A death of reason
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c804 (Published 10 February 2010) Cite this as: BMJ 2010;340:c804
All rapid responses
I am rather baffled by the argument put forward by Colette Reid et al
and her "non-fatal" alternative for patients who are dying.
I have been a GP interested in palliative care for thirty years, and
about once a year a patient who has had the benefit of our excellent local
palliative care services expresses the wish to me that they could have
their suffering ended. As a "well-educated, empowered middle class" person
I have to decline their request. So it certainly true that "many of the
people we care for do not have a voice" in such circumstances. It seems
that Dr Reid feels that by legalising their wishes we "might potentially
remove both their voice and their choice". A bit hard, I would have
thought, since at the moment they have neither.
When people actually get their chance to express their views in
opinion polls on the subject, about 75% generally favour allowing terminal
ill people the choice of when and how to die. Of course, if Dr Reid really
has a non-fatal alternative to death that would be a different matter.
Given the usual situation, all of them do actually die. And since well-
educated, middle class palliative care professionals won't give these
patients a voice or a choice, it is high time that those actually
empowered to help - i.e. members of the House of Commons - promoted a
change in the law to give dying people control of their dying, and doctors
the means to be humane in this situation.
Competing interests:
None declared
Competing interests: No competing interests
Des Spence argues that the medicalisation of death causes prolonged
dependence and therefore loss of dignity. Evidence confirms that we are
seeing more and more interventions being done to those who are dying and
this may result in an undignified death for some, however to offer ‘some
version of assisted suicide’ as the alternative is to assume that a
premature, highly medicalised end to life through assisted suicide will
necessarily provide a more dignified death.
He states, ‘as for palliative medicine, much has improved in the care
of dying people with the adoption of the Liverpool Care Pathway’.
Unfortunately, there is currently little evidence to prove that patient
care is improved, and such statements propagate misconceptions about
palliative care being only about care of the imminently dying. Perhaps
Spence should spend some time with specialist palliative care teams in
acute trusts to see that we are trying to improve the care and quality of
life of patients with incurable illness, by striving for excellent symptom
control, minimizing invasive interventions, stopping unnecessary
medications and trying to meet patients’ wishes for their remaining time
and preferred place of death. This is done by engaging with clinical
teams, educating our colleagues about palliative care and advocating for
patients.
Dying does not have to be synonymous with pain, loss of control or
loss of dignity; most patients who understand what is happening to them do
not report that their quality of life is declining. Surely what we should
be tackling is the medical culture that pursues ‘futile and thoughtless
interventions’ rather than replacing them with a fatal alternative.
Currently, we are hearing from those with a voice - the well
educated, empowered middle class - about individual choice and assisted
dying. Many of the people we care for do not have a voice; legalising
assisted dying might potentially remove both their voice and their choice.
Competing interests:
None declared
Competing interests: No competing interests
As usual , Des Spence provides one of the best bits in the BMJ , but
he is not the "control freak". That title belongs to some of those carers who
wish to be in charge of what happens to patients at the end of life. One
of the most prominent has likened the doctor's position to that of an air-line pilot and his passengers. We continue to distinguish medically between
decisions to withhold or withdraw treatment and the moral equivalent of
assisting death in the dying. Is it just a co-incidence that the first is
a decision made by doctors and the second stems from a request by the
patient? Terry Pratchett tried to open a serious debate on how the
"vulnerable" might be protected when the law changes to allow some form of
assisted dying. Opponents do not seem willing to have such a debate. It
seems equally true that some of those fighting "ageism" have lost sight of
respect for the elderly and their views. I remember past pressures to put
in feeding tubes - at least that has recently led to some common sense
guidelines by the RCP.
Competing interests:
Member of Dignity in Dying
Competing interests: No competing interests
We agree that a patient’s age is a relevant clinical consideration.
However, surely chronological age is irrelevant? If a patient’s age is
used to guide clinicians, perhaps methods to estimate a patient’s frailty
and biological age (functional age)[1, 2] are more useful, and should be
adopted more widely.
1 Graham J, Mitnitski A, Mogilner A, Rockwood K: The dynamics of
cognitive aging: distinguishing functional age and disease from
chronological age in a population. Am J Epidumiol 1999, 150:1045-1054.
2 Mitnitski A, Graham J, Mogilner A, Rockwood K. Frailty, fitness and late
-life mortality in relation to chronological and biological age. BMC
Geriatrics. 2002; 2:1 doi:10.1186/1471-2318-2-1
Competing interests:
None declared
Competing interests: No competing interests
Dr Spence reveals his self-knowledge in his opinion piece,
and shows a lack of insight. To say "(his) reasoning is not
cluttered by a faith" is dead wrong - we all have faith in
some set of assumptions and beliefs underlying our reason.
Failing to acknowledge this exposes more clutter than
declaring it does.
The high church of secularism is not uncluttered by faith,
it merely assumes that whatever it has faith in is somehow
more reliable than its neighbours' faiths. The usual
'religious' tripe. It also assumes that the ideas of anyone
who declares “a faith” is somehow a puppet of the hierarchy
of some group or other. Amongst real people (as opposed to
the usual straw men of argument) I think that is an
exception, if it exists. The high priests of secularism (or
atheism, however they like to define themselves) are no less
cluttered by their equalising mere human infants with other
“sentinent beings”, than I am by my belief that all humans
are somehow different in value to all other created animals
from conception onwards. Harris, Singer, Dawkins and even Dr
Spence display their clutter when their high thoughts come
into conflict with reality - whether caring for a
(presumably valueless by the philosophical reasoning)
dementing parent, or "I wish to be remembered for what I am,
not what I was" does not really mean (does it?) that Dr
Spence wants his kids to remember dear old Dad, a pile of
ash in the garden, in years to come. I daresay he remembers
Winston Churchill, or any number of other remembered
individuals, publicly and privately, for what they were, not
what they ‘am’.
In fact we all need to acknowledge that we have faith in
whatever it is we trust in; we have unprovable assumptions
which we rely on in all our thinking. “I think therefore I
am” … prove it! We need to respect our differences and get
on with the discussion, rather than to claim the higher
ground, belittling others' "clutter" whilst denying our own.
Secularists and atheists can contribute to discussions
around caring for others, just as well as any church or
mosque (etc) member can contribute to sensible discussions
of limiting ICU admissions to those which actually have a
reasonable prospect of improved outcomes, or of withdrawing
futile treatment because it is, well, futile. These are
discussions of science AND wisdom, which we may each
contribute to (and benefit or suffer from). When should we
allow a human to kill another human? That is not subject to
science, only to wisdom (whatever that is ...). So-called
theologians and philosophers can then argue the toss of how
these decisions relate to their particular thoughts.
Such popular thinking as Dr Spence (and others mentioned
above) deals in was common across the modern world, until
Hitler’s regime enacted the thoughts of many towards
disabled, sick, ‘mentally ill’ and elderly people, as well
as towards various ‘races’ of humans (the ‘Jewish problem’
was a racial, not a religious one. ‘Jews’ did not escape by
declaring themselves of any alternate faith, or ‘none’).
Hitler’s regime was based on ‘we are best’ ideals, not any
other ideals usually defined as ‘faith’ based.
Modern thinkers need to be wary of climbing the ladder of
the Judaeo-Christian heritage of ‘laws’ in science, or
reasonable morals, then kicking off the ladder whilst
clinging to an imaginary ‘reality’. It doesn’t work, except
within their own close-minded forums. Outside these (at
least), they seem always to rely on dogmas they reject. (I
owe the ladder image to author Os Guinness, “The Case for
Civility”, HarperOne, 2008)
Competing interests:
I trust in the historical
resurrection of Jesus. I am
of Jewish (and Holocaust)
heritage.
Competing interests: No competing interests
A “non-fatal” alternative to dying
I salute Dr Reid and her colleagues’ semantic triumph in devising “a
non-fatal
alternative” to death.
Yet it’s sad that, after endorsing Des Spence’s criticism of “futile
and
thoughtless” medical interventions they felt the need to indulge in
semantics
rather than accept his conclusion: “Until we stop the medicalisation of
death
and can avoid prolonged periods of dependence, I support some version of
assisted suicide”.
Having watched my wife, whom I loved dearly, endure attenuated
“ethical”
death by starvation and dehydration, I am angered by the casuistry that
infects much medical discussion of euthanasia, by which I mean the simple
OED definition, “An easy and peaceful death”.
My wife had a great fear of the form of dying to which she was
subjected and
had made me promise to do all I could to protect her from it. I tried to
reassure her with talk of palliative care and of changing medical
attitudes …
and I will never forgive myself for failing her.
Though ashamed of my own behaviour, I am grateful to the nurses — the
doctors were notable for their absence — who cared for her each day with
great skill and kindness as they trod their prescribed pathway. They did
their
best to keep her at peace but the moments that dominate my memory are her
spells of lucidity when her physical and audible signals were those of
someone being tortured rather than comforted.
For all the talk that goes on in High Places – well-meaning folk
discussing
concepts of “active” and “passive” euthanasia, “natural death”, and “the
importance of intention” before a break for lunch – I, like many others,
had to
face the reality served up in 21st century general wards uninhabited by
consultants in palliative care.
If Dr Reid and her colleagues wish to make a real semantic
breakthrough,
they should seek a non-fatal alternative to living.
Now, that would be an achievement.
mod@doctors.org.uk
Competing interests:
None declared
Competing interests: No competing interests