Assisted dying
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e4075 (Published 13 June 2012) Cite this as: BMJ 2012;344:e4075
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In her editorial about assisted dying Fiona Godlee argues that legalization is a decision for society, not for doctors. Obviously she is right that the legislative power in society is not held by doctors. Thus it will not be up to doctors to make the final decision about legalization. However, Godlee makes a – literally – fatal error in her reasoning. The fact that doctors might be forced by a democratic process to accept assisted dying as a part of health care does not justify neutrality on the issue. The ethical standard of our profession cannot be dictated by the general population. Rather we should as a profession defend life, promote the advance of comprehensive palliative care and oppose the view that dependence implies lack of dignity. A profession dealing with life and death needs a solid ethical basis which is not subject to changing views in the population. If we as medical professionals fail to take position on the important ethical issues we become mere executioners of public policy. History provides repeated examples of societies where doctors have failed to adhere to professional standards and instead blindly followed the dictates of power. Such mistakes must not be repeated. As medical professionals we must build our ethical code on some unchanging truths, one of which is that doctors should neither kill patients nor assist in suicide. Adhering to sound professional ethics cannot be combined with neutrality on assisted dying. Following the line of thought demonstrated by Godlee would not only lead to acceptance of assisted dying. If we as doctors blindly follow the view of the public majority we will over time be left without a professional code of ethics.
Competing interests: The text is written on behalf of the Norwegian Christian Medical Association
In her editorial dedicated to the question of so-called “assisted death”, Fiona Godlee (1) proposes, with particular delicacy and notable balance, an essentially equidistant position between the attitudes of those who have for some time been arguing the legitimacy of such an approach to the patient, and those who on the other hand have insisted on its impossibility: for Godlee, legislators should resolve the question once and for all and the healthcare professionals should remain neutral, avoiding involvement in this theme of multitudinous moral implications, with varied and contrasting understandings.
Not without purpose, Godlee suggests parallels to the debate that took place prior to the introduction of the UK Abortion Act, in distant 1966. We note how on this argument she in essence simply follows in the footsteps of Thomas More, who in Utopia foresaw a future legislated scenario in which “magistrates and priests” would exhort the suffering and incurably ill to “abandon this earth” (2).
In any case, we hold that the proposed “neutralist” view deserves refutation under other considerations.
First, while uninformed on British events of 1966, but having first-hand experience of what took place in Italy ten years later, we do not believe that one can trace parallels between abortion and euthanasia. Yes, at least apparently, in both cases there is the conflict of the right to freedom (of the woman or the patient) with the right to life (of the unborn or the patient himself). But in fact, in the one case, the right to freedom, although perhaps sometimes limited by conditions of vulnerability (of financial or social nature), is still exercised by a person (the pregnant woman) who is fully autonomous, while in the second case the right to freedom would be invoked by a person not only rendered vulnerable by illness and suffering, but also at that point deprived of effective autonomy; who in the final phases of an existence debilitated by illness, has become dependent on the others who offer assistance at the level of his most essential acts (eating, getting dressed, washing, etc.).
In the first case, retrospectively, it is almost certain that the current of thought favourable to abortion had centred its argument on the right of women’s self-determination, in the conviction that the choice of interrupting pregnancy (a choice often much suffered, and thus vulnerable) could in practical fact be taken by the woman alone, and thus only the lack of formal (legal) recognition of the full autonomy of the woman could, up until that time, present an obstacle to the full expression of such right of freedom.
Yet in the second case, can we be so certain of the actual “freedom of expression” of the terminally-ill patient?
Whoever has read Dependent Rational Animals, by Alasdair MacIntyre, can well understand how much the fact of vulnerability and, above all of dependence, can present an obstacle to liberty in self-determination (3).
It appears still more debatable to call for the adoption of neutrality, almost as if the medical world need not take interest in the theme of so-called “assisted death”, instead requesting that all decisions be made by the law-makers.
The “euthanasia question” has accompanied the practice of medicine since its earliest days. And the answer, since earliest times, has not in the least been neutral.
In fact, in the Hippocratic Oath (5th century BC), we read: “I will neither give a deadly drug to any one, even if asked, nor suggest any such counsel”.
“Primum non nocere” (First, do not harm!): the objective of medical practice, for all times.
How could such a precept ever be reconciled with so-called “assisted death”?
The answer will be – or rather already is: “but you’re just blocking the wishes of a patient who doesn’t want to suffer!”
And here we enter into a dialectical fiction: meaning treatment of pain (and/or the anguish of living), we attempt to substitute provision of death.
But it is one thing to give a drug with the intention of treating pain, with the side-effect – never originally sought – of shortening the patient’s existence (primum non nocere), and another to administer it with the exclusive aim of provoking rapid death, even if it is collaterally painless.
This is not morality in play here; it is the nature of medical practice itself.
It was Epimetheus (the everyman), not Asclepius (a doctor) who closed – late as it was – Pandora’s box, leaving only the spirit of hope entrapped within: something we could never again offer the patient if the legislator Epimetheus were to close the box of suffering, applying the lid of assisted death.
And it isn’t only the nature of medical practice that is in play here.
The independence of the physician is also in play: both in respect to the patient, before whom everything must give, including the non-harmful nature of our art, and under the laws of the nation.
Here we could cite the WMA’s resolution on euthanasia, adopted at the 53rd General Assembly in Washington, 2002, which indicates “the firm conviction that euthanasia is in conflict with the fundamental ethical principles of medical practice”, and encourages all national medical associations to abstain from participating in euthanasia, even if national laws permit or do not sanction it.
But in our judgment, such a call is insufficient: a doctor cannot be a mere enactor of the will of the state, being able or, more truthfully, sometimes obliged to put the interests of the individual patient before those of the state. In fact, the 2002 declaration calls on the physician not only to abstain, or to cite conscientious objection, but to attempt to change the law.
Finally, we might accept the principle that the physician, confronted by legislated intervention on the theme of so-called “assisted death”, could only accept to apply the law. But at that point, what right would we ever have in the future, to resist the imposition of a state that, in carrying out the death penalty, requires the presence of a doctor to assist in the lethal injections? (4)
References
1. Godlee F. Assisted dying. BMJ, 2012; 344: e4075;
2. More T. Utopia. 1516; II, 5;
3. MacIntyre A. Dependent Rational Animals: Why Human Beings Need the Virtues. Chicago: Open Court, 1999;
4. Tanne J H. US anaesthesiologists are told not to take part in executions by lethal injection. BMJ 2010; 340: c2432.
Competing interests: The authors work in a Catholic institution.
Could we have a little more integrity in the debate about assisted dying please? Dr Wong expresses "great sympathy" for individuals with unrelievable suffering such as Tony Nicklinson, as did many of the speakers in this week's BMA debate. But as Tony Nicklinson tweeted in the Observer, are they "seriously telling me that I must sacrifice my life for the common good?" Do they "seriously ask me to accept that intelligent people who can work out how the universe began can't devise a few simple rules to that those who need protection get it while those like me get assistance?"
Of course there are solutions, and to ignore them is not showing sympathy but cruelty.
Graham Winyard
Competing interests: No competing interests
It's unsurprising that the poll on whether doctors' organisations should stay neutral produced such a strong no vote.
Firstly, many of those strongly opposed to assisted dying saw this as a vote on assisted dying itself. I know this because I was at a palliative care conference a few days after Fiona Godlee's editorial and several people said to me “I see that the BMJ has come out in favour of assisted dying.” The subtlety of the argument was lost on many people.
Secondly, those who are opposed to assisted dying are very passionate and well organised.
This passion and organisation are probably the main reason why we don't have a law on assisted dying when we know that 80% of the population support it. I was at the Southbank death festival when a member of the audience asked a policy expert on assisted dying why we not only didn't have a law but also why the issue is rarely debated in the House of Commons.
The expert said that MPs heard a great deal from those opposed to assisted dying but little from those who support it. The MPs prefer to stay away from the subject, seeing it as vote loser.
If we are to have a law on assisted dying those in favour will have to get themselves much better organised.
All this reminds me of the debate over fluoride. Very few have managed to match the passion and organisation of the small number of people opposed to fluorididation of the water supply.
Competing interests: I was the editor of the BMJ and support a change in the law on assisted dying.
With reference to Tony Delamothe's analysis of the poll, just to point out it is not necessarily so that individuals are voting more than once as more than one person may be using the same computer. I share mine at times so with topics of shared interest and opinions it could seem incorrectly that an individual is voting several times (whether to agree or disagree).
Competing interests: No competing interests
In a poll that ran on bmj.com from 14 June to 25 June 2012 the voting was as follows:
Should doctors' organisations be neutral on assisted dying?"
Yes: 1137 (17%)
No: 5455 (83%)
Of the total 6592 respondents, some 72% were from the UK; we don’t know the proportions of doctors and non-doctors among them. Although the poll software is meant to prevent this, there were a few examples suggestive of single individuals voting multiple times. The most extreme example was someone who voted “No” 168 times (and “Yes” just once) from two Icelandic IP addresses.
The breakdown of responses by day (table) suggests the existence of campaigns to get supporters of both sides to vote. For the first 6 days the “No” vote averaged 64%, with a few per cent daily variation. However, on 20 June the “No” vote dropped to 28%.
The next day ten times as many people voted, almost all of them voting “No.”
The average for the first six days of the poll is therefore probably closer to the “true” result.
Competing interests: I conducted further analysis on the results of the poll. I believe that the law on assisted dying should be changed.
I do not understand why putting patients to death could ever be a part of a doctor's remit. Killing patients is the antithesis of our morals, our aspirations, our skills and knowledge. The technical process of IV cannulation can be learnt by anybody. If legalised termination of life ever became a reality I suggest an alternative profession (the judicary or funeral directors) take up the post or a new profession be developed (a mortician ?). It has nothing to do with doctors and as already mooted, can only harm our relationship with our patients.
Competing interests: No competing interests
"Nuper erat medicus, nunc est vsipillo Diaulus:
Quod vispillo facit, fecerat et medicus" (1)
"Recently, Diaulus was a doctor. Now he is an undertaker.
What he does as an undertaker, he used to do as a doctor".
Reference
1. Martial, Epigrams, I d.C.; 1.47.
Competing interests: No competing interests
In Dr Godlee’s editorial, she has highlighted that the recent poll commissioned by Dignity in Dying found that 62% of 1000 GP surveyed has supported neutrality on the issue of assisted dying, but did not seem to give as much weight to the survey of doctors’ attitudes on euthanasia and physician-assisted suicide done by Professor Seale in 2009 (Ref 1), which sampled a much broader spectrum of doctors, including neurologists, specialists in care of the elderly, palliative medicine and other hospital specialties, which showed that 65% doctors surveyed are against assisted dying.
It is true that the decision to changes in law with respect to assisted dying rests with the society and the parliament. However, it has been shown that despite repeated lobbying by the pro-assisted dying groups, we are nowhere near to legalising assisted dying, as shown by the defeat of Lord Joffe’s Assisted Dying for the Terminally Ill Bill in 2006 (which is closely modelled on the Oregon Death with Dignity Act), the defeat of Margo MacDonald’s End of Life Assistance (Scotland) Bill in 2010, and the endorsement of the DPP policy on assisted suicide. This is precisely because the law exist to protect the vulnerable, and it would be extremely difficult (if not impossible) to set up adequate safeguard to ensure that patients are protected adequately.
I respect personal autonomy and individual’s right to self determination, and have great sympathy for patients with terminal conditions who are suffering from unrelievable pain, be it physical or psychological. I also have great sympathy for Tony Nicklinson, the gentleman with locked-in syndrome who is campaigning for the right to die. However, as a member of society, I think there should be a limit to an individual’s choice when it has profound impacts on others. Changing the legislation to allow for physician assisted dying will have a wide impact on society, particularly a negative impact to the terminally ill and disabled. For those who have not entertained the idea of committing suicide, the legalisation of assisted dying may make the sick and vulnerable feel obliged to choose this option for the wrong reason, such as for financial reasons or for feelings that they are burden to their family or society and create a lot of anxieties. Furthermore, if we use individual’s right to self determination as one of the principle arguments for allowing physician assisted dying, there will invariably be cases whereby patients who are not terminally ill but have chronic conditions that cause them to suffer unbearably would also seek doctors help to end their life. We would be in real danger of the slippery slope.
Should assisted dying be legalised, it would be necessary for doctors to play a fundamental role in the process, be it assessment of the patient, prescribing a lethal medication or overseeing the suicide of the patient (and to deal with any complications that arises from botched suicide). One of our underpinning professional code is to ‘do no harm’ to patients. Patient entrust their health and life to us. If our role as doctors encompasses any form of intentionally killing of patients, it can irrevocably damage the doctor-patient relationship, and erode the trust given to us. It may have a particularly negative impact on vulnerable patients and make them fearful of seeking medical help from doctors. Therefore I think it is irresponsible for us to take a neutral stance on such an important matter.
Reference:
1. Seale C. Legalisation of euthanasia or physician-assisted suicide: survey of doctors’ attitudes. Palliat Med2009;23:205-12
Competing interests: No competing interests
Dying With Dignity - the fundamental questions
Due mainly to public health measures, but also to advances in medicine and therapeutics, people on average are living longer in real terms (there is a statistical skew here which I won't go into). But this has raised another set of issues.
Living longer has allowed people to hopefully enjoy the fruits of living longer but has presented other problems, especially if one is not in good health. Living longer does not necessarily mean living better—especially not at the end of life and especially not when one is "living" with terminal illnesses, experiencing intractable pain, unable to breathe independently, unable to cope with the psychological stress of continuing and constant dialysis treatment, in a vegetative state, with loss-of-self to advanced Alzheimer's, or even deteriorating breathing ability resulting in suffocation due to amyotrophic lateral sclerosis (ALS, Lou Gehrig's disease).
In these circumstances, isn't it time to stop and ask the question whether one's life is more important than the quality of one's life? This question raises the far more provoking question as to whether people should have the right to "opt out", to bring about their own deaths and, if so, when? This then raises the even more provoking question of who facilitates it, by self or with the help of others.
Next is the question of who has control over any person's life? Who has control over your life? This raises the issue of autonomy. Is not the principle of autonomy—an individual's right to determine their own life path—central to any understanding of basic human rights?
If you wish to take your life, it is yours to take and you have the right to end it. A society may make the taking of one’s life illegal, but what is society to do if one does so? Is the state going to prosecute a dead body?
But, what if you can no longer physically take your own life, but you still have the full mental capacity to make the decision that it is time to leave this world? What, as in the case of a suffering infant, one does not have that capacity? Should others be empowered to help? But who should be empowered to help? Should a physician, or a panel of physicians, or a state panel, be empowered to supply an appropriate means to an individual wishing to terminate their life, who may not even be fully competent, to make the decision to "opt out"? But why place an onus on physicians or others for what should be an autonomous decision if one is capable, or a public health question if one is unable to do so for themselves?
However, these questions typically yield a cacophony of competing voices, fueled by ethical, moral, religious and personal beliefs. Observing these questions from a world-wide perspective, the number of people asking these questions and seeking solutions is exponentially expanding. Many pressures are being placed by social, political, and economic forces on people seeking answers to these questions and relief for their concerns.
Who and/or what is right?
Leonard Bernstein, DMD, MPH
Competing interests: No competing interests