to procure death and a desire not to pursue futile or pointless treatments or those treatments a patient would choose to avoid. In relation to indirect intent, whilst it is clearly virtually certain and foreseeable that withdrawing life sustaining treatment such as mechanical ventilation will result in the death of the patient it is quite another step in law to move towards a finding of intention to commit serious bodily harm or murder.2 Despite this it is clear that it is only a single step and it behoves physicians to pay close attention to the fine line between good medical care and a charge of murder that could arise all the more readily if physician assisted euthanasia were to become readily available in this country. Practically it would seem that there is good in addressing the autonomous decision of what might amount to several hundreds of patients per year. Clearly there would be a great need for clinical, social and legal safeguards. One solution might be to provide a clearly defined, discrete set of multidisciplinary teams whose main function would be to assess, filter and treat those persons who feel that physician assisted euthanasia might be of benefit to them. They could treat depression, assess social pressures, ensure persisting competent decisions and provide palliative care where appropriate. Within these teams only a few specialists would then have licences to practice physician assisted suicide. They could be required to provide full information for central monitoring. This would relieve the greater body of the profession of the burden such licences would impose whilst providing a route they could use to refer appropriate patients for assessment. This solution might relieve the current pressures for change and could be readily enacted through statute. 1 Burke v GMC [2005] EWCA Civ 1003 para 50(v) 2 R v Woollin 1998, HL http://www.parliament.the-stationery- office.co.uk/pa/ld199798/ldjudgmt/jd980722/wool.htm Competing interests: None declared |
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Charles A Foster, Barrister Outer Temple Chambers, London WC2R 1BA
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Margaret Branthwaite (‘Time for change’, BMJ 2005;331:681-3) makes it all sound very simple. For the assisted dying lobby, autonomy is the ruling principle in medical ethics. It trumps all other principles. But there is a deep irony here: death abolishes autonomy. Dead men cannot choose. So if one really respects autonomy, one has to be very careful about giving autonomy its head. Of course if people are simply asked: “Would you like to be in control when you die?”, most would say that they would. But being truly in control means being in possession of sufficient information to make an informed choice, and being in a state of mind properly to consider that information. Sufficient information, in the case of a truly autonomous assisted dying, must mean all relevant information: there will be no chance to review things later. Very few people at the stage of considering assisted dying for themselves will have either all the relevant information or be able to weigh it. The relevant information will include medically sophisticated details of prognosis and all the palliative options, including terminal sedation to unconsciousness(1). It will be impossible for even well-meaning clinicians giving such counseling to exclude entirely their own view of the matter and give impeccably objective advice. Vulnerable patients will quite easily be talked into death. Many patients will be (treatably) depressed, which will interfere with their ability to weigh the information given to them. Many will opt for assisted dying not because they have autonomously decided on the evidence that death is the best option, but because they do not want to be a burden to their carers or their family. Autonomy would mourn such deaths, and the lawyers, applying the conventional principles of the law of consent, will be out to avenge them. It is wrong to let autonomy reign alone, but if it does, it actually forbids the conclusion argued for in its name. Charles Foster References (1) Foster, Charles. Misrepresentations about palliative options and prognosis in motor neurone disease: some legal considerations. Journal of Evaluation in Clinical Practice 11 (1), 21-25 Competing interests: None declared |
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Graham H. Charkham, Barrister 20 Essex Street, London WC2R 3AL
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Mr Braithwaite argues that "the proposed change should be supported as a matter of both principle and practicality" on the grounds that it will increase personal autonomy and provides a logical extension to the right to refuse life-sustaining treatment. There is an unacceptably high risk that the Bill will decrease personal autonomy for the vulnerable. The "safeguards" in the Bill are unlikely to prove safe. For example: 1. Passing legislation like this is likely to make elderly people feel that they have a duty to die. Once you have done that can you be sure that a request to die is truly voluntary? 2. The physicians who will determine whether the patient fulfils the requirements of the Bill will not have had any previous knowledge of the patient. The risk of non diagnosis of depressive illness and mis- diagnosis is significant. The statistics Mr Branthwaite relies upon are questionable. The House of Lords select committee noted:- "The findings should be treated with great caution. Very litte research exists which is built on techniques appropriate for so complex and sensitive a subject as euthanasia and whether it should be legalised. Research sponsors frequently appear to have been more concerned to achieve statistics for media consumption than to work towards achieving a comprehensive understanding of public and health sector attitudes” [Appendix 7, para 2] There is a clear distinction between the right to refuse treatment and a new right to demand a specific form of “treatment”: namely a lethal injection. The latter is not a “logical extension” of the former. Experience in other juridictions must be treated with caution. One can not extrapolate from Oregon to England. Competing interests: None declared |
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A. Joseph R. Shaw, Tutorial Fellow in Philosophy, St Benets Hall, Oxford University St Benet's Hall, Oxford OX1 3LN
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Braithwaite acknowledges the key, principled source of opposition to new legislation, writing: “Some people would argue that because assisted dying introduces new intervention—the drug used with specific intent to procure death—it is different from allowing death by withholding or withdrawing life sustaining treatment.” However, her response to this is very strange. Again, I quote: “if life sustaining treatment such as mechanical ventilation is withdrawn, whether at the patient's request or because it is deemed futile, death is a virtually certain consequence and doctors are aware of this when they act. In other words, their action fulfils the legal criteria for indirect intent. The motive may be benevolent but the intention is to kill or to permit a preventable death.” Now she seems to recognise that her opponents think there is a real difference between withdrawing futile treatment because it is futile and giving a lethal injection with the intention to kill. If, as she says, “the legal criteria for indirect intention” is simply to act in the knowledge that death will occur, that is evidently not the criterion opponents of euthanasia are using. On the contrary, in her terminology they are interested in “direct intention”; in ordinary English the concept expressed by plain “intention”, not expection but actually aiming at the outcome. The fact that there is a difference between the concept at issue in the euthanasia debate and a legal concept with a similar name does not prove anything. The legal concept of “indirect intention”, which is used in the context of murder, has never been applied in the context of patient care. If it were, as Braithwaite seems to recognise, it would usually be illegal to withdraw futile treatment. The historical legal understanding (that is, until the Bland case) makes use of the very distinction Braithwaite is rejecting. A doctor who withdraws futile treatment is not guilty of murder: it has always been recognised that “indirect intention” (i.e. expectation) of death is not enough for murder here. On the other hand, giving a lethal injection would be murder. Why? Because that implies direct intention of death (i.e. aiming at it), since there is no medical justification for it (it is evidently not aiming at the patient’s medical welfare). What exactly is Braithwaite’s problem with this? What we need to see from Braithwaite and others like her is an argument to show that the distinction embedded in the law and in common sense alike is either incoherent or morally iniquitous. What Braithwaite actually gives us is simply an attempt to fudge the distinction, to make intelligent debate about it impossible. Competing interests: None declared |
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John D Holden, General practitioner Garswood Surgery, Lancashire WN4 0LS
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Everyone caring for vulnerable, often frightened terminally ill patients soon hears, "they would be better off without me"! Knowledge of a right to die would then suggest a duty to die, a belief that it would be impossible to know was not the prime reason for a request for assisted dying. The principal group clearly against assisted dying remains doctors. The only group to canvass current opinion, the largest Royal College, the RCGP, has changed a neutral stance into opposition to a change in the law. GPs have daily contact with those patients potentially being considered for assisted dying and have often cared for them for years before their terminal illness. The option of assisted dying would complicate and hinder effective care for these people, and for their families. There is a growing realisaton that we could do much more to help people die peacefully, with dignity and at the end of their natural lives in their own homes. If the energy consumed by the assisted dying debate were in future directed to that end we could all agree that those who otherwise might feel obliged to ask for an early death had had their burdens eased. Competing interests: None declared |
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Kenneth R. Stevens, Jr., M.D., Radiation Oncologist Physician Oregon Health & Science University, Portland, Oregon 97239
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Experience in Oregon and The Netherlands has shown that there can be a decreased incentive to care for the symptoms and needs of a patient who has received a prescription for lethal medication or where euthanasia is legal. NG and CA Hamilton in Competing paradigms of response to assisted suicide requests in Oregon. Am J Psychiat. June 2005;162:1060-5, describe an Oregon man with depression and lung cancer who had a lethal amount of barbiturates in his home. When he was being discharged from a psychiatric unit, a consultant recommended that he have home attendant care, however, because he had the lethal medication in his home, "attendant care was considered a moot point". Testimony to the Select Committee on the Assisted Dying for the Terminally Ill Bill from a Netherlands' physician including the following concern: "Providing euthanasia as a solution to every difficult problem in palliative care would completely change our knowledge and practice...This is my biggest concern in providing euthanasia and setting a norm of euthanasia in medicine: that it will inhibit the development of our learning from patients, because we will solve everything with euthanasia." (Assisted Dying for the Terminally Ill Bill. Volume II:Evidence, HL Paper 86-II,page 449, 4 April 2005). Competing interests: None declared |
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Michael R Jarmulowicz, Consultant Histopathologist Northwick Park Hospital. HA1 3UJ
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Sir, There is a continuing and concerted campaign to legalise euthanasia. The medical profession will do itself a great disservice if it forgets its history. The reason that we can work the way we do is that patients trust us, literally, with their lives. You only have to study the history of the times of Hippocrates to see and understand why that school of physicians pushed for the absolute prohibition of euthanasia, which has survived for 2,500 years. Imagine the scenario when you are ill and fearful that you might die. The friendly doctor sees the patient in the next bed and compassionately writes up a lethal prescription. He / she then comes to you and in an equally compassionate way asks how they might be of help. Would you have unfailing trust in that physician? Would you really place your precious life, that you were scared of losing, into their hands? I certainly would not. My anxiety would be how that individual viewed my suffering or future quality of life? If you agree that a patient is justified in their request for euthanasia / assisted suicide you have in effect agreed and accepted that they have a life no longer worth living. Such a view will undoubtedly influence the way you practice medicine. This is confirmed by those already practising euthanasia who have freely admitted that there have been occasions when, without the patient’s consent, they have ‘helped’ those who did not have the sense or courage to ask for the obvious. Our society seems obsessed with demanding our individual rights and desires, with no regard to corresponding responsibilities or consideration of the effect that our actions might have on others. It is because many will lose their trust in the medical profession, if euthanasia is permitted, that we have to adhere unconditionally to the hippocratic tradition that so successfully underpinned the practice of medicine over these many centuries. It is pure self deception to think that we / society has changed so fundamentally that it could accept euthanasia without causing an irretrievable breakdown in the doctor-patient relationship, which is an essential part of medical care. Suggesting an opt-out for those with a conscientious objection is not an option. For patients to have trust in their physicians it must be universal. As soon as there is a realistic probability that there are doctors who are willing to kill patients - in whatever euphemistic terms we wish to describe that process - then a large section of the population will lose trust in their doctor. For that reason any relaxation of the prohibition of euthanasia must be resisted. Competing interests: None declared |
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Jane E Seymour, Sue Ryder Care Professor of Palliative and End of Life Care Studies School of Nursing, University of Nottingham, Queen’s Medical Centre, Derby Road, Nottingham, NG7 2RD
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Dear Editor, Branthwaite argues that society should be the arbiter in the debate about assisted dying, citing growing public support for changing the law in the UK. However it is questionable whether ‘society’ is able to make a fully informed judgement on this critical issue. I have been involved in research with older members of the general public which suggests that they find it difficult to find reliable information about a range of issues to do with end of life care options, and find confusing the distinctions between medically permissible practices at the end of life and euthanasia or physician assisted suicide. My teaching experiences suggest that many health care professionals are in the same situation. I fear that arguments about assisted dying deflect attention away from the need to have a much broader debate about what needs to be done to improve public and professional knowledge about end of life care. Ignorance is a dangerous thing and has been one underlying factor contributing to bad deaths for far too long. Legalising assisted dying is not the answer. Competing interests: JS has received research funding to develop public education materials addressing end of life care from The Health Foundation and Help the Aged. |
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Joseph M O'Neill, GP 105 East Millwood Road, Liverpool, L24 6TH, Dr. Averil Fountain, Consultant in Palliative Care, North Cheshire
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We wish to express our profound concern with the biased, pro- euthanasia stance of this 'Education and Debate'. This was not a balanced debate, with 4 pro-euthanasia articles versus one anti-euthanasia article. This has confirmed our longstanding suspicion that the BMJ is a pro-euthanasia organization, but is afraid to say so outright - the stance that dare not speak its name - covertly indicating its approach in a biased selection of articles. In contrast the Royal College of General Practitioners has now dropped its 'neutrality' position, and has now indicated that a change in legislation on assisted dying for the terminally ill is not needed. In the 1930's Hitler's euthanasia policy was greatly aided both by German doctors' failure to provide moral leadership and a government media campaign . The refusal of some German doctors to participate in the euthanasia programme was accepted, provided they did not speak out againast it (1). Indeed, euthanasia in Germany was probably only brought to a halt by a courageously - worded denunciation in August 1941 written by Bishop Clemens von Galen (" the Lion of Munster") (1). Historical parallels with attempts to bring in legal controls on abortion in the 1960's in the UK have not restricted terminations of pregnancy as was hoped. The "slippery slope" is all too real. Such proposed legislation on assisted dying wil prevent the further development of Palliatve Care, for which the UK is the acknowledged world leader. It will also delay the urgent transfer of Palliative Care expertise to the large numbers of non-cancer patients who so badly need it. We will never be involved in assisted dying or euthanasia, and will continue to use and support the development of the excellent (but underfunded) Palliative Care services. Yours sincerely, Joseph O'Neill (General Practitioner) Averil Fountain (Consultant in Palliative Medicine, North Cheshire) References: 1. Taylor,J & Shaw, W. The Dictionary of the Third Reich, Penguin, London, 1997: p91 Competing interests: None declared |
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william r primrose, consultant physician AB15 6XS
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Dear Sir The incremental change in attitude to euthanasia and physician assisted suicide does not bode well for the vulnerable, the profession or society , and “pro” lobby propaganda should be viewed with great concern. A key aspect of our profession is trust, which underpins the relationship with the patient, their family and other team members. When patients are nearing the end of life the foremost priorities are the relief of suffering with the avoidance of unnecessary interventions, and these principles underpin good clinical practice. Occasional well publicised scenarios concern us all, but the principle of “difficult cases make bad law” holds good and the prompt to legislate in this area should be opposed. The inadequate verification and policing seen in the Dutch experiment reflect , in part , the corrupting influence of power with policy being progressively eroded. We should not follow this road! As a geriatrician with 20 years experience I feel the profession should not be party to the promotion of permissive legislation in this area and that existing guidance acts in the best interests of patients and their families. Yours sincerely William R Primrose
Competing interests: None declared |
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Alison B. Chapple, Senior Research Fellow Department of Primary Health Care, University of Oxford, Old Road Campus, Headington, OX3 7LF
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Dear Editor, We have read with interest your recent article by Branthwaite, who suggests that a change in legislation is needed. We also see that in response to that article many professionals argue against a change in the law. We believe that those facing death themselves, as well as other patients, should influence future debate. The DIPEx (Personal Experiences of Health and Illness) website, www.dipex.org, now has a section called “Living with Dying”. Follow the “Talking about” section to a summary called “Suicide and euthanasia”. There you can see a summary of what people, who defined themselves as having a terminal illness, had to say about euthanasia and assisted dying. You can listen to what they had to say and in some cases see a video recording of part of the interview. Yours sincerely, Alison Chapple Competing interests: The author is a member of the DIPEx steering group |
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James D M Douglas, General Practitioner Tweeddale Medical Practice, Fort William PH33 6EU
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The medical euthanasia lobby should reflect upon the lessons of history and societies unknown future. Every doctor in the UK has been adversely affected by the actions of one clinical fool, Shipman. Perhaps he started by thinking he was doing the right thing with his first child death in Pontefract (ref 1) and grew to like the misplaced medical power of death. The Nazi technology of eugenics and death camps began with a medical rationalization by post First World War German Psychiatrists faced with rationing medical resource in mental asylums (ref 2). They justified their asylum euthanasia with the judgement of “a life unworthy of a life” in mental defectives and their medical procedure was high jacked by the 3rd Reich. How will doctors respond to the demographic time bomb and the new genetics with medical killing in our therapeutic options and societies future resource dilemmas? Finally, how will we respond on a Saturday night in A+E? Will it be the 3rd or 4th overdose when we decide that clear intent to suicide has been expressed without mental illness and be unable to justify infringing on that personal right with a resuscitation attempt? Yours sincerely Dr James D M Douglas MD, FRCGP, FRCP Edin. DOccMed References 1 The Shipman inquiry – Sixth Report www.the-shipman- inquiry.org.uk/finalreport.asp 2 Burleigh, Michael. Death and Deliverance - ‘Euthanasia’ in Germany - Cambridge University Press 1994 : P11-42 Competing interests: None declared |
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Colin Brewer, Research director (and retired addiction physician) The Stapleford Centre, 25a Eccleston St. London SW1W 9NP
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I was unaware of DIPEX until I read Dr Chapple's letter but having visited the website, I would urge others to do so. 17 cases are presented in the 'Living with dying' section. However, for those without the luxury of semi-retirement, I have reviewed and categorised the opinions of the DIPEX patients. I excluded four cases involving the carers of patients - mainly with dementia - because they do not tell us what the patients themselves might have thought about voluntary euthanasia/assisted suicide (VE/AS). (Though in my experience, most members of the Voluntary Euthanasia Society would not want to be kept alive with well-established dementia.) Only two patients are definitely opposed to VE/AS. Both cite the doctrines of their (unspecified) churches as the main reason. One believes that palliative care will always porevent severe pain; the other believes that good can come out of suffering. Three patients say that VE/AS is a very complex issue and they find it difficult to decide but one gives it her reluctant agreement and though clearly very religious, feels that God would not want some people to continue living in pointless suffering. Another, though worried about possible abuses, would nevertheless like the option for himself. The others are in favour of legalising VE/AS. The patient who was sure that palliative care would defeat severe pain would probably be right most of the time, though pain is far from the only thing that can distress the dying or those with nasty progressive illnesses. However, I am amused by the Hospice Movement's recent enthusiasm for 'terminal sedation' as a way of dealing with the relatively small number of cases of truly intractable pain. First of all, intractable severe pain does not necessarily occur only when patients are likely to die in a few days or weeks. A cousin of mine, paralysed by spinal metastases but far from terminal, was morphinised to death over a couple of days in a hospice. This was, I am sure, fine by her (and me) but what is the ethical, philisophical or legal difference between sedating someone to death over two days and doing it over 20 minutes? None at all, I think. It is merely a difference of style and aesthetics. And of course, it allows the 'double-effect' devotees to claim that it wasn't the morphine that killed her, it was the pneumonia. Secondly, if death is an unfortunate, unwanted 'double effect' of giving high doses of opiates, then surely - if it really is 'unwanted' - these patients should be intubated and ventilated to prevent their premature death? Especially if, like my cousin, they could probably have survived on a ventilator for several months. Terminal sedation is euthanasia and to pretend otherwise is ludicrous. Furthermore, it must often prevent patients and their families from making their formal farewells, as many would like to be able to do. I could go on but I hope I have at least encouraged BMJ readers to look at the DIPEX website for a patient's-eye view of this old medico- philosophical chestnut. This contribution is not submitted for paper publication. Colin Brewer MB.MRCPsych Competing interests: None declared |
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Susan P Closs, Consultant In Palliative Medicine Swansea NHS Trust, SA6 6NL
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Editor: Have no doubt that the legalisation of physician-assisted suicide and its almost inevitable sequel, euthanasia, will place our most vulnerable members of society in great jeopardy. There are an articulate, intellectual, few members of society at present who are determined to persevere in the mistaken belief that autonomy taken to its extreme, overrides all other considerations. For many people and the families of people, the consideration of death as a possible outcome of an illness or an admission to hospital is unacceptable. Perhaps this is just a reflection of increased expectations fuelled by the media and internet. Doctors are implored constantly to find another treatment option even with the knowledge that the disease process is unresponsive and active treatment has failed. Patients and families with terminal illness more frequently require treatment to be continued even in the face of futility. Many patients now forgo the opportunity of good palliative care in a mistaken belief that its acceptance will prevent opportunity of offer of a “miracle” cure. Carried to an extreme, this prevents patients and families making appropriate choice of place of care at the end of life. It is odd therefore that at the same time as this change in our society that we are progressing towards the legislation for euthanasia. With increasing longevity there will be increasing numbers of elderly people needing care at a time when our economy is already stretched and the working population is shrinking. Many of these patients will have dementia or reduced capacity for decision making. Many patients in residential or nursing homes at present do not have the capacity to even choose which television channel they are exposed to when the residents are placed around a screen theoretically to provide “stimulation”, much as the television has become a childminder for the very young but this time in the interest of “education”. Are these frail elderly patients able to participate meaningfully in decisions about the end of life? As physicians, we are probably unaware of coercion and bulling of elderly patients within families - how are we to know whether pressure has been applied to patients? Are we ready to accept euthanasia as a common cause of death as in Holland? It would certainly make economical sense when there is no longer the capacity in our hospitals and nursing homes. Are we as a civilised society prepared to stand by and allow the passage of legislation which will give authority to a solution reminiscent of Hitler’s Germany where the most vulnerable were killed, a process which also allowed for destruction of people deemed to be unacceptable by the ruling body? I suspect many people who request euthanasia do not have any conceptualised vision of what it actually entails. Has anybody dared to publicise the exact details of the process to the public from decision making to the delivery of the lethal dose of medication? Perhaps many patients would like to believe that at some unspecified time, without warning a doctor would slip something into their night time cocoa and they would not wake in the morning! The reality needs to be publicised. I have, as a Palliative Care Physician, in twenty years only encountered one patient who has persisted in a request for euthanasia and have met several who have banded around the topic for discussion but have not wanted further exploration following the introduction of good symptom control. Of course, there are inevitably the perceptions of families of patients suffering and the frequent quotation “ if he were my dog he would not be allowed to suffer” – but suffering is subjective and even in what is perceived as a “good death” ( a comfortable and peaceful passing ) by professionals will not be described by the family as good , as no death is good and they suffered too. Our medical profession is rapidly changing. It is no longer the norm for patients to be known by their GP as a family doctor or see the same doctor in outpatients or even at the bedside with shift patterns, now for more than two or three occaisions. How are patients going to trust the medical profession if they are aware the healers can also be available to end life? Part of the physician’s role is to develop trust to enable communication of total pain – be it physical, spiritual, emotional or social - are we as physicians willing to throw away the most precious and rewarding part of our honoured position - our relationship with patients. As the late Dame Cicely Saunders promised, that even if there is nothing else to be done – just staying with the patient is all that is asked of us. Assisting patients to die or practising euthanasia is not part of the code under which I wish to practice medicine. Susan P Closs, Consultant in Palliative Medicine Morriston Hospital Swansea NHS Trust, SA6 6NL susan.closs@swansea-tr.wales.nhs.uk Competing interests: None declared |
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John C Chambers, Macmillan Consultant and Medical director Katharine House Hospice, East End, Adderbury, Oxon, OX17 3NL
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Branthwaite twice cited respect for autonomy and twice cited loss of autonomy as arguments for legalising euthanasia for the terminally ill (1). In my opinion, these are mutually exclusive arguments and neither is valid. Firstly, if we are to respect autonomy, all we have to do is step back: true autonomy does not require the permission or assistance of others. Secondly, a person who has lost autonomy does not naturally aquire an authority over others that an autonomous person lacks, such as the authority to instruct representatives from society (doctors who are willing and satisfied to perform the task have been suggested) to help kill them. I personally don't believe that Branthwaite is convinced by either of her own arguments. Why else would she have singularly failed to develop them properly? Her real argument actually appears to be that euthanasia should be legalised because some “determined people” with “fervent wishes” and who are used to “indulgence” and “being in control of their lives” want it. Such people are referred to five times in her article. If they require approval and assistance to achieve their goals, then they might be strong-willed but they are certainly not acting autonomously. Rather than suffering from intractable physical symptoms, data from Oregon shows that people requesting assisted death are typically accustomed to being in control of their lives and have lost some of their autonomy, dignity and ability to participate in enjoyable activities. However, helping them to die instead of helping them to restore enjoyment and dignity to their lives strikes me as highly dismissive of their real plight as articulated by them, and it is possibly the ultimate disrespectful response to their existential anguish. The only autonomy I can see in assisted death is that of the doctor in deciding whether or not to help kill. 1 Branthwaite MA. Taking the final step: changing the law on euthanasia and physician assisted suicide. BMJ 2005;331:681-683 Competing interests: Hospice doctor |
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Donal Martin, Consultant physician Helath Service Executive North West Ireland
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Editor- This year the BMJ has joined the assisted suicide debate with a cover (24/9/05) emblazoned with a Raymond Briggs-esque cartoon of two elderly stereotypes gratefully shuffling their aged bent bodies into the rosy light of extinction. The caption in large font below this image poses the question: “time to legalise assisted dying?” (as opposed to less attractive wording, assisted self-killing) and places the cover image in a context sympathetic to the thrust of MA Braithwaite’s article “Taking the final step”1 The arguments for euthanasia are not novel despite their repeated presentation, nor are they convincing because the cost of euthanasia as ever, remains too high. On the other hand, Palliative Medicine is a new attempt to positively address terminal suffering with a healing approach (i.e. alleviation) in the absence of cure (i.e. fix). Championed in the early 1960’s by the late Dame Cicely Saunders2, it addresses human terminal distress in ‘total suffering’ terms and supersedes the medical model to include the physical, psychological, social and spiritual aspects of a persons being. The person is given a unique value because they exist and not for any other attribute. The despair that almost everyone feels on dying is acknowledged and attenuated. Even the most sceptical of pro-euthanasia proponents would not deny the significant inroads palliative care has made into improving quality of life and relieving all the dimensions of human terminal suffering. The euthanasia movement hold twin underlying assumptions that are rarely clearly expressed. (1) Palliative medicine must provide total alleviation of all suffering in all terminal care patients (tenable in no other branch of clinical care) and (2) suffering is always devoid of any positive outcome. This is not to imply whatsoever, that suffering is to be tolerated or underestimated, but rather to recognise that it is in the struggle to overcome suffering that patient’s carers and clinical professionals become the people we all have the potential to be. Braithwaite’s article reports the often quoted argument “respect for personal autonomy”. This so-called ethical pillar3 is frequently produced as an unimpeachable “carte blanche” in complex ethical situations. Autonomy rarely, if ever, exists in a vacuum and remains intertwined with the self determination of others. At the end of our lives we certainly have our own autonomy to consider, but also that of our carers, our society, and yes – even that of our physicians. Realistically, despite initial stringent safeguards, the demand for “autonomous” assisted suicide will eventually deteriorate into an invasion of that most personal autonomy of all – the right to exist. Neither is it reasonable to expect that euthanasia should remain the prerogative of the terminally ill. There are many with chronic debilitating illness, psychiatric illness, mental and physical handicap who would have equal claim to self extinction if euthanasia were adopted. How will euthanasia on demand impact on the development and future funding of these specialist areas of medical care? Euthanasia will not remain only for a select few, but will inexorably extend to the many. In the fiction ‘ Fahrenheit 451’ the writer Ray Bradbury proposes a dystopian future where firemen, who for decades had displayed a vocational calling to extinguish flames, are now called upon by society to start fires in piles of banned literature. The tenuous logic behind such thinking is paralleled here, where a spurious reasoning supposes that a doctor who has devoted years of training in the preservation of life will have simultaneously developed the expertise of a painless executioner and would therefore be the perfect candidate for the job. The majority of doctors will never comfortably don the mantle of assisted death technician. Medicine has at its core a strict philosophy, elucidated initially by pragmatic Greek thinkers who realised that any society embracing euthanasia would eventually erode the healing practice of medicine. Hence, that other ethical pillar, nonmaleficence, was wisely afforded a respect even higher than beneficence. “Above all, do no harm.” With Palliative Medicine we have a chance to take an evolutionary leap forward into a heightened regard for the uniqueness of human life (and death) and to challenge the human despair that can come with a terminal prognosis. In recent times, mankind with evil intent has indulged the expediency of ‘euthanasia’ for the mentally ill, handicapped and the unwanted. Let us reflect, before well intentioned argument drags us into repeating history again so soon. 1. Branthwaite M. Taking the final step: changing the law on euthanasia and physician assisted suicide. BMJ 2005;331:681-683. 2. Clark D. Cicely Saunders Founder of the Hospice Movement Selected Letters 1959-1999: Oxford University Press, 2005. 3. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. Fifth ed: Oxford university press, 2001. Dr Donal Martin,
Competing interests: None declared |
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Bernard Choi, General Practitioner Brookside Group Practice Reading RG6 7HG
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Mr Braithwaite's assumption that the current law on euthanasia needs changing because it stops doctors from "helping" their patients to take the final step with physician assisted suicide, is fundamentally flawed. The Doctor-Patient relationship is the cornerstone of practice of medicine, which is based on trust, that the doctor seeks to do good to his patient, not harm. Legalisation of assisted dying will present legalised killing as a potential good rather than a fundamental harm for the first time. It will establish killing as a viable ‘therapeutic option’ that, if deemed valid in some cases, will need to be considered in all cases. This will fundamentally change the whole ethos of medicine. As a profession, and as a society, we have always seen the wish to die, for example in the suicidal person, as a cry for help, an indication that something is wrong that needs to be addressed. The medical profession has been built on seeking ways to relieve suffering, treat illness and preserve life; to restore dignity and hope. This bill changes the role of doctors and the doctor-patient relationship by introducing the option of doctors killing their patients. Moreover, many elderly people already feel a burden to family, carers and a society which is cost conscious and short of resources. They may feel pressure, real or imagined, to request assisted dying. They need to know that we, as doctors and as a society, are committed to their well being, even if this does involve expenditure of time and money. The desire for death is most significantly correlated with measures of depression in terminally ill patients. [1] Yet nearly 80% of psychological and psychiatric morbidity in patients with cancer goes unrecognised and untreated. [2] It is important that efforts are focussed on addressing these issues in patients. The debate about assisted dying must recognise the importance of psychiatric conditions, which are potentially treatable. While we recognise that certain mental stresses are not treatable – existential angst, loss of dignity, fear of the dying process – these factors are not medical as such, and do not warrant a ‘medical’ solution in the form of assisted dying. The spiritual and emotional nature of these issues may require the input of people from outside the medical profession. Doctors cannot be expected to be pastors and counsellors; they are not necessarily equipped to address the many needs behind a patients expressed wish to die. Allowing them to kill patients is not the answer to that problem. As professionals and society we need instead to get on with the task of working for that genuinely ‘gentle and easy death’ all patients deserve. Pope John Paul II showed us what real ‘death with dignity’ means: facing the end with courage, hope and serenity with balanced medical intervention and effective palliative care. The proposed bill is fundamentally flawed and would substantially change the way medicine is practised in this country. The law should not be changed. [1]Chochinov HM et al. Desire for death in the terminally ill. Am J Psychiatry 1995;152:1185-1191 [2]Maguire P. Improving the detection of psychiatric problems in cancer patients. Soc Sci Med 1985;20:819-23 Competing interests: None declared |
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Renate P. Wright, Housewife, Volunteer W2
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British Medical Journal
"Assisting patients to die or practising Euthanasia is not part of the code under which I wish to practice medicine" concluded Susan Closs' letter to the editor dated 4th October 2005. I would want to sincerely believe in the code of practice of the medical profession and therefore find legislation inappropriate. Just imagine one day when your body wants to die, because you do not have a life, which is self-supporting, your physician will be able to decide to administer the lethal dose and furthermore determine the date of your death? Do you want to live or die on your birthday, the physician would ask you? Do you really want the medical profession to be in control of your death and make that choice? The answer is no. Surely it is time for change, but change of a different kind, for family education and for family members to learn how to care during the process of a close relative dying. If society supports and finances maternity leave, society should also promote serious illness/compassionate leave on equal terms. We know more and more about keeping our body young but the challenge in future will be the need to educate the young about dying. We need a forum of people with knowledge of caring and an open discussion on caring for the dying patients and not assisting patients to die. Yours faithfully, Renate Wright Mother, catholic of the parish of Saint Mary of the Angels Competing interests: None declared |
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