There is nothing holy about agony: religious people and leaders support assisted dying too
BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n2094 (Published 09 September 2021) Cite this as: BMJ 2021;374:n2094Read our coverage of the assisted dying debate
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Dear Editor
The assertion proffered by Romain and Carey – that religious opposition to doctor-assisted dying “is not largely on theological grounds” and that “nothing in our religious texts opposes” it – is theologically flawed.
The Torah (e.g., Exodus 21:19) obligates us to care for those who are unwell, and the Talmud famously equates the saving of life with the saving of an entire world (Sanhedrin 37a). When faced with such tragic circumstances, Jewish law permits us to pray for a terminally ill patient to die in order to relieve their suffering, for while this expresses a compassionate human response towards others, the responsibility of deciding the moment of death firmly remains a Divine prerogative. God mandates that humans intervene to heal but clearly forbids taking a life (Genesis 9:6, Exodus 20:13 and Deuteronomy 5:17).
The authors state that the “God barrier has long been pushed aside both at the beginning and end of life, with humans acting in lieu of God.” There is no theological comparison between the creation of new life through fertility treatments, the saving and prolonging of life through medical intervention versus the premature active ending of life through doctor-assisted dying, irrespective of the actor’s good intentions.
We do not seek to impose our own view on others, respecting their right to self-determination. Neither do we doubt their compassion. But by attempting to rationalise doctor-assisted dying in theological terms even to relieve suffering, the authors have rooted their own moral anchors outside their faith traditions.
Competing interests: Rabbi Dr Moshe Freedman is a member of The Moral and Ethical Advisory Group (MEAG), which provides independent advice to the UK government on moral, ethical and faith considerations on health and social care related issues. He also trains Medical Examiner Officers (MEOs) and speaks at conferences for MEOs. He is writing in a personal capacity. Dr Aryeh Greenberg is an Associate Examiner at the General Medical Council. He is writing in a personal capacity.
Dear Editor,
It is not possible for modern medicine to guarantee a smooth, pain free, suffering/agony free, dignified natural or intentional death for all.
The characteristics and frequency of clinical problems with the performance of the intentional killing of a human being ( e.g. euthanasia and assisted suicide) are rarely discussed. The public, politicians and many professionals may not be aware of the possibility of complications and/or failure during the procedure to intentionally end a human life.
For all forms of ‘assisted dying’, there appears to be a relatively high incidence of vomiting (up to 10%), prolongation of death (up to 7 days), and re-awakening from coma (up to 4%), constituting failure of unconsciousness (1).
In the Netherlands, complications occurred in 7 percent of cases of assisted suicide, and problems with completion (a longer-than-expected time to death, failure to induce coma, or induction of coma followed by awakening of the patient) occurred in 16 percent of the cases; complications and problems with completion occurred in 3 percent and 6 percent of cases of euthanasia, respectively (2). The physician decided to administer a lethal medication in 21 of the cases of assisted suicide (18 percent), which thus became cases of euthanasia.
It is important the debate on this grave matter includes public discussion of the many clinical (e.g. above), technical ( e.g. difficulty finding suitable veins) and other problems (e.g. availability of lethal medications) that arise that may prevent the intentional death being dignified, agony/pain free etc.
A truthful debate requires all the facts.
1.Sinmyee, S., et al., Legal and ethical implications of defining an optimum means of achieving unconsciousness in assisted dying. Anaesthesia, 2019. 74(5): p. 630-637.
2. Groenewoud, J.H., et al., Clinical problems with the performance of euthanasia and physician-assisted suicide in The Netherlands. N Engl J Med, 2000. 342(8): p. 551-6.
Competing interests: No competing interests
Dear Editor,
Rabbi Romain and Archbishop Carey declare "...there is nothing in our bibles or prayer books that directly mentions this matter. " ( assisted dying )
Yet there is! "Thou shalt not kill" - Exodus ch20 v13. Numerous passages forbid and condemn murder and murderers. That mercy-killing is not "directly mentioned", as the authors seem to have wished, shows that there is no such exemption to this God-given Law which is inscribed in human conscience.
I notice that members of other Faiths (non Jewish and non Christian) have written in disagreement with Romain and Carey. I also know many doctors who profess no Faith and yet are opposed to assisted dying.
Abraham Cutajar
Competing interests: I care about living and dying well
Dear Editor
As the Islamic/Muslim view was not seen or published among all the responses regarding Assisted suicide, and as we have about 3 million British Muslims and 20 000 Muslim doctors in the UK (2 billion Muslims in the world), I believe it is fair to put the missing Islamic view in a new updated Muslim response to Assisted suicide.
We Muslims are in support with the Jewish teacher before Gabriel Y Cohn and the recent Christian Catholic physician Thomas Caroll (14 Sept) in his sensible Christian remarks and response on suffering.
Obviously first we would like to express our horror and disgust as believers in the same one GOD among the 3 Abrahamic faiths – Judaism, Christianity and Islam -- to hear about the new unethical inhumane decision of the BMA recently to stay neutral on Assisted suicide !
This is a slippery decision, no doubt, and preparation for the legalisation of Assisted suicide!
It is a fact the 3 Abrahamic Faiths all share the same Pro-life view on the sanctity of human life.
Allow me first to give the basic Islamic pro-life beliefs and practices according to the 2 basic Islamic Holy Scriptures: AL QURAN and the SAYINGS and ACTIONS of the final Prophet MUHAMMAD (peace be upon him):
-LIFE IS SACRED
-GOD Started life ...and GOD only will end a human life
-GOD, our Creator is the only Owner of every one's life.
-The end of every one's life is fixed by GOD the Creator and not by the patient or the doctor or the judge/court or the Parliament
-We all are ordered to submit to the Creator and to die in the natural way...without human interference
-No one should rush his/her own death
-Severe punishment/hell is for anyone "playing GOD" by killing himself/herself (suicide) or by getting any help from a doctor or relative to end his/her own life(Assisted suicide)
Now please allow me now to mention some of the Islamic Holy Scriptures which are clearly against suicide/assisted suicide/attempted suicide and euthanasia.
First - Few VERSES FROM THE QUR'AN WHICH DO PROHIBIT SUICIDE:
In the Name of GOD (Allah), the Most Compassionate the Most Merciful
"DO NOT KILL YOURSELVES, FOR VERILY ALLAH/GOD HAS BEEN TO YOU MOST MERCIFUL"
(chapter 4, verse 29)
"....TAKE NOT LIFE WHICH ALLAH HAS MADE SACRED"
(chapter 6, verse 151)
"AND (ALLAH) IS THE ONE WHO GAVE YOU LIFE, THEN SHALL HE ORDAIN YOU TO DIE, THEN SHALL HE GIVE YOU YOUR LIFE AGAIN, TRULY MANKIND IS UNGRATEFUL"
(chapter 22, verse 66) .
Second: A SAYING OF THE FINAL PROPHET MUHAMMAD (peace be upon him):
"Whoever purposely throws himself(herself) from a mountain (or high building) and kills himself(herself), will be in the Hell Fire falling down into it and abiding therein perpetually forever.
And whoever drinks poison (like drugs/Overdose) and kills himself(herself) with it, he will be carrying his poison in his hand and drinking it in the Hell Fire wherein he will abide eternally forever.
And whoever kills himself(herself) with an iron weapon (knife/gun..), he will be carrying that weapon in his hand and stabbing his abdomen with it in the Hell Fire wherein he will abide eternally forever".
All types of Assisted suicide/Suicide and Euthanasia (voluntary or non-voluntary, direct or indirect, active or passive) are prohibited in Islam (as stated by the European Muslim Council for Ifta/Islamic ruling and Research).
Finally, we would like to explain the many pressures/reasons/risk factors which “push" our innocent vulnerable patients to ask for Assisted suicide
These are:
-Suffering and pain
Today we have a lot of new modern medical treatments which will alleviate and take away most pain. Besides, GOD Almighty will take away all the sins when one is suffering
There is nice saying in the UK: Kill the pain, not the patient.
-Having a chronic continuous medical problem affecting one's ability to do his/her own's things
This is because of the medical profession today’s failure in preventing or treating well, the medical problem or disease
Perhaps some doctors do feel guilty about their failure when they see the patient frequently in the same bad medical condition or in pain and feel USELESS, helpless, and unable to offer any more help
So, the easy way out: get rid of the patient.
Muslims strongly believe that for every disease there is a cure
As stated, before by the final Prophet MUHAMMAD (peace be upon him)
(is HOPE THERAPY TOO)
-The GUILT feeling in the patient himself/herself as he/she feels to be A BURDEN on the family the NHS or on the society as a whole
We need badly to address and take away this dangerous feeling and pressure
-Problems in the relationship with one's family
-The presence sometimes of SUB CLINICAL DEPRESSION which unfortunately is missed and undiagnosed by doctors
-Doctors who, contrary to all medical ethics, are involved in assisting the patient to end his/her life and be killed...are really betraying their own medical Hippocratic Oath “to protect and save life and do no harm."
-No doubt the major reasons among doctors and patients and some Bishops today is the lack of a strong Religious belief in the Sacredness of human life and that only GOD the Creator is the Owner of one's life with the lack of awareness about the coming serious severe punishment by GOD in the afterlife to all those who challenged the full Authority of the Creator, GOD, who is the only OWNER of human life
Any Muslim committing suicide or Assisted suicide to end his/her life will go to the hellfire as mentioned before
All the above risk factors/causes are likely to “push” and pressurise many patients to try to end their life if Assisted suicide is legalised
Sincere caring medical doctors should address and prevent all the above reasons/causes which will make our innocent vulnerable patients ask for Assisted suicide.
DR MAJID KATME
Retired psychiatrist
Ex-President Islamic Medical Association/UK
Competing interests: No competing interests
Dear Editor,
It's a long time since I attended Sunday school, so I looked it up to be sure. I can confirm there's definitely something in the Bible about not killing people.
Competing interests: I am alive
Dear Editor
Not withstanding the quote from Ecclesiasticus and its consequent argument, I am compelled to counter it with the ‘Disability Paradox’ concept and my 30 years of experiences of enduring, awe-inspiring, resilient holiness in scores of people with disability including e.g. people with spinal cord injury who live all their lives with incontinence. I cannot speak for them but as their doctor, this headline ignores their experiences. I am told that leading disability rights groups (including Inclusion Scotland, Disability Rights UK, Scope and Not Dead Yet) oppose changing the law. I can see why.
Except for one patient (who subsequently changed their mind), in my 30 years of close and long interactions with permanently and severely disabled patients in three countries, none of my patients have opted or requested this of me. Indeed, I hold the greatest admiration and respect for their zest for life. Even the ones who do not see the point of long life have held back from wanting to take their own lives for many reasons - the commonest being their love for family. Changing the law will affect how disabled people view their own worth, and how they are viewed by others. We should be valueing their heroism, asking them to teach us and our children endurance and fortitude.
A positive alternative has been tried in the Highlands: a small effort informally called ‘Plus One’ in the Highland Hospice had been very helpful in offering longer term neuropalliative care (not just in the last few months or weeks of life) and users were reassured of sufficient health and social care support and it became very popular with my patients (till Covid restrictions stopped it).
Yours sincerely
Dr A. S. MacAden
Ref
BMJ 2021;374:n2094
Albrecht GL, Devlieger PJ: The disability paradox: high quality of life against all odds. Soc Sci Med. 1999, 48: 977-988.
Competing interests: No competing interests
Dear Editor,
The very title of this essay ignores 2000 years of Catholic Teaching. There is, in fact, something very holy about suffering. Indeed, paragraph 1505 of the Catechism of the Catholic Church states, in part, "By his passion and death on the cross Christ has given a new meaning to suffering: it can henceforth configure us to him and unite us with his redemptive Passion."
While former Archbishop Carey and Rabbi Romain may disagree, this headline and article completely ignore the ancient and consistent Teaching of the Catholic Church and, by extension, the belief of nearly 1.3 billion or so of their fellow human beings.
Sincerely,
Thomas Carroll
Competing interests: No competing interests
Dear Editor
I was rather concerned about the misleading title of this article: it should really be entitled some leaders support assisted dying too as clearly so many do not.
Although it is written in the book of Ecclesiasticus that "There is a time to live and a time to die", the last words in that book urge the reader to follow God's commandments. The most famous commandments are the ten commandments and this emphatically states that one should not kill.
Yours sincerely,
Anne Pauleau
Competing interests: No competing interests
Dear Editor
Rapid Response to: ‘There is nothing holy about agony: religious people and leaders support assisted dying too’[1]
The representatives of ‘a new religious alliance in support of doctor assisted dying’ have stated that they wish to counter ‘the impression being conveyed that all faith groups are implacably opposed to changes in the law to help people longing to die on their own terms, without discomfort, indignity, or extreme pain.’
The Church of England does not oppose enabling people to die well; that is a goal shared with every palliative care professional, hospice worker and healthcare chaplain. Its opposition is to a change in the current law on assisted suicide.[2]
This distinction is not a matter of semantics; it is a legal imperative.
The writers assert that on this issue, Church leaders are out of touch with their members and cite opinion polls to that effect. The arguments for and against assisted suicide are complex and cannot be addressed in an opinion poll. The Church of England debates serious issues with serious intent, not least through its elected, representative bodies at deanery, diocesan and national level. The General Synod has voted unequivocally, to oppose a change in the current law on assisted suicide.[3] Correctly, policy is decided by informed debate, not by opinion polls.
The appeal to Biblical ‘proof-texts’, employed by the authors is not indicative of Anglican hermeneutics in which a respectful, reasoned reading of the texts illuminates the narrative and theological arcs and motifs contained in the Scriptures. From these (not proof-texts), emanate core beliefs and principles.[4] These principles reflect Christian theological beliefs, but can be shared by people of other faiths or of none.
In the context of this brief response to the authors’ article, the principle of caring for the vulnerable requires considered examination though it is also the case that any shift in the law or societal norms that undermines our egalitarian commitment to the intrinsic value of every human life or anything that lessens our relational and societal bonds with one another is deeply flawed.
The authors speak of ‘safeguards’ to ensure that vulnerable people are not put at risk and reference the provisions of the ‘Meacher Bill’. Safeguards on paper, however, are worthless unless they can be consistently, universally and comprehensively translated into practice.
It is a tragic irony that on the day the authors’ article was published, News headlines were dominated by the deaths of three vulnerable adults in Care.[5] In spite of every written policy, protocol, and approved practice, their reality was tragically different.
These were not isolated incidents; we have only to think of the hundreds of avoidable deaths in the Mid-Staffs hospital scandal[6], abuse of residents with learning disabilities in Eldertree Lodge[7] and ‘systemic biases contributing to unequal mortality outcomes in ethnic minority women and women facing multiple problems and deprivation’.[8]
We can add to this, the recent experience of many elderly care home residents in the early months of the COVID-19 pandemic who were given DNACPR notices without proper protocols being followed.[9]
Human lapses and failings build upon one another until catastrophic outcomes ensue…a process that, in too many instances, no amount of assumed monitoring or paper safeguards has been able to capture, never mind stop.
What can possibly give us confidence that similar safeguards will provide a better outcome if the law on assisted suicide were to be changed?
The authors point to the experience of the Oregon Death with Dignity Act, but Oregon gives us no grounds for confidence at all. Far from being a model of good practice (as is often claimed), over twenty years of experience in Oregon indicates, inter alia, an alarming failure to maintain rigorous reporting and monitoring information[10], failure to pursue adequate psychiatric evaluation[11] and failure to evidence physician presence at ingestion.[12]
The authors stress the need for uncoerced consent to be gained before any process begins that might lead to an ‘assisted death’, but it is not possible to ensure that this can be consistently and effectively guaranteed for vulnerable, terminally ill people. The charity Hourglass (formerly Action on Elder Abuse) affirms that some 500,000 elderly people are neglected or abused in the UK each year[13], often for financial reasons.[14] It is naive in the extreme to believe that some of these would not fall prey to pressure to end their lives prematurely if the law were to be changed.
The authors state that ‘there is nothing holy about agony’. While many Christians might suggest that the crucifixion of Jesus indicates otherwise, it is essential that people are given high quality physical, mental and spiritual care at the end of life…and most are. Some 600,000 people die each year in the UK[15] and while every instance of suffering is tragic, mercifully very few die in the sort of ‘extreme pain’ that lies at the heart of appeals to change the law on assisted suicide[16]. Better palliation, not assisted suicide, should be our goal.
We must acknowledge that there are many vulnerable people involved in any discussion of end of life care: those who wish to end their lives, their families, healthcare professionals, those who wish to live, but who are prey to covert or overt pressure…all of us who live with the consequences of changes in societal mores.
Sadly, it is not possible to meet the aspirations of all and we have to face that fact openly and honestly.
In such circumstances, we must act to protect and care for as many vulnerable people as fully as possible. The aspirations of a very small number of individuals seeking a change in the law, whose needs and concerns are nonetheless genuine, must not endanger the very large numbers of people who will be put at grave risk by any such change. In failing to pass previous ‘Assisted Dying’ Bills, both Houses of Parliament have recognised this.
We must not gamble with vulnerable people’s lives in the hope that somehow, against all evidence to the contrary, we will get it right this time.
[1] BMJ 2021;374:n2094
[2] Why the Church of England Supports the Current Law on Assisted Suicide. https://www.churchofengland.org/sites/default/files/2017-11/Assisted%20S...
[3] https://www.churchofengland.org/sites/default/files/2018-01/item%208_Feb...
[4] McCarthy B, Hilborn M, Hill M, Newcome J. At the End of the Day: Church of England perspectives on end of life issues.2014
[5] https://www.theguardian.com/society/2021/sep/09/vulnerable-patients-deat...
[6]Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (The Francis Report). 6th February 2013. https://www.gov.uk/government/publications/report-of-the-mid-staffordshi...
[7] https://www.cqc.org.uk/news/releases/cqc-publishes-report-staffordshire-...
[8] Limb M. Disparity in maternal deaths because of ethnicity is “unacceptable”. 18th January 2021. BMJ 2021;372:n152
[9] CQC Review, Protect, respect, connect – decisions about living and dying well during COVID-19. 15th April 2021. https://www.cqc.org.uk/publications/themed-work/protect-respect-connect-...
[10] Oregon Public Health Division, http://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH...
[11] Examining the Impact of ‘Death With Dignity’ Legislation A Conversation With Charles D. Blanke, MD, FACP, FASCO. 25th March 2017. http://www.ascopost.com/issues/march-25-2017/examining-the-impact-of-dea...
[12] Ibid.
[13] https://www.thenationalcareline.org/AccessingHelp/ActionOnElderAbuse
[14] https://www.wearehourglass.org/financial-abuse
[15] https://www.statista.com/statistics/281488/number-of-deaths-in-the-unite...
[16] Zamora, B., Cookson, G. and Garau, M., 2019. Unrelieved Pain in Palliative Care in England. OHE
Consulting Report, London: Office of Health Economics p.10. https://www.ohe.org/publications/unrelieved-pain-palliative-care-england
Competing interests: No competing interests
Re: There is nothing holy about agony: religious people and leaders support assisted dying too
Dear Editor,
The former Archbishop of Canterbury George Carey and Rabbi Jonathan Romain’s essay is both misleading in content and condescending in tone.
It is misleading; the declaration that “there is nothing holy about agony” deliberately ignores the central figure of Christianity, the Lord Jesus Christ himself. He suffered the kind of agony that very few others will have to face at death. There are no pat answers to the mystery of human suffering but I, like millions of Christians through the centuries, draw immense comfort from the fact that Jesus knows what it is to suffer, and can therefore sympathise with us at the very deepest level. This goes for suffering of all kinds and at all stages of life, not just the last few months.
Furthermore, they declare, “it is our duty to use our God given abilities as much as possible. We could argue, therefore, that assisted dying is part of the constant act of playing God”. In this the authors confuse the communicable attributes of God, such as being loving, creative and just, with the non-communicable attributes, such as his sovereignty, omniscience, and eternal nature. We do not have God’s perfect knowledge, wisdom and goodness; it is therefore not for us to decide when we die.
It is condescending in tone; Lord Carey and Rabbi Roman make it sound as though the Bible is either best left to ‘faith leaders’ to interpret what it says, or that the Bible is ambiguous regarding God’s commitment to the value of human life and wellbeing. I find it extraordinary that the authors claim so boldly that the Bible has so little to say on these most basic questions of life and death. May I encourage anyone tempted to leave it to those in powerful positions to tell them what the Bible says to simply take a look for themselves? The Bible is not a collection of proof texts to be volleyed to and fro across the floor of the debate. Rather it is (amongst other things) a beautiful account of a Creator God of awesome power and of extraordinary love who cares about the individual concerns of all people. It is available in almost any language in the world making it easier than any time in history for anyone to see for themselves what the Bible has to say about life, death and in fact almost any other kind of human experience.
Yours faithfully,
Dr. Joanna Ulley
Specialist Registrar in Geriatric Medicine
Competing interests: No competing interests