This article appears in the November 2006 edition of the Catholic Medical Quarterly
The Danger of Physician Assisted Suicide
Keynote Speech at the Annual Conference of the Catenian Association, July 2006
The world wide drive to introduce euthanasia is relentless and well organised. The current Bill introduced by Lord Joffe that was before the House of Lords is but one of many attempts to introduce it. Characteristically, euphemisms replace plain speaking and there are strong appeals to compassion based on hard cases. Thus "Assisted Dying for the Terminally Ill Bill" is actually about legalising medical suicide. In yesterday's debate his Bill was defeated by a wrecking amendment on a substantial majority of 48. Anglican bishops joined peers with disabilities to give a powerful appeal to their colleagues. We have not yet had a chance to analyse the debate but Lord Joffe has already declared his intention to reintroduce his Bill again.
The most emotive cases which are often highlighted in the media are individuals with severe conditions who commit suicide abroad. Sometimes they are portrayed as heroes but in a letter signed by 23 consultants in palliative care published in the Daily Telegraph on May 9, they said of these high profile cases;
"We, together have very many years of experience of care of the dying, have come to the considered opinion that the hard cases that are publicised could have been handled with respect for autonomy, with dignity and humanely within the present law by harnessing what has been learnt within palliative care".
The doctors then called for the rejection of Lord Joffe`s Bill. Yesterday's debate was not the end of the argument by any means . Lord Joffe has introduced three Bills in the last three years and more can be expected and the well orchestrated media campaign will continue. The biased media reporting, especially by the BBC will continue. Yesterday as we drove here to Eastbourne we heard news bulletins every hour. With only one exception they were pro Joffe. The proponents of suicide are conducting a slick and focused media campaign.
In Europe a number of countries have both euthanasia and physician
assisted suicide and the numbers of people dying as a result rises year
on year. In the United States a dozen Bills have been introduced, and in
Oregon one succeeded and Lord Joffe`s current Bill is (was ) based upon
it. The drive will not slacken because it is inspired by a particular
and popular view of the individual being entitled to absolute autonomy.
More attractive slogans are being coined to win over the public the most
recent being "dignity in dying". An attempt to trademark that phrase has
so far been rejected by Companies House, apparently because it already
belongs to a funeral parlour! The real purpose of the proposed Bills ,
however circumscribed, is to cross the Rubicon of euthanasia killing of
the sick, and the introduction of a general right to suicide coupled
with a legal duty to provide the means. The lawyer at the centre of the
Dignitas clinic in Zurich has indicated that their ultimate goal is
death on demand.
In addition to the campaign to change the law, is another which takes advantage of the fact that public prosecuting authorities here and elsewhere turn a blind eye to those organisations which promote or facilitate suicide. You can buy a plastic bag designed to go over your head, for example. For a little more you can buy one with a fur collar!
So far attempts to establish a so called "right to die" have failed in the courts, the most noteworthy case in this country being that of Dianne Pretty which you may remember went through every level of appeal and finally went to Strasbourg. If you need clarity, that judgement established that there was no "right to die," least of all, by the hand of another.
Today I would like to examine some of the arguments that have featured in the current debate because the question is not going to go away and being ill informed or inactive in the face of such persistence could let it come in. Furthermore, each attempt in Parliament and the publicity it attracts, is itself a step down that road. Indeed a single judgement could legalise it or the reluctance on the part of the Crown Prosecution Service to bring prosecutions could change the legal climate. Some of us have been worried that the Law Commission's recent report on the Homicide law, which may well lead to legislation, could be "hijacked" on its way through Parliament, and used to legalise or downgrade so called "mercy killing".
The attitude of the media has become increasingly sympathetic and professional bodies like the BMA are expressing themselves "neutral" towards a change in the law. I attended the BMA annual meeting where this stance was adopted. A debate which largely went our way, was separated from the vote by two days and the vote was taken an hour before the close of the meeting when 40% of the delegates had gone home. The "neutral" stance was adopted by 11 votes from representatives of 150,000 doctors. Any attempt to reverse this is likely to be resisted by an influential clique, some of whom actually gave evidence to Parliament on behalf of the Voluntary Euthanasia Society. After a revolt by grass roots members the Royal College of General Practitioners and the Royal College of Physicians both have now changed their neutral stance to one of opposing Lord Joffe`s Bill. After a revolt by grass root members clique The Royal College of Psychiatrists have also said that they are "deeply worried" about the likely effects of such a Bill being enacted. These changes have come about because of resistance which is bubbling up from below, after officers flirted with the belief that such a law would come in.
What of the position of Government? Under the last Lord Chancellor the opposition of government was settled, but during the debates on Lord Joffe`s Bills they have adopted a neutral stance and say they are listening carefully. We fear that whilst outwardly neutral, some government departments are covertly supportive, and through the giving of parliamentary time, the government could allow a private member's Bill to pass on a free vote. This, you will remember, is how the Abortion Act was passed in 1967.
Until January of this year there was no broadly based organised opposition to the Bill, but an alliance of opponents known as Care Not Killing (CNK) has now been formed. It includes the Catholic Union of Great Britain and the Guild of Catholic Doctors. I trust that more Catenians will consider joining the Catholic Union under the presidency of Lord Brennan. In all 32 organisations are involved, including disability rights groups, palliative care associations, faiths bodies, and individuals. A few of you may have seen the CNK web site ( www.carenotkilling.org.uk ), or their DVD which was sent to all parishes.
Now there is also an All Party Parliamentary Group on Dying Well, but there remains a huge mountain to climb to reverse the present momentum towards physician assisted suicide and euthanasia. This is going to be a long haul, lasting for the life of this Parliament and beyond. In addition to opposing dangerous legislation, we need to be promoting the alternative of good palliative care, and working to win over public opinion.
Given that this a serious debate let us look at some of the basic principles.
Firstly we must all assume personal responsibility for our health. If truth be told, we often imprudently indulge in unhealthy habits, but at various times we may be called upon to make choices about medical treatments. In this regard our personal values and beliefs will come in and our decisions are rightly our own. This is autonomy based on principles and there is scope for us to decide which treatments we are prepared to accept or refuse. There will be some treatments where we think the benefits outweigh the burdens and are proportionate and acceptable in the circumstances.
Secondly we are likely to distinguish between ordinary and
extraordinary treatments and bear in mind that there is no moral
obligation to prolong life by any or every means. We are likely to
consult family members, doctors or increasingly priests and chaplains.
But we are aware that medical decisions effecting our own lives, may
well bear upon others and even the common good of society. Thus, there
can be no absolute autonomy over life and death. But it is this very
claim to have an absolute right to choose when and how we die, that lies
at the heart of the euthanasia argument. The essence of it is that this
is an assertion that such a choice is no different from any of the other
choices we make in life.
In arguing the contrary I can do little better than to quote from the judgement of the ground breaking case of Vacco v Quill, concerning medical suicide , and the ruling of the US Supreme Court;
"The State's interest goes beyond protecting the vulnerable from coercion; it extends to protecting disabled and terminally ill people from prejudice, negative and inaccurate stereotypes, and societal indifference."
Let us turn to the correct role of doctors. I place a trust in my medical advisors like many of you believing that they will never knowingly harm me. This state of affairs has not come about because of any superior morality on their part, but because of the ancient and respected ethic of "first do no harm". This concept is not a result of any particular religion, though it is supported by virtually every faith and jurisdiction, but has long been thought of as a given by the citizens of this country. That could change however as a result of the new culture which would follow the sanctioning of medical killing. It is argued by the proponents of assisted suicide, that doctors would still be playing a benign role and would be rendering one last service to their patient. For this society should offer them immunity from prosecution or even investigation.
But is this what would actually happen? Consider the great disparity in power between the sick person and the doctor. Who makes the diagnosis of terminal illness upon which such a fateful decision depend? Do doctors ever get things wrong? Well yes I'm afraid it happens, and it happens frequently. For example, there are many published papers which compare ante mortem and post mortem diagnosis . Leaving aside minor discrepancies, if the main cause of death is right in 75% of cases, that is considered a good result. There is an even greater difficulty over prognosis. Prognosis is notoriously difficult as the following case illustrates. In Oregon, under the Death With Dignity Act an application for lethal drugs can only be given if death is anticipated within six months . Prognosis, however, is only a matter of medical opinion. One patient in lived 18 months and eventually died naturally. This will not come as a surprise to many who will have had a similar experiences of unexpected survival amongst patients, families or friends.
To what extent then, will the doctor be held accountable for any mistaken diagnosis or prognosis? Well in fact, under the Oregon Death with Dignity Act, there are no prescribed penalties and no mechanism to ensure compliance with reporting requirements. Dr Katrina Hedberg, an Oregon health official, summarised the situation when she said referring to physician's reports;
"For that matter, the entire account could be a cock-and-bull story. We assume, however physicians were their usual careful and accurate selves"
So the doctor makes the diagnosis and the prognosis, reporting and compliance, are on trust. Is it any surprise that here is suspicion of the official statistics? Yesterday the BBC gave prominence to Joan Ruddock MP who claimed that the Oregon Death with Dignity Act was working successfully in the US. This is very far from being the case. One man took the drugs and then woke from a 60 hour coma. Where is the patient's autonomy, one may ask? The doctor gives his or her opinion, with greater or lesser accuracy, a vital decision is made, overdoses prescribed and there is no penalty for being wrong. Who really had the power in this situation? You may well ask who controls the doctors? Maybe if we put this question into the context of our own country, we should ask ; who employs the doctors? Professional and regulatory bodies aside, the answer is that the State employs them.
The recent intervention by the Department of Health, in the case before the High Court of Appeal of a competent but physically deteriorating patient, Mr Leslie Burke, made it quite explicit that resources was an issue. Anyone following the case, might have recognised that when the representative for the Department of Health mentioned the sum of over £1000 a day, this was actually the cost of a day in intensive care, but all that Mr Burke was asking for was a feeding tube and liquid nutrients given at home. Resources may not be explicit in the current parliamentary debates, but this case brings home something that anyone working in the NHS is only too aware of, namely the relentless downward pressure on costs. Decisions on costs are not necessarily applied by fiat from on high, it is much more subtle than that . There is team working , protocols and Guidelines drawn up by officials, which Trust Managers will be expected to see complied with if they want to qualify for their bonuses. In the end, economy will trump autonomy.
Let us also resist the idea that there can be only a little bit of killing, such as the 650 deaths a year mentioned by one peer. As the Anglican and Catholic Churches said in their submission to Parliament;
"A change in the law to permit assisted dying would also change the cultural air we all breathe, affects attitudes to older people and those with chronic illness. For example, the law permitting abortion has profoundly changed society's attitude towards the status of the foetus".
In truth, once such a cultural change has been brought about, there is no knowing how many people will die as a result.
At present the law rightly defends those who through illness or disability deserve special care and protection. It should also protect those who lose their mental powers and are unable to make decisions for themselves. It would be nice to say that the rights of the incompetent patient are always safeguarded, but there is an unwelcome shift discernible away from the sanctity of life ethic, to a different ethic which places more emphasis on quality of life.
In 1994 the House of Lords decided there should be no change in the law on assisted suicide and euthanasia and Lord Walton, chairman of the House of Lords Select Committee on Medical Ethics said;
"We concluded that it was virtually impossible to ensure that all acts of euthanasia were truly voluntary and that any liberalisation in the law in the United Kingdom could be abused. We were also concerned that vulnerable people - the elderly, lonely sick or distressed- would feel pressure, whether real or imagined, to request early death".
That conclusion still holds. If anything the history of the last 10 years has vindicated those wise words. In the Netherlands there is a code of practice for the euthanasia of disabled new-borns, and with regard to adults, the original boundaries have become eroded, and terms changed to include "unbearable suffering", both physical and mental. Nearly half of the euthanasia deaths are not reported as required by Dutch law, or falsely attributed to natural causes. There is, though, a certain deadly logic about euthanasia. It can be expressed as the question, "If it is in one person's best interests to be euthanased who has requested it, is it not also in the best interests of another person, similarly affected but who did not or could not request it." The logic is hard to resist, once the principle of euthanasia or assisted suicide has been accepted, voluntary will give way to involuntary in similar cases.
A disability rights group called "Not Dead Yet", was formed in the US and a British Group has just been established. It warns that a large part of the problem is that the media often conflates the terms "terminal illness" and "disability". Ms Jane Campbell , who is also a British Disability Rights Commissioner, spoke of terminal illnesses and disability being "so inextricably linked that the terms are interchangeable in the eyes of the public". Ms Liz Sayce of the Disabilities Rights Commission in her evidence to Parliament said;
"if assisted dying became legal, decisions could be made through the prism of the prejudice and inequality that does still pervade our society. Indeed far from giving disabled people autonomy it would increase disabled people's feeling of pressure from this culture and if euthanasia and assisted suicide were legalised, would be "coercion dressed up as choice".
As we have seen there are legitimate choices to be made on treatments at the end of life, but as the House of Lords Select Committee on Medical Ethics said in 1994 and after considering the evidence and arguments over legalising assisted suicide and euthanasia;
"The right to refuse treatment is far removed from the right to request assistance in dying. We spent a long time considering the very strongly held and sincerely expressed views of witnesses who advocate voluntary euthanasia....Ultimately, however, we do not believe that those arguments are sufficient reason to weaken society's prohibition of intentional killing. That prohibition is the cornerstone of law and social relationships".
Now I would like to turn to the very positive developments which, whilst originating in the very remarkable life and work of Dame Cecily Saunders, has inspired developments in palliative care here and abroad. For those who work in a hospice team, they find it rewarding. It is truly "life affirming", as Dame Cecily said. One important aspect is that it gives a proper regard to respecting persons and the life that remains to them. You could put it the other way round and ask, " how can you respect a person if you don't respect their life?"
We have a highly developed palliative care service in this country though it is still subject to the post code lottery and needs to be extended further into hospitals and the domiciliary setting. There are now a number of good models for this but much more needs to be done. Hospices still rely largely on charitable moneys though they are free and complimenting the NHS. In most NHS Trusts they are now being used for training of hospital nurses.
Those who are healthy now, who may not feel they could face a decline in health and powers do not necessarily feel the same as death approaches. Many people who answer questionnaires are really "the worried well". Time after time, surveys reveal a wish to live out one's natural span when actually facing the end of life. The true meaning of medical killing, implies that a person's life is no longer worth living. It is a but short step from that to saying, you are not worth treating, or that you are in fact worthless, and that chills the soul.
Cutting short a life for whatever reason, least of all because of human frailty or dependence, is neither an honourable thing nor a charitable thing. On the other hand, affirming human dignity, is recognising the essential inner spirit and inestimable worth of each unique person. It is not we that gives human beings their dignity, but rather our recognition of their God given dignity. The proponents of euthanasia talk of "dignity in dying " but that is a slogan designed deceive and to confuse the public who may think it is the same as the motto of the hospice movement which is well known to be "dying with dignity". When hospice patients ask for dignity and help they are not asking for euthanasia .
Finally, we need to step back and look at the wider picture. The present laws defending the vulnerable are adequate and offer real protection and apply to us all impartially. The real needs of the dying can be addressed at present. It is deeply misguided to propose a law by which it would be legal for terminally ill people to be killed or assisted to suicide by those caring for them, even if there are safeguards. To take this step would fundamentally undermine the basis of law and medicine and the duty of the State to care for and protect vulnerable people. It would risk a general erosion of values which over time would lead to cold financial calculations being made about the care of the old and the dying. It would result in many who may feel a burden to others to ask for death. The "right to die" would become the "duty to die."
Dr Tony Cole JP FRCP KSG
Chairman, Parliamentary and Public Affairs Committee
Union of Great Britain
With grateful acknowledgements to the Catena