Time for change
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7518.681 (Published 22 September 2005) Cite this as: BMJ 2005;331:681All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Mr Braithwaite's assumption that the current law on euthanasia needs
changing because it stops doctors from "helping" their patients to take
the final step with physician assisted suicide, is fundamentally flawed.
The Doctor-Patient relationship is the cornerstone of practice of
medicine, which is based on trust, that the doctor seeks to do good to his
patient, not harm. Legalisation of assisted dying will present legalised
killing as a potential good rather than a fundamental harm for the first
time. It will establish killing as a viable ‘therapeutic option’ that, if
deemed valid in some cases, will need to be considered in all cases. This
will fundamentally change the whole ethos of medicine.
As a profession, and as a society, we have always seen the wish to
die, for example in the suicidal person, as a cry for help, an indication
that something is wrong that needs to be addressed. The medical profession
has been built on seeking ways to relieve suffering, treat illness and
preserve life; to restore dignity and hope. This bill changes the role of
doctors and the doctor-patient relationship by introducing the option of
doctors killing their patients.
Moreover, many elderly people already feel a burden to family, carers
and a society which is cost conscious and short of resources. They may
feel pressure, real or imagined, to request assisted dying. They need to
know that we, as doctors and as a society, are committed to their well
being, even if this does involve expenditure of time and money.
The desire for death is most significantly correlated with measures
of depression in terminally ill patients. [1] Yet nearly 80% of
psychological and psychiatric morbidity in patients with cancer goes
unrecognised and untreated. [2] It is important that efforts are focussed
on addressing these issues in patients. The debate about assisted dying
must recognise the importance of psychiatric conditions, which are
potentially treatable. While we recognise that certain mental stresses are
not treatable – existential angst, loss of dignity, fear of the dying
process – these factors are not medical as such, and do not warrant a
‘medical’ solution in the form of assisted dying. The spiritual and
emotional nature of these issues may require the input of people from
outside the medical profession. Doctors cannot be expected to be pastors
and counsellors; they are not necessarily equipped to address the many
needs behind a patients expressed wish to die. Allowing them to kill
patients is not the answer to that problem. As professionals and society
we need instead to get on with the task of working for that genuinely
‘gentle and easy death’ all patients deserve. Pope John Paul II showed us
what real ‘death with dignity’ means: facing the end with courage, hope
and serenity with balanced medical intervention and effective palliative
care.
The proposed bill is fundamentally flawed and would substantially
change the way medicine is practised in this country. The law should not
be changed.
[1]Chochinov HM et al. Desire for death in the terminally ill. Am J
Psychiatry 1995;152:1185-1191
[2]Maguire P. Improving the detection of psychiatric problems in
cancer patients. Soc Sci Med 1985;20:819-23
Competing interests:
None declared
Competing interests: No competing interests
Editor-
This year the BMJ has joined the assisted suicide debate with a cover
(24/9/05) emblazoned with a Raymond Briggs-esque cartoon of two elderly
stereotypes gratefully shuffling their aged bent bodies into the rosy
light of extinction. The caption in large font below this image poses the
question: “time to legalise assisted dying?” (as opposed to less
attractive wording, assisted self-killing) and places the cover image in a
context sympathetic to the thrust of MA Braithwaite’s article “Taking the
final step”1
The arguments for euthanasia are not novel despite their repeated
presentation, nor are they convincing because the cost of euthanasia as
ever, remains too high. On the other hand, Palliative Medicine is a new
attempt to positively address terminal suffering with a healing approach
(i.e. alleviation) in the absence of cure (i.e. fix). Championed in the
early 1960’s by the late Dame Cicely Saunders2, it addresses human
terminal distress in ‘total suffering’ terms and supersedes the medical
model to include the physical, psychological, social and spiritual aspects
of a persons being. The person is given a unique value because they exist
and not for any other attribute. The despair that almost everyone feels on
dying is acknowledged and attenuated.
Even the most sceptical of pro-euthanasia proponents would not deny the
significant inroads palliative care has made into improving quality of
life and relieving all the dimensions of human terminal suffering. The
euthanasia movement hold twin underlying assumptions that are rarely
clearly expressed. (1) Palliative medicine must provide total alleviation
of all suffering in all terminal care patients (tenable in no other branch
of clinical care) and (2) suffering is always devoid of any positive
outcome. This is not to imply whatsoever, that suffering is to be
tolerated or underestimated, but rather to recognise that it is in the
struggle to overcome suffering that patient’s carers and clinical
professionals become the people we all have the potential to be.
Braithwaite’s article reports the often quoted argument “respect for
personal autonomy”. This so-called ethical pillar3 is frequently produced
as an unimpeachable “carte blanche” in complex ethical situations.
Autonomy rarely, if ever, exists in a vacuum and remains intertwined with
the self determination of others. At the end of our lives we certainly
have our own autonomy to consider, but also that of our carers, our
society, and yes – even that of our physicians. Realistically, despite
initial stringent safeguards, the demand for “autonomous” assisted suicide
will eventually deteriorate into an invasion of that most personal
autonomy of all – the right to exist. Neither is it reasonable to expect
that euthanasia should remain the prerogative of the terminally ill. There
are many with chronic debilitating illness, psychiatric illness, mental
and physical handicap who would have equal claim to self extinction if
euthanasia were adopted. How will euthanasia on demand impact on the
development and future funding of these specialist areas of medical care?
Euthanasia will not remain only for a select few, but will inexorably
extend to the many.
In the fiction ‘ Fahrenheit 451’ the writer Ray Bradbury proposes a
dystopian future where firemen, who for decades had displayed a vocational
calling to extinguish flames, are now called upon by society to start
fires in piles of banned literature. The tenuous logic behind such
thinking is paralleled here, where a spurious reasoning supposes that a
doctor who has devoted years of training in the preservation of life will
have simultaneously developed the expertise of a painless executioner and
would therefore be the perfect candidate for the job. The majority of
doctors will never comfortably don the mantle of assisted death
technician. Medicine has at its core a strict philosophy, elucidated
initially by pragmatic Greek thinkers who realised that any society
embracing euthanasia would eventually erode the healing practice of
medicine. Hence, that other ethical pillar, nonmaleficence, was wisely
afforded a respect even higher than beneficence. “Above all, do no harm.”
With Palliative Medicine we have a chance to take an evolutionary leap
forward into a heightened regard for the uniqueness of human life (and
death) and to challenge the human despair that can come with a terminal
prognosis. In recent times, mankind with evil intent has indulged the
expediency of ‘euthanasia’ for the mentally ill, handicapped and the
unwanted. Let us reflect, before well intentioned argument drags us into
repeating history again so soon.
1. Branthwaite M. Taking the final step: changing the law on
euthanasia and physician assisted suicide. BMJ 2005;331:681-683.
2. Clark D. Cicely Saunders Founder of the Hospice Movement Selected
Letters 1959-1999: Oxford University Press, 2005.
3. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. Fifth ed:
Oxford university press, 2001.
Dr Donal Martin,
Regional Consultant in Palliative Medicine,
Health Service Executive (North West Area)
Dept of Palliative Medicine,
Letterkenny General Hospital,
Letterkenny,
Ireland.
Competing interests:
None declared
Competing interests: No competing interests
Branthwaite twice cited respect for autonomy and twice cited loss of
autonomy as arguments for legalising euthanasia for the terminally ill
(1). In my opinion, these are mutually exclusive arguments and neither is
valid. Firstly, if we are to respect autonomy, all we have to do is step
back: true autonomy does not require the permission or assistance of
others. Secondly, a person who has lost autonomy does not naturally aquire
an authority over others that an autonomous person lacks, such as the
authority to instruct representatives from society (doctors who are
willing and satisfied to perform the task have been suggested) to help
kill them.
I personally don't believe that Branthwaite is convinced by either of
her own arguments. Why else would she have singularly failed to develop
them properly? Her real argument actually appears to be that euthanasia
should be legalised because some “determined people” with “fervent wishes”
and who are used to “indulgence” and “being in control of their lives”
want it. Such people are referred to five times in her article. If they
require approval and assistance to achieve their goals, then they might be
strong-willed but they are certainly not acting autonomously.
Rather than suffering from intractable physical symptoms, data from
Oregon shows that people requesting assisted death are typically
accustomed to being in control of their lives and have lost some of their
autonomy, dignity and ability to participate in enjoyable activities.
However, helping them to die instead of helping them to restore enjoyment
and dignity to their lives strikes me as highly dismissive of their real
plight as articulated by them, and it is possibly the ultimate
disrespectful response to their existential anguish. The only autonomy I
can see in assisted death is that of the doctor in deciding whether or not
to help kill.
1 Branthwaite MA. Taking the final step: changing the law on
euthanasia and physician assisted suicide. BMJ 2005;331:681-683
Competing interests:
Hospice doctor
Competing interests: No competing interests
I was unaware of DIPEX until I read Dr Chapple's letter but having
visited the website, I would urge others to do so. 17 cases are presented
in the 'Living with dying' section. However, for those without the luxury
of semi-retirement, I have reviewed and categorised the opinions of the
DIPEX patients. I excluded four cases involving the carers of patients -
mainly with dementia - because they do not tell us what the patients
themselves might have thought about voluntary euthanasia/assisted suicide
(VE/AS). (Though in my experience, most members of the Voluntary
Euthanasia Society would not want to be kept alive with well-established
dementia.)
Only two patients are definitely opposed to VE/AS. Both cite the
doctrines of their (unspecified) churches as the main reason. One believes
that palliative care will always porevent severe pain; the other believes
that good can come out of suffering.
Three patients say that VE/AS is a very complex issue and they find
it difficult to decide but one gives it her reluctant agreement and though
clearly very religious, feels that God would not want some people to
continue living in pointless suffering. Another, though worried about
possible abuses, would nevertheless like the option for himself.
The others are in favour of legalising VE/AS.
The patient who was sure that palliative care would defeat severe
pain would probably be right most of the time, though pain is far from the
only thing that can distress the dying or those with nasty progressive
illnesses. However, I am amused by the Hospice Movement's recent
enthusiasm for 'terminal sedation' as a way of dealing with the relatively
small number of cases of truly intractable pain.
First of all, intractable severe pain does not necessarily occur only
when patients are likely to die in a few days or weeks. A cousin of mine,
paralysed by spinal metastases but far from terminal, was morphinised to
death over a couple of days in a hospice. This was, I am sure, fine by her
(and me) but what is the ethical, philisophical or legal difference
between sedating someone to death over two days and doing it over 20
minutes? None at all, I think. It is merely a difference of style and
aesthetics. And of course, it allows the 'double-effect' devotees to claim
that it wasn't the morphine that killed her, it was the pneumonia.
Secondly, if death is an unfortunate, unwanted 'double effect' of
giving high doses of opiates, then surely - if it really is 'unwanted' -
these patients should be intubated and ventilated to prevent their
premature death? Especially if, like my cousin, they could probably have
survived on a ventilator for several months. Terminal sedation is
euthanasia and to pretend otherwise is ludicrous. Furthermore, it must
often prevent patients and their families from making their formal
farewells, as many would like to be able to do.
I could go on but I hope I have at least encouraged BMJ readers to
look at the DIPEX website for a patient's-eye view of this old medico-
philosophical chestnut.
This contribution is not submitted for paper publication.
Colin Brewer MB.MRCPsych
Competing interests:
None declared
Competing interests: No competing interests
Editor:
Have no doubt that the legalisation of physician-assisted suicide and
its almost inevitable sequel, euthanasia, will place our most vulnerable
members of society in great jeopardy.
There are an articulate, intellectual, few members of society at
present who are determined to persevere in the mistaken belief that
autonomy taken to its extreme, overrides all other considerations.
For many people and the families of people, the consideration of
death as a possible outcome of an illness or an admission to hospital is
unacceptable. Perhaps this is just a reflection of increased expectations
fuelled by the media and internet. Doctors are implored constantly to
find another treatment option even with the knowledge that the disease
process is unresponsive and active treatment has failed. Patients and
families with terminal illness more frequently require treatment to be
continued even in the face of futility. Many patients now forgo the
opportunity of good palliative care in a mistaken belief that its
acceptance will prevent opportunity of offer of a “miracle” cure. Carried
to an extreme, this prevents patients and families making appropriate
choice of place of care at the end of life.
It is odd therefore that at the same time as this change in our society
that we are progressing towards the legislation for euthanasia.
With increasing longevity there will be increasing numbers of elderly
people needing care at a time when our economy is already stretched and
the working population is shrinking. Many of these patients will have
dementia or reduced capacity for decision making. Many patients in
residential or nursing homes at present do not have the capacity to even
choose which television channel they are exposed to when the residents are
placed around a screen theoretically to provide “stimulation”, much as the
television has become a childminder for the very young but this time in
the interest of “education”.
Are these frail elderly patients able to participate meaningfully in
decisions about the end of life? As physicians, we are probably unaware of
coercion and bulling of elderly patients within families - how are we to
know whether pressure has been applied to patients? Are we ready to accept
euthanasia as a common cause of death as in Holland? It would certainly
make economical sense when there is no longer the capacity in our
hospitals and nursing homes. Are we as a civilised society prepared to
stand by and allow the passage of legislation which will give authority to
a solution reminiscent of Hitler’s Germany where the most vulnerable were
killed, a process which also allowed for destruction of people deemed to
be unacceptable by the ruling body?
I suspect many people who request euthanasia do not have any
conceptualised vision of what it actually entails. Has anybody dared to
publicise the exact details of the process to the public from decision
making to the delivery of the lethal dose of medication? Perhaps many
patients would like to believe that at some unspecified time, without
warning a doctor would slip something into their night time cocoa and
they would not wake in the morning! The reality needs to be publicised.
I have, as a Palliative Care Physician, in twenty years only encountered
one patient who has persisted in a request for euthanasia and have met
several who have banded around the topic for discussion but have not
wanted further exploration following the introduction of good symptom
control. Of course, there are inevitably the perceptions of families of
patients suffering and the frequent quotation “ if he were my dog he would
not be allowed to suffer” – but suffering is subjective and even in what
is perceived as a “good death” ( a comfortable and peaceful passing ) by
professionals will not be described by the family as good , as no death
is good and they suffered too.
Our medical profession is rapidly changing. It is no longer the norm
for patients to be known by their GP as a family doctor or see the same
doctor in outpatients or even at the bedside with shift patterns, now for
more than two or three occaisions. How are patients going to trust the
medical profession if they are aware the healers can also be available to
end life?
Part of the physician’s role is to develop trust to enable communication
of total pain – be it physical, spiritual, emotional or social - are we
as physicians willing to throw away the most precious and rewarding part
of our honoured position - our relationship with patients.
As the late Dame Cicely Saunders promised, that even if there is nothing
else to be done – just staying with the patient is all that is asked of
us.
Assisting patients to die or practising euthanasia is not part of the code
under which I wish to practice medicine.
Susan P Closs, Consultant in Palliative Medicine
Morriston Hospital
Swansea NHS Trust, SA6 6NL
susan.closs@swansea-tr.wales.nhs.uk
Competing interests:
None declared
Competing interests: No competing interests
The medical euthanasia lobby should reflect upon the lessons of
history and societies unknown future. Every doctor in the UK has been
adversely affected by the actions of one clinical fool, Shipman. Perhaps
he started by thinking he was doing the right thing with his first child
death in Pontefract (ref 1) and grew to like the misplaced medical power
of death.
The Nazi technology of eugenics and death camps began with a medical
rationalization by post First World War German Psychiatrists faced with
rationing medical resource in mental asylums (ref 2). They justified
their asylum euthanasia with the judgement of “a life unworthy of a life”
in mental defectives and their medical procedure was high jacked by the
3rd Reich. How will doctors respond to the demographic time bomb and the
new genetics with medical killing in our therapeutic options and societies
future resource dilemmas?
Finally, how will we respond on a Saturday night in A+E? Will it be
the 3rd or 4th overdose when we decide that clear intent to suicide has
been expressed without mental illness and be unable to justify infringing
on that personal right with a resuscitation attempt?
Yours sincerely
Dr James D M Douglas
MD, FRCGP, FRCP Edin. DOccMed
References
1 The Shipman inquiry – Sixth Report www.the-shipman-
inquiry.org.uk/finalreport.asp
2 Burleigh, Michael. Death and Deliverance - ‘Euthanasia’ in Germany
- Cambridge University Press 1994 : P11-42
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
We have read with interest your recent article by Branthwaite, who
suggests that a change in legislation is needed. We also see that in
response to that article many professionals argue against a change in the
law. We believe that those facing death themselves, as well as other
patients, should influence future debate. The DIPEx (Personal Experiences
of Health and Illness) website, www.dipex.org, now has a section called
“Living with Dying”. Follow the “Talking about” section to a summary
called “Suicide and euthanasia”. There you can see a summary of what
people, who defined themselves as having a terminal illness, had to say
about euthanasia and assisted dying. You can listen to what they had to
say and in some cases see a video recording of part of the interview.
Yours sincerely, Alison Chapple
Competing interests:
The author is a member of the DIPEx steering group
Competing interests: No competing interests
Dear Sir
The incremental change in attitude to euthanasia and physician
assisted
suicide does not bode well for the vulnerable, the profession or society ,
and
“pro” lobby propaganda should be viewed with great concern. A key aspect
of
our profession is trust, which underpins the relationship with the
patient, their
family and other team members.
When patients are nearing the end of life
the foremost priorities are the relief of suffering with the avoidance of
unnecessary interventions, and these principles underpin good clinical
practice. Occasional well publicised scenarios concern us all, but the
principle of “difficult cases make bad law” holds good and the prompt to
legislate in this area should be opposed. The inadequate verification and
policing seen in the Dutch experiment reflect , in part , the corrupting
influence of power with policy being progressively eroded. We should not
follow this road! As a geriatrician with 20 years experience I feel the
profession should not be party to the promotion of permissive legislation
in this area and that existing guidance acts in the best interests of
patients and their families.
Yours sincerely
William R Primrose
Consultant Physician FRCP
Competing interests:
None declared
Competing interests: No competing interests
We wish to express our profound concern with the biased, pro-
euthanasia stance of this 'Education and Debate'.
This was not a balanced debate, with 4 pro-euthanasia articles versus
one anti-euthanasia article. This has confirmed our longstanding suspicion
that the BMJ is a pro-euthanasia organization, but is afraid to say so
outright - the stance that dare not speak its name - covertly indicating
its approach in a biased selection of articles.
In contrast the Royal College of General Practitioners has now
dropped its 'neutrality' position, and has now indicated that a change in
legislation on assisted dying for the terminally ill is not needed.
In the 1930's Hitler's euthanasia policy was greatly aided both by
German doctors' failure to provide moral leadership and a government media
campaign . The refusal of some German doctors to participate in the
euthanasia programme was accepted, provided they did not speak out
againast it (1). Indeed, euthanasia in Germany was probably only brought
to a halt by a courageously - worded denunciation in August 1941 written
by Bishop Clemens von Galen (" the Lion of Munster") (1).
Historical parallels with attempts to bring in legal controls on
abortion in the 1960's in the UK have not restricted terminations of
pregnancy as was hoped. The "slippery slope" is all too real.
Such proposed legislation on assisted dying wil prevent the further
development of Palliatve Care, for which the UK is the acknowledged world
leader. It will also delay the urgent transfer of Palliative Care
expertise to the large numbers of non-cancer patients who so badly need
it.
We will never be involved in assisted dying or euthanasia, and will
continue to use and support the development of the excellent (but
underfunded) Palliative Care services.
Yours sincerely,
Joseph O'Neill (General Practitioner)
Averil Fountain (Consultant in Palliative Medicine, North Cheshire)
References:
1. Taylor,J & Shaw, W. The Dictionary of the Third Reich,
Penguin, London, 1997: p91
Competing interests:
None declared
Competing interests: No competing interests
Educate the Young about Dying
British Medical Journal
"Time to legalise assisted dying?"
My contribution to the debate on the Joffe Bill:
Dear Sir/Madam,
"Assisting patients to die or practising Euthanasia is not part of
the code under which I wish to practice medicine" concluded Susan Closs'
letter to the editor dated 4th October 2005. I would want to sincerely
believe in the code of practice of the medical profession and therefore
find legislation inappropriate.
Just imagine one day when your body wants to die, because you do not
have a life, which is self-supporting, your physician will be able to
decide to administer the lethal dose and furthermore determine the date of
your death? Do you want to live or die on your birthday, the physician
would ask you? Do you really want the medical profession to be in control
of your death and make that choice? The answer is no.
Surely it is time for change, but change of a different kind, for
family education and for family members to learn how to care during the
process of a close relative dying. If society supports and finances
maternity leave, society should also promote serious illness/compassionate
leave on equal terms. We know more and more about keeping our body young
but the challenge in future will be the need to educate the young about
dying.
We need a forum of people with knowledge of caring and an open
discussion on caring for the dying patients and not assisting patients to
die.
Yours faithfully,
Renate Wright
Mother, catholic of the parish of Saint Mary of the Angels
Competing interests:
None declared
Competing interests: No competing interests