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Battle over euthanasia

The debate in Britain about legalising euthanasia is moving into Parliament. The Tabletssistant editor explores the arguments

PARALYSED, doubly incontinent, unable to communicate except in grunts and frustrated howls ? nor able, at the end, to breathe independently ? this was Diane Pretty in the television documentary that followed the final days of her life. It was difficult to watch with anything but sympathy for her fight to ?die with dignity?. Two weeks before her death, the European Court in Strasbourg denied Pretty permission to commit suicide with the assistance of her husband, Brian. It was the end of a long legal battle that pushed the issue of euthanasia into the forefront of public consciousness.

Now, a year after her death, Pretty?s supporters, including her husband and the Voluntary Euthanasia Society (VES), have thrown their weight behind a private member?s bill to legalise euthanasia. On 6 June the House of Lords will have its second reading of legislation introduced by Lord Joel Joffe, a retired human rights lawyer. The law would allow adults ?suffering unbearably as a result of a terminal or a serious and progressive physical illness? to receive medical help to end their lives or, at their request, to have it ended by a doctor. The Patient (Assisted Dying) Bill has no government backing and is unlikely to become law unless that changes in the future. But its introduction is indicative of the gathering momentum behind the movement to legalise euthanasia. According to VES, which says the bill is precisely what it is campaigning for, public support of euthanasia has grown even stronger since January, when a motor neurone disease patient, Reginald Crew, travelled to Switzerland to end his life with a lethal dose of barbiturates.

In introducing his bill, Lord Joffe said that ?the Diane Pretty and Reginald Crew cases highlighted the pressing need to allow terminally ill, competent adults greater choice in the manner of their death?. The issue had, he said, ?been debated at length in the media, and every poll in the last decade shows over 80 per cent public support in favour of changing the law?. At a briefing in the House of Lords last week, Baroness Trumpington, a former health minister, said that she had not received one letter opposing the proposals to legalise euthanasia, but a flood of orrespondence supporting it.

But doctors are mostly opposed. The British Medical Association, which represents 80 per cent of them, has repeatedly debated physician-assisted suicide and euthanasia and consistently rejected legalisation. Some 74 per cent of doctors say that they would refuse to perform assisted suicide if it were legalised, according to a recent poll by Opinion Research Business.

The issue is fraught with legal and ethical complexities, but at the heart of it there are three questions: do human beings have the right to decide when they will die? If they do, does this include the right to involve someone else in implementing that decision? These first two questions can be debated endlessly. But the third question is a pragmatic one: is it possible to draw up laws that allow euthanasia while protecting those who are old, ill or disabled but do not want to die?

Lord Joffe?s bill attempts to provide safeguards. The parliamentary joint committee on human rights ? which examines the human rights implications of legislation ? endorses the bill because, it says, these safeguards make it compatible with the European Convention on Human Rights. Under the proposals, a competent adult who is either terminally ill or who has a serious incurable physical illness would need two doctors, one of them a consultant, to confirm their diagnosis, and prove that alternatives, including palliative care, had been considered. The patient would need to make a written declaration that he wished to die, which would then be witnessed by a solicitor. The bill contains an opt-out clause for doctors who would not want to help a patient die and an additional safeguard for the patient ? a waiting period after the request to die was made so that he or she could give more thought to the decision.

But these measures provide the vulnerable with nothing like sufficient protection, according to Dr Nigel Sykes, who works every day with the dying as medical director of St Christopher?s Hospice in London, a leading palliative care and research centre set up by the pain-control pioneer Dame Cicely Saunders. Indeed, Sykes believes that one of the bill?s main safeguards ? that an adult must be competent in order to qualify for assisted dying ? holds one of the greatest dangers because it opens the bill to criticism that it is discriminatory. ?What of incompetent patients?? he asks. ?I have patients who appear to be in pain; they can?t ask me for a painkiller but they benefit from painkillers. I suggest that it would be morally and logically indefensible not to progress to further modifications to the bill ? and to include non-physical illness too.?

These complexities lead Dr Sykes to the conclusion that, whatever people?s views on the morality of euthanasia, such legislation should not be passed. ?Once you legitimise euthanasia, morality dictates that you must gallop down that slippery slope as fast as possible?, he says.

The breadth of the bill, which does not require a patient to be terminally ill to qualify for assisted dying, also alarms him. ?One has become accustomed to euthanasia being linked to terminal illness ? but this bill is rather different?, he says. ?It talks about people with serious or progressive illnesses with unbearable suffering and doesn?t say whether this unbearable suffering can be alleviated by means other than death. By my measure this bill covers such illnesses as diabetes and rheumatoid arthritis.?

Nor does the criterion of competency satisfy Dr Tim Maughan, an oncologist who directs the Wales Cancer Trials Network at Cardiff University. More than 80 per cent of patients whose doctors assist them to die have cancer. Maughan says that he has seen most cancer patients go through a period of severe depression and, in a small number of cases, he has been asked by his patients to help them end their lives.

?And yet, in each case, if you look with the patient at their situation, talk to them about their relationship with their families and friends, they come to regret making that request,? he says. Lord Joffe?s bill calls for a psychiatric opinion if the physician considers the patient to be incompetent, ?but these patients are competent when they ask for euthanasia?, says Maughan. ?The point is that their desires are short-lived.? The bill does demand a ?waiting period? between the request for euthanasia and its implementation ? but the seven days required in the case of a terminal patient and the 30 days for a patient with a serious physical illness may not be enough for a period of depression to lift.

Lord Joffe?s bill states that a doctor attending a patient who requests euthanasia should ?be satisfied that his request has been made voluntarily and that it is not the result of external pressure?. But both Sykes and Maughan say that it would be impossible ever to be certain that this demand had been met.

?I am very concerned about those patients who feel themselves to be a burden, as many do in our burdened NHS and increasingly disjointed society,? says Maughan. ?They themselves want to live but they feel themselves a burden. There may not even be any pressure, but they feel a pressure. The bill would lead to great danger for the most vulnerable.?

He is also concerned by the impact of the bill on hospital staff; of the effect, for example, that it would have on the drive to find treatments for cancer. ?Some Dutch doctors have become immensely weary?, he says. (Euthanasia has been legal in Holland since 1990.) ?They feel: ?This is not what we became doctors to do.? I admit that sometimes when I go into a ward, I feel terrible for all the sick people around me. But when I go up to one of my patients and talk to them, I feel completely different. It is an extraordinary testament to humanity how people deal with the most difficult situations.?

In addition to the moral support that patients should ideally receive from their doctors, medication also makes a great deal of difference to patients? feelings about life and death. Palliative care professionals say that the demand for euthanasia invariably disappears when a patient?s pain is controlled. ?In fact euthanasia is a minority interest among people who are actually dying?, says Sykes.

It may indeed be that only a small number of people request euthanasia, and that those determined about choosing the time and manner of their death are a tiny minority. Nevertheless, VES says that such cases should not be overlooked. A spokeswoman for VES, Tamora Langley, cites the recent case of Robert and Jennifer Stokes, who were helped by a Swiss euthanasia group to die without any proof that they were terminally ill ? euthanasia is unregulated in Switzerland. The publicity surrounding the Stokes case, according to Langley, has encouraged other Britons to follow suit, hastening the need for ?a regulated and transparent? system of voluntary euthanasia. She says that voluntary euthanasia in any case takes place illegally in Britain.

But because of his experience of euthanasia in Holland Dr Peter Hildering, president of the Netherlands Physicians League, disagrees with this argument.

?In Holland, our legislation was made originally at the request of doctors who saw suffering they could not cope with ? patients for whose suffering there was no relief?, he says. ?It was said: ?Why don?t we pass laws that make euthanasia transparent and controlled by the Government??? But in Holland, he says, many cases of euthanasia are not because of unbearable pain. Often, waiting lists and family pressures play a part in the decision to die. So transparency would not be achieved by making euthanasia legal, only by investigating every death ? which is not feasible.

Euthanasia has changed Dutch society adversely, he adds. ?In many cases it has damaged the relationship between patient and doctor. In the last 15 years I have met many people in my practice who are scared of being admitted into hospital ? people are choosing to go instead to Germany for medical treatment.?

Hildering does not believe that good palliative care can exist where doctors have euthanasia as a possibility at the back of their minds, a concern that is echoed by Sykes. Palliative care in Britain, he says, is a well-established and growing area, but its funding is precarious; the NHS funds about 30 per cent of the costs of voluntary hospices, which have to raise the remainder through fundraising. ?If euthanasia is legalised, people will begin to think: What is the point of funding expensive hospice care??

Disability rights groups are also alarmed by Lord Joffe?s bill. Jane Campbell, commissioner of the Disability Rights Commission, a wheelchair user who has a neuro-muscular impairment, says that the lives of many disabled people are seen as inferior to the lives of the able-bodied. During a recent spell in hospital with pneumonia, a doctor told her it was assumed that she would prefer not to be put on a ventilator if she suffered respiratory failure ? a clear example of the risks that would face vulnerable people if Lord Joffe?s bill was made law.

In a recent paper on the dangers of legalising assisted suicide, Campbell wrote: ?While I would defend a person?s choice to end their own life, I could never accept the dangers that would attend the legalisation of assisted suicide and, if that means that a very small number of people are forced to live against their will, then so be it.?

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