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J was a patient of mine in general practice. He had been action man personified in work and sport, but several years of progressive multiple sclerosis with no remissions had left him almost tetraplegic. He was well looked after, with maximum nursing and homecare input, and despite no specific treatment several hospital specialists supervised his management. I visited regularly for support.
After a couple of years, J suddenly asked, 'Doc, go out to your car, get something, and put me out of this. If I was an animal, you'd have to.' For a moment, my heart agreed with him, but then a lot of other realisations kicked in. 'J', I said, and I was so glad to be able to say this, 'that's against the law and I'm not going to do it. And you know I'm a Christian and what you've just said gives me a particular problem. But I'm glad you've raised it, because I hadn't realised how bad things had got, and I promise that from now on we're going to work twice as hard for you.'
And we did. Even so, J made the same request monthly for about two years. You will conclude I never performed euthanasia, although the story didn't end there. But first, this story illustrates well the focus of the current debate.
With interest surrounding the House of Lords' Select Committee report considering Lord Joffe's Assisted Dying for the Terminally Ill Bill (1) (awaited as I write), all medics need to know the arguments for and against legalising euthanasia. There are essentially three arguments for:
The last time a House of Lords Select Committee reported on euthanasia in 1994, it unanimously recommended no change in the law to permit euthanasia. The debate then centred on the compassion case, but partly because of the success of the hospice movement and its derived specialty, palliative care, it has moved to arguments based on choice, control, rights and autonomy (self-determination). It has moved from euthanasia as a needed response to symptoms, usually in cancer cases, to euthanasia as an autonomous choice by those with, for example, progressive neurological disease.
The Christian case against euthanasia can be stated very briefly. No Scripture can be found in favour and the sixth Commandment, 'You shall not murder', (2) which prohibits the intentional killing of the legally innocent applies. (3) But as J's story illustrates, most of us will meet situations where we ask ourselves, however momentarily, 'Why does God say that?'
Christians should support autonomy in so far as it reflects the unique value of each human being made 'in the image of God' (4) but autonomy is not absolute. I will now major on four arguments against the autonomy case for euthanasia, and conclude with brief reflections only on the other two arguments. These answers go some way towards explaining the 'No' an infinitely wise and loving God has clearly given us; because they are essentially secular they do this in ways that a non-Christian public can understand and identify with.
Where a patient's autonomy is followed so far that they receive a prescription for lethal medication or are put to death at the end of a needle, the doctor's autonomy is compromised. The euthanasia lobby reply, 'So what? There is a Conscience Clause in Lord Joffe's Bill. Objectors need not be involved.' But we know the Conscience Clause in the 1967 Abortion Act has only worked partially, (5) and abortion has kept many doctors away from obstetrics/gynaecology and general practice.
While you can avoid abortion as a doctor and still have career choice, there is no branch of medicine where you can entirely avoid issues of death and dying. What impact might euthanasia legislation have on recruitment and retention of staff in all medical specialties? Manpower is an ever-growing difficulty for the National Health Service.
Those who care for the dying know the (relatively few) who currently ask for euthanasia usually have another question behind their question. This may be physical - a distressing symptom needs treating; psychosocial - they want honesty within their family; or spiritual - they have questions like 'Why me?' or 'Why now?'
There is an old medical adage: 'No treatment without a diagnosis'. If we bother to make a real diagnosis and then treat that, the request for euthanasia usually goes away. Prescribing euthanasia, even with the proposed safeguards, would far more often undermine autonomy than underline it.
J's requests were deliberated. Why with controls can't there be a law to accommodate exceptional cases? The answer is a development of the previous point. For the reasons hinted at there, and bearing in mind inevitable uncertainty about prognosis, to change the law to allow euthanasia for this small minority within a minority would mean it was performed far more often when it was 'wrong' than when some would see it as 'right'. To protect that majority, the minority forego a right that doesn't exist anyway.
This sounds utilitarian but it has to be so in complex inter-connected societies. In road traffic legislation for example, we all accept limitations on our 'freedoms' in order to protect vulnerable others. John Donne's famous words 'no man is an island' hint at the issues of community and relationships central to the euthanasia debate. Respect for the right of autonomy has to be balanced with the responsibilities that accept restrictions.
'Slippery slopes' exist. If we change the law to allow voluntary euthanasia for those who are suffering and have the capacity to ask for it, surely compassion means we should similarly provide euthanasia for that patient who is suffering at least as much but has no capacity to request it? This logical slippery slope follows when doctors decide that any patient's life is not worth living (the euthanasia lobby argue the patient decides - but the doctor has to agree).
There are other slippery slopes, in practice and in doctors' attitudes. The progression from voluntary to non-voluntary euthanasia (the patient lacks capacity) or involuntary euthanasia (a patient with capacity is not consulted) is well documented in the Netherlands.
The Remmelink Report (6) was a statistically valid analysis of all 129,000 deaths in the Netherlands in 1990: 3% were euthanasia. Of that 3%, 1 in 3, 1% of all deaths in the Netherlands in 1990, were euthanasia 'without explicit request'. In 1990 Dutch doctors killed more than 1,000 patients without their request. This is not patient autonomy but doctor paternalism of the worst kind.
Briefly, this stands or falls on the answer to the question: Do we have to kill the patient to kill the symptoms? Palliative care has answered that question with a resounding 'No', though the harder symptoms to deal with are not positive physical ones but negative ones of patients' losses - the things they can't do any more. The challenge to healthcare becomes bringing meaning and hope in the face of suffering.
As the Dutch statistics confirm, we cannot control it. How ever could we, when the key witness, the person police would most want to interview, is dead?
Of course, another way to exercise some control over euthanasia would be to require doctors to notify cases to the authorities so that checks could subsequently be made. Such a situation was in force in the Netherlands in 1990, as one of the so-called 'strict safeguards'. According to Remmelink there should therefore have been 3,700 notifications in 1990 (3,300 cases of euthanasia and a further 400 of physician assisted suicide). How many notifications were there? There were 454.
In the vast majority of cases doctors chose to conceal what they had done, in the process perjuring themselves on death certificates and other legally binding documents. The euthanasia movement has argued that the doctors were only trying to spare relatives the distress of legal enquiries on top of their grief, but how do we know that was always the case? Perhaps some of those doctors had something to hide.
The reporting rate has been checked several times since then but the rate in 2001 was still only 54%. (7) Even since the complete legalisation of euthanasia in 2002 (in 1990 it was only 'legally sanctioned'), numbers of reported cases have continued to fall. This has prompted the Dutch health minister to order a follow up study in 2005. (8)
The 'We can control it' claim does not work, and hence the public policy argument fails too.
There is no 'right' to be killed by a doctor, we do not need euthanasia, and we could never control it. All three arguments are tried and found wanting. Let us instead commit ourselves to working for that genuinely 'gentle and easy death' all our patients deserve.
J eventually stopped asking for euthanasia. With no input from me, except prayer, he came to a quiet Christian faith. He died peacefully about five years later, 20 minutes after receiving communion.
Extracts from the Assisted Dying for the Terminally Ill Bill: (1)
The attending physician shall have:
- been informed by the patient that the patient wishes to be assisted to die
- examined the patient and the patient's medical records and have no reason to believe that the patient is incompetent
- made a determination that the patient has a terminal illness
- concluded that the patient is suffering unbearably as a result of that terminal illness
- informed the patient of his medical diagnosis; his prognosis; the process of being assisted to die; the alternatives, including, but not limited to, palliative care, care in a hospice and the control of pain
- if the patient persists with his request to be assisted to die, satisfied himself that the request is made voluntarily and that the patient has made an informed decision
- referred the patient to a consulting physician
Offer of palliative care
The attending physician shall ensure that a specialist in palliative care who shall be a physician or nurse has attended the patient to discuss the option of palliative care.
Further duties of the attending physician
Before taking any step to assist the patient to die the attending physician shall have:
- informed the patient of his right to revoke the declaration
- verified immediately before assisting the patient to die that the declaration is in force and that it has not been revoked by the patient
- asked the patient immediately before assisting him to die whether he wishes to revoke the declaration
Duties of physicians, and conscientious objection
- No person shall be under any duty, whether by contract or by any statutory or other legal requirement, to participate in any diagnosis, treatment or other action authorised by this Act to which he has a conscientious objection.
- If an attending physician whose patient makes a request to be assisted to die in accordance with this Act… he shall take appropriate steps to ensure that the patient is referred without delay to an attending physician who does not have such a conscientious objection.
- If a consulting physician to whom a patient has been referred…has a conscientious objection…he shall take appropriate steps to ensure that the patient is referred without delay to a consulting physician who does not have such a conscientious objection.
What can you do?
There are lots of things we can do to effect positive change in this situation:
Read - www.cmf.org.uk is an excellent resource. Other suggested material includes:
- Wyatt J. Matters of Life and Death. Leicester: IVP, 1998 (available from email@example.com)
- Fergusson A (ed). Euthanasia. London: CMF, 1994 (available free from firstname.lastname@example.org)
Get yourself informed so you can have a positive influence on discussions with family, friends and colleagues.
Pray - 'The Most High is Sovereign over the kingdoms of men' (Dan 4:17) and we must ask him to overrule in this situation. We can pray for:
- CMF staff, especially Peter Saunders (General Secretary) and Andrew Fergusson (Strategy Advisor on Euthanasia) as they speak, write and network
- the church to respond and stand firm in the face of opposition
- the government to be under God's rule
- ourselves individually to speak up on euthanasia
Act - You could organise a talk or debate on euthanasia at your medical school - contact the CMF office, your local CMF staffworker or Relay worker for suggestions of speakers.
The House of Lords Select Committee will have reported by the time you read this, but the bill would still need to go through the Commons. You can write to your local MP, expressing your concerns on the issue.