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EDUCATION AND DEBATE: Yvonne Y W Mak, Glyn Elwyn, and Ilora G Finlay Patients' voices are needed in debates on euthanasia BMJ 2003; 327: 213-215 [Full text]

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Patient dilemma in discussing euthanasia

John Parfitt   (28 July 2003)

Spurious premises

Philip S Jones   (5 August 2003)

Patient dilemma in discussing euthanasia 28 July 2003
John Parfitt, None; retired librarian; patient BS14 8SZ Send response to journal: Re: Patient dilemma in discussing euthanasia	The authors argue that voluntary euthanasia should not be legalised until more research has been done; but British patients dependent on medical care, aware that their doctors and nurses may be accused of murder if they are suspected of hastening death, will scarcely be anxious to raise or discuss the topic with them. We know that euthanasia takes place in this country, but as long as it cannot be discussed openly medical investigators are unlikely to discover patients' true feelings and wishes, especially if the illness does not involve severe pain under which the doctrine of "double effect" might be held to apply. One way to advance the study of the social & personal effects is to consider the experience of members of a society similar to our own in which voluntary euthanasia is legal and in which a good quality of palliative care is available. Your article on the Dutch experience shows that there is a continuing demand there for voluntary euthanasia, mainly among cancer sufferers, unaffected by the availablity of palliative care and psychological counselling. Competing interests:   None declared
Spurious premises 5 August 2003
Philip S Jones, SpR in Anaesthetics St Andrew's Centre for Burns and Plastic Surgery Send response to journal: Re: Spurious premises	EDITOR - In Mak et al's article (1), the preamble cites the arguments opposing euthanasia, most of which do not stand up to scrutiny. First comes the warning that doctors should strive to "relieve suffering, not end the life of the sufferer". These actions are not, in fact, mutually exclusive, as any vet might tell us, but even if we suppose that they are, there is no reason why doctors should be the ones to terminate life. We are not trained, or motivated, to end lives; this is irrelevant to the issue of whether euthanasia should be legal. I agree that the "will to live often fluctuates widely during terminal illness". Few advocates for euthanasia would advance criteria that included anyone in this category, however, and the authors' wording suggests that this observation is by no means universal. It is difficult to see why a factor that excludes some terminally ill patients from euthanasia should necessarily exclude everyone else too, regardless of how fervently and consistently they express the desire for death as a release from their suffering. The argument that euthanasia cannot be securely enforced is a tacit admission that euthanasia is justified on some occasions, but should be blocked just in case it is used inappropriately. The law is clear that competent patients may exercise their autonomy in refusing life-saving treatment, including in the form of an advance directive, and in the setting of terminal illness there is no reason that similar clarity should not apply to requests to die. Finally we hear the familiar argument that "excellent palliative care obviates the need for euthanasia". Apart from the fact that euthanasia may incorporate the essential elements of excellent palliative care, this ignores a number of circumstances. Not all terminal conditions are physically painful, and therefore palliable with, for instance, strong opioid analgesia (one is reminded of Diane Pretty), and such patients are denied a pharmacological basis for hastening their end thanks to something as arbitrary as their diagnosis. Cook argues in the same issue that the law, as it stands, prevents her from being relieved of her suffering at the time she will need it most (2). For some patients' views to be discounted in an article that purportedly seeks to give patients a greater say is rather mystifying. Was I alone in gaining the impression that patients can give any answer they wish on the subject of euthanasia, provided it is the answer that their doctors want to hear? 1 Mak YYW, Elwyn G, Finlay IG. Patients' voices are needed in debates on euthanasia. BMJ 2003;327:213-5 2 Cook L. Law needs to be changed to allow terminally ill people choice of a dignified death. BMJ 2003; 327:225-6 Competing interests:   None declared