The moral character of clinicians or the best interests of patients?
BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7196.1432 (Published 29 May 1999) Cite this as: BMJ 1999;318:1432
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Professor Doyal assumes it is in the "best interests" of a patient
with low "quality of life," in terms of poverty, loneliness and
progressive blindness, to have his life shortened. Even if this were so,
doctors have no mandate to make treatment decisions on such grounds.
The Samaritans are told by their clients of similar sad situations
every day, but they do not prescribe suicide as the remedy.
Yours faithfully,
Peggy Norris,
Hon. Secretary,
Doctors who Respect Human Life.
Competing interests: No competing interests
EDITOR - Professor Doyal argues (1) that the doctrine of double
effect is part of 'a code of ethics that places the moral integrity of the
individual clinician above his duty when there may be conflict between
them'. He would prefer to see emphasis placed on conformity to the
'independent standards' of the 'broader professional environment'. Such a
change would have the effect of removing the legal and moral
responsibility that now rests with the individual doctor looking after a
terminally ill patient and placing it, probably, in the hands of some kind
of local consensus group basing its decisions on published clinical and
legal guidelines.
However, the moral decision in the individual case cannot be avoided
by the use of such criteria. Consequences are not the only ethically
significant aspects of actions. The law, of course, has always recognised
the paramountcy of personal responsibility, and doctors who are not
doctrinaire utilitarians would surely agree that this is also a vital
moral consideration. Even if these procedural changes were introduced, the
distinction between foreseen and intended actions would therefore have to
be made. The effect would be not only to remove responsibility from the
patient's personal physician but also, by making decisions impersonal and
'objective', to disguise and undermine their moral
importance.
Doyal provides three hypothetical cases to illustrate possible
problems with double effect. Two are rather puzzling choices in that they
describe what would clearly be legally and morally unjustifiable
management of non terminal patients. In the third example a physician
decides to prolong a patient's life, even while agreeing that this is
against his best interests, because she is unsure of the purity of her
intent. This is indeed a problem, but the difficulty does not lie with the
doctrine of double effect itself; it lies in the question of who takes
responsibility. It is possible that a consensus group would be at least as
likely to allow a patient to suffer unnecesarily as an individual who
knows the patient. Individuals' decisions will inevitably err on
occasions, but to preserve what is arguably one of the most valuable
things we can offer a terminally ill patient - a relationship with a
caring and personally responsible physician - this is a price worth
paying.
AC McKay
Consultant Anaesthetist
Belfast City Hospital
Belfast BT7 2AB
1 Doyal L. The moral character of clinicians or the best interests of
patients? BMJ 1999; 318: 1432
Competing interests: No competing interests
Len Doyal’s contribution to the subject of terminal care(1) is to be welcomed even if, or perhaps partly because it confuses some of the issues. At one point in his article he talks of foreshortening life, and in another of foreshortening death. His two clinical examples are of patients not deemed to be terminal. And, referring to the slippery slope, he deliberately blurs the distinction between good medical care of someone who is dying and the deliberate taking of life.
Even the title of the leading article is confusing. We should not be concerned with “the moral character of clinicians or the best interests of patients’ but with both. The best interests of patients is of the highest possible importance, but when one judges the morality of a clinician’s actions, the intention of that clinician is all important. There may be situations when it is appropriate for a surgeon to make a hole in someone's abdomen, and that action may remain appropriate even if the patient subsequently dies. It is unlikely to be appropriate for a youth at a dark bus-stop to make a hole in someone’s abdomen.
By contrast Raanan Gillon’s article(2) is much clearer. The doctrine of double effect allows doctors to do their best for their living, and dying patients. It is not about mercy killing. It is just a pity that he was lured into translating euthanasia for us, because the literal meaning of the word actually spans both subjects, and though it’s use to describe mercy killing is a euphemism, that is the way the word has come to be used.
Charles West, General Practitioner - Church Stretton.
(1) BMJ 1999;318:1432-3
(2) BMJ 1999;318:1431-2
Competing interests: No competing interests
Derek Jones's point is a good one. I suppose the answer is that
narcotic antogonists are not administered because the burden of that
treatment (a short life of immense pain) outweigh any benefits
(temporarily deferring death). Again the point is that death is foreseen
but not intended (by the non-administration of the narcotic antaogonist).
Competing interests: No competing interests
The usual medical responce to a respiratory arrest from inadvertant
iatrogenic narcotic "overdoses" is either to support the patients
ventilation, until return of spontaneous breathing or to administer a
narcootic antagonist. If neither was done, then the purity of a clinicians
intent to only releive pain [and not to shorten life], seems to be called
into question.
Competing interests: No competing interests
Legalising euthanasia will not help to protect vulnerable patients
Editor
Professor Doyal criticises the reliance of English law on the
doctrine of double effect, and argues that this prevents a "real debate"
on the legalisation of active euthanasia1. He demonstrates how the
application of the doctrine may result in the denial of life-saving
treatment or adequate pain relief, and the premature death of a patient
with a good prognosis. Analysis of his three examples, however, reveals
that the doctrine has been truncated, and has not been considered, as is
customary, alongside the moral and legal doctrine of the sanctity of life.
This has led to false conclusions in two cases. In addition, the examples
given are all of incompetent patients and of non-voluntary euthanasia.
Much of the debate centres on competent patients and voluntary euthanasia.
Although the latter is illegal in this country, the primacy of the
principle of autonomy is such that competent patients have an absolute
legal right to refuse life saving treatment. This right of choice exists
even if the reasons given are …"rational, irrational, unknown or even non-
existent".2
The sanctity of life is an important, but not absolute, imperative in
law. Lord Hoffman, in the Bland case, said "that full weight has to be
given to the principle of the sanctity of life before deciding that a test
of best interests justifies a decision to allow the patient to die"3. It
is highly unlikely that the patient in the first example would pass this
test.
The doctrine of double effect has four components, and one of these
stipulates that the good effect must outweigh the bad effect. In the third
example, the doctor's overarching aim would be to save the person's life.
If adequate pain relief significantly jeopardised the chances of recovery,
then the patient would be allowed to suffer temporary pain. Death could
not be accepted as a "side effect".
Furthermore, removal of an absolute prohibition to an action appears
to result in the inexorable broadening of the scope for that action. The
1996 Dutch survey of Jochemsen and Keown 4 provides some disturbing
empirical evidence for this. The legal restrictions on euthanasia were
extensively ignored, and non-voluntary and involuntary euthanasia was
admitted to in one fifth of the cases (810 patients).
In conclusion, the current legal principles may provide us with an
imperfect and
incomplete framework for decision-making at the end of life. Nevertheless,
no argument or evidence to-date has persuaded me that legalising voluntary
euthanasia will provide better protection for vulnerable patients.
Indeed, the reverse may be true.
Paquita de Zulueta
Clinical lecturer
Department of General Practice and Primary Care
St Mary's Campus. Imperial College School of Medicine
Norfolk Place
London W2 1PG
1 Doyal L. The moral character of clinicians or the best interests
of patients? BMJ 1999;318:1432-3.
2 re T. (Adult refusal of treatment). [1992] 4 All E.R. 786 (C.A). Per
Lord Donaldson of Lymington M.R.
3 Airdale N.H.S. Trust v. Bland, (C.A.) [1992] 2 W.L.R. 358 per Hoffman
L.J.
4 Jochemsen H, Keown J. Voluntary euthanasia under control? Further
empirical evidence from the Netherlands. Journal of Medical Ethics
1999;25:16-21.
Competing interests: No competing interests