This article appears in the November 1998 edition of the Catholic Medical Quarterly
When Can I Go, Doctor?
Such a plea may be heard frequently if advanced directives are legalised. The doctor, having decided that enough is enough, responds affirmatively and leaves a little medication beside the bed with suitable instructions. This is different from euthanasia, we are told by the BMA News Review of September 12. It is to be regarded as a caring action by a compassionate doctor for a patient who fears degeneration and indignity more than death. It is based on the principle that the patient is autonomous and has the right to determine the future of his or her own body; it is dressed up under the cushion of 'physician assisted suicide'.
But it is euthanasia; an action to terminate life for merciful reasons. Only the retarded or malevolent could think otherwise. And the doctor, who presumably up to this point has been endeavouring to restore the patient to health, is the willing agent to effect the supposedly autonomous wish.
A cursory examination is sufficient to dispel this illusion of autonomy. For it is the doctor who makes the diagnosis. The doctor decides that this action is needed under the given circumstances. It is the doctor who obtains consent. The doctor decides when treatment should be stopped. The doctor decides what medication should be used or discontinued and then decides the appropriate time when the patient is to die. Assisted suicide means signing over one's autonomy to the doctor. Total individual independence is a concept much heralded in current society, but was described by Shaw in Pygmallon as 4a middle class blasphemy. We are all dependent on one another, every soul on earth'. When someone says 'let me die', as Dr. Cicely Saunders has pointed out in this journal, it is often not a request for a deliberate hastening of death but rather refers to a fear of treatment aimed at prolonging a burdensome existence.
Many say there is no difference between helping a patient die in assisted suicide and the removal of treatment in order that the patient dies. The US Supreme Court was confronted with this opinion last year and, unanimously and with little hesitation, struck it down. Assisted suicide was recognised for what it is - euthanasia.
Others claim that large numbers of patients are being mercifully killed at present. A figure of one thousand annually is being trailed. Such claims of course cannot be substantiated: if they were, they would be liable to criminal investigation, for it is a criminal action. It must be admitted this is a grey area in the management of a dying patient when an increased dose of medication may contribute to a patient's death. It is the intention here that is all important. The intention to keep a patient comfortable is one thing and is certainly ethical. On the other hand the intention to bring about a patient's death is quite another and is distinctly unethical.
Uncontrollable pain and suffering were formally advanced as major reasons for euthanasia; but now palliative care consultants are confident they can control over 98% of severe terminal pain. Even in the Dutch experience, of those who requested euthanasia or assisted suicide, pain was the major reason in only 5% of cases. Emotional and psychological suffering are more difficult to control. Depression is an unmistakable step in the final journey, made worse by loneliness, abandonment, despair, fright and anxiety.
In previous decades, it was evident that doctors persisted too long to keep patients alive and did not know 'when to let go'. That phase has largely passed, but perhaps the pendulum has swung too far the other way and 'do not resuscitate' orders may appear prematurely.
But dying patients are not really those whom the proponents of euthanasia and assisted suicide have in their sights. Rather they are a group of people who may be classified as 'biologically tenacious'. These are the senile, the Alzheimer sufferers, the severely incapacitated and the handicapped: persons whom many think ought to die but don't: those who have had strokes, who have progressive neurological diseases, quadriplegics and those with severe head injuries. They are to be encouraged to comply with assisted suicide and thereby be no longer a burden on their families and society. But they are 'biologically tenacious' and prefer to cling to what others regard as a diminished quality of life until the final passage occurs.
Physician assisted suicide has now become a major ethical issue. It was raised at the last two ARMs of the BMA. This year a resolution was passed: "the BMA commits itself to holding a conference to promote the development of a consensus on physician assisted suicide and should circulate arrangements by the 1999 annual conference" As if that was not enough, the secretary of the Ethics Committee of the BMA., Dr. Michael Wilks, while welcoming the idea of a conference, thought it would be ambitious to imagine a consensus would arise from a single conference. So we are promised a long campaign. It is interesting to observe the use of the term ,consensus' - a bland creation perfumed with moderation. We all know how well the manipulators are able to achieve their objectives in such situations. Moderation may appear as a 'civilised' way of disposing of the 'biologically tenacious'; but, if confronted with racism or anti-Semitism in the community, presumably the Association would act with firm resolution rather than moderation.
What patients are really asking for, when they make some form of advanced statement or directive, is a desire to die in peace and that excessively burdensome or futile treatment should not be implemented. This would appear to be a natural response to the magnitude of modern therapeutic technology. Palliative medicine has now made it possible.
Now we learn that the newly elected government in Holland is pressing ahead with a proposal to legalise 'assisted suicide' by doctors; if it succeeds it will be the first of its kind in Europe. In response, as more and more become alarmed at the prospect of being killed prematurely by over enthusiastic doctors if they fall ill, over 10,000 Dutch people have started carrying anti euthanasia passports requesting " that no medical treatment be withheld on the grounds that the future quality of my life will he diminished .... and that I am of the opinion that people do not have the right to end life".