Memorandum by the Christian Medical Fellowship
INTRODUCTION
The Christian Medical Fellowship (CMF) is an interdenominational
organisation with more than 4,500 members. The membership comprises
British doctors who are Christians and who desire their professional
and personal lives to be governed by the Christian faith as revealed
in the Bible. Members practise in all branches of the profession,
and through the International Christian Medical and Dental Association
are linked with like-minded colleagues in over 100 other countries.
CMF regularly makes submissions on ethical matters
to Government committees and submitted evidence to the 1993 Lords
Select Committee on Medical Ethics.[1]
We have also published widely on the subjects of euthanasia and
assisted suicide (please see our website at www.cmf.org.uk and
our CMF Files on Euthanasia[2]
and Assisted Suicide[3]).
We are grateful for this opportunity to comment on the difficult
issues raised by the Assisted Dying for the Terminally Ill Bill
and would be very willing to give oral evidence to the Select
Committee if invited.
Our submission is divided into two sections.
The first addresses our general concerns about the legalisation
of assisted dying. The second addresses specific elements of the
Assisted Dying for the Terminally Ill Bill. Our conclusion is
that euthanasia and assisted suicide should not be legalised and
that this bill should not proceed.
SECTION ONE
General concerns about the legalisation of assisted
dying
In the terms of the bill assisted dying means
the attending physician either providing the means to end the
patient's life, or if the patient is physically unable to do so
ending the patient's life. This bill if passed would therefore
legalise both assisted suicide and euthanasia. The arguments against
euthanasia and assisted suicide are essentially the same. We have
used the term "assisted dying" to encompass both practices,
and have outlined below our objections to the major arguments
in their favour.
1. THE ARGUMENT
FOR ASSISTED
DYING FROM
AUTONOMY
One of the major arguments in favour of assisted
dying is that of autonomy, the so-called "right to die".
We all value living in a free society but for society to function
there must be limits on individual autonomy. Rights need protection,
but must be balanced against responsibilities and the rights of
others. No person chooses assisted dying in isolation. Friends,
relatives, healthcare staff and society are affected by the wider
ramifications of the process. The effects of individual decisions
on others now living and on future generations must be considered.
Autonomy is never as uncomplicated as "my right to die".
Therefore although we recognise the importance of autonomy we
have the following concerns in relation to this bill.
1.1 The "right to die" will change
the role and vision of the medical profession
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.
Calls for assisted dying have been encouraged
either by the failure of doctors to provide adequate symptom control,
or by their provision of inappropriate interventions which neither
lengthen life nor improve its quality. This has understandably
provoked distrust of doctors by patients. However, legalising
assisted dying is not the answer to this problem. Patients' fears
of being kept alive by futile medicine will be replaced by the
fear of being killed prematurely without their consent.[4]
Rather what is needed is a relationship of trust, where the role
of the doctor is to assist the patient in being in control of
what happens. Patients want above all a doctor who will listen
to them, take their concerns seriously, explain the options clearly
and respect their wishes; a doctor who will strive to offer the
best care available. This is what lies at the heart of the doctor-patient
relationship. This is the way to calm patients' fears, and restore
autonomy.
1.2 The "right to die" will in reality
be the right to be killed and will increase the power of the medical
profession not the autonomy of the patient
In the Netherlands, some 30 per cent of euthanasia
requests are rejected by doctors on the basis that the patient's
suffering is not sufficiently severe.[5]
Conversely, approximately 1,000 deaths (0.8 per cent of the total)
are due to patients being killed against their wishes or without
explicit consent.[6]
The bill requires a doctor to make a judgement about the patient's
request. Ultimately it is the doctor's assessment of diagnosis,
treatment options, prognosis and the anticipated degree of future
suffering that is the decisive factor, not the patient's autonomy.
Assisted dying legislation makes doctors less
accountable and more powerful. Patients decide on the basis of
information given to them by doctors. However it can be difficult
to be certain in these areas; diagnoses may be mistaken,[7]
prognoses misjudged, there may be new treatments of which the
doctor is unaware, the doctor may not be up-to-date in symptom
control. Furthermore, doctors are human and subject to temptation.
Sometimes their own decision-making may be affected, consciously
or unconsciously, by extrinsic pressures and influences, such
as their own emotional state, discussion with family members and
the views of other health care professionals.
1.3 The "right to die" puts vulnerable
patients at risk
The law is always concerned to protect vulnerable
groups in our society. The Select Committee on Medical Ethics,
in its 1994 report, unanimously ruled that there should be no
change in the law.[8]
Lord Walton reflected on this in a speech to the House of Lords
on 9 May 1994:
"We concluded that it was virtually impossible
to ensure that all acts of euthanasia were truly voluntary and
that any liberalisation of the law in the United Kingdom could
not be abused. We were also concerned that vulnerable people—the
elderly, lonely, sick or distressed—would feel pressure,
whether real or imagined, to request early death."
This conclusion still holds.
1.4 The "right to die" simplifies
the difficulties in ensuring a decision is truly autonomous
Many patients with a terminal illness are vulnerable
and lack the knowledge and skills to alleviate their own symptoms.
They may well be fearful about the future and anxious about the
effect their illness is having on others. Their decision-making
may also be affected by depression, confusion, and dementia. There
are many anecdotal accounts of patients who, on admission to a
hospice, say "let me die", but are grateful that their
request was not acceded to once they have received effective symptom
relief.
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. As has been noted elsewhere, "A sense of
a duty to die is all too easy to create and all too difficult
to detect."[9]
These patients need to hear that they are valued and loved. 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.
In the 2002 study by Kelly et al[10]10
there is an acknowledgment that "the wish to hasten death
has been shown to be temporally unstable, raising concerns about
assisting a patient's request for suicide at any particular point
in their illness." Poor communication, lack of emotional
support from doctors and a concern that the patient was a burden
to others were associated with a greater desire for a hastened
death. Where these factors were absent there was a low likelihood
of a patient expressing an interest in an accelerated death.
The desire for death is most significantly correlated
with measures of depression in terminally ill patients.[11]
Yet nearly 80 per cent of psychological and psychiatric morbidity
in patients with cancer goes unrecognised and untreated.[12]
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—and that a patient's desire to die will often
decrease over time. 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.
1.5 The "right to die" is the "choice"
mainly of those who are well not those who are terminally ill
In Emanuel et al.[13]
60 per cent of the terminally ill respondents supported euthanasia
in a hypothetical situation involving others, but only 10 per
cent seriously considered euthanasia for themselves. Less than
4 per cent had discussed these interventions with a physician
or hoarded drugs for suicide and a very small minority of patients
took concrete action such as requesting assistance to die. The
paper concludes that patients' personal interest in assisted dying
is not a stable preference but may shift over time.
Interest in assisted dying is far less in the
terminally ill than in the general population (if surveys that
cite 81 per cent support for it amongst the public are to be believed[14])
and it cannot be assumed that a desire for assisted dying at one
point in time will remain as death actually approaches.
1.6 The "right to die" of the few
may open the door to a slippery slope that puts the vulnerable
at risk
The "slippery slope" is a contentious
issue, but we believe a real one. Human nature seems such that
it will push beyond what lawmakers originally intend. For example,
those who framed the 1967 Abortion Act did not envisage the abortion
on demand practices of the 21st century. Would a similar slippery
slope follow the legalisation of assisted dying? There is no evidence
to prove it would not. Without entering the philosophical debate,
we are greatly concerned by aspects of the Dutch practice of euthanasia.
Philosophically it is hard to limit assisted
dying to just those who are terminally ill. If relief of unbearable
suffering is the aim then why not extend it to other patient groups
who are suffering unbearably? To refuse assisted dying for patients
who are not terminally ill but with similar symptoms could be
seen as discriminatory. And why just limit it to patients who
can request assisted dying? Surely it would be "bad practice"
and "uncompassionate" to see someone suffering unbearably
but not to offer them assisted dying because they were unable
to request it themselves.
The Royal Dutch Medical Association (KNMG) and
the Dutch Commission for the Acceptability of Life Terminating
Action have recommended that active termination of the lives of
patients suffering from dementia is morally acceptable under certain
conditions. Two earlier reports from the commission affirmed the
acceptability of similar action for severely handicapped neonates
and comatose patients.[15],
[16]
A study of Dutch neonatal doctors showed that just under half
had assisted the death of a handicapped newborn child, despite
this situation being outside the euthanasia legislation.[17]
Case reports include a child killed for no other reason than it
possessed abnormal genitalia and a woman killed at her own request
for reasons of "mental suffering".[18]
Involuntary euthanasia will happen, regardless
of the intentions of the legislators. According to the first Remmelink
Report,[19]
there were over 3,000 deaths from euthanasia in the Netherlands
in 1990. More than 1,000 of these (0.8 per cent of all deaths)
were without an explicit request from the patient. The most recent
figures show that the problem persists.[20],
[21]
Furthermore, the lack of full reporting indicated in the third
"Remmelink" report is a major cause for concern and
would invalidate the reliability of any monitoring commission
that might be set up.[22]
1.7 Autonomy is not the real question—it
is the issue of compassion
If patient autonomy were the only yardstick
by which decisions are measured, assisted dying would effectively
be on demand. Furthermore we would agree that anyone who wanted
to die, for whatever reason, has the right to do so. Clearly it
is not just the desire to die but the suffering of the terminally
ill that is driving this debate—the argument is that it
is compassionate to end the patient's life if their suffering
is severe. This is no longer an argument from autonomy but from
compassion.
2. THE ARGUMENT
FOR ASSISTED
DYING FROM
COMPASSION
This argument accepts that killing can be compassionate
and thus changes fundamentally the values of our society and the
medical profession. In the UK we have had up to now a different
definition, based in the Judeo-Christian tradition, of what it
means to be compassionate: "to suffer with" (com-passion).
Our nation has prided itself on developing ways to care for the
terminally ill that have been envied the world over. Hundreds
of doctors from abroad every year come to see how British palliative
care has developed new and creative ways of relieving suffering,
restoring dignity and hope to the dying. This bill would undermine
the efforts of so many dedicated NHS and Hospice staff to continue
to provide the personally costly service of caring for the dying.
Advances in palliative medicine mean that many
of the unpleasant symptoms experienced during terminal illness
can be relieved or substantially alleviated. We acknowledge that
palliative care doesn't work for every patient. Experience in
the hospice movement has shown, however, that restoration of dignity
through creative care is possible for the vast majority.
Regrettably such a standard of care is not yet
available to every dying patient. The recent report of the Commons
Health Committee on palliative care recommended that more should
be done to develop palliative care and improve accessibility.
The disparities in regional distribution of services also need
to be addressed and effective training made more widely available.
A study of over 1,000 doctors, nurses and social
workers showed a negative correlation between willingness to endorse
assisted suicide and knowledge of symptom management.[23]
If assisted dying is legalised, the incentive for creative caring
will decrease. Additionally, where doctors do not have good knowledge
of symptom management, there will be an increased tendency to
see death as the "treatment" of choice.
The European Association for Palliative Care
has re-affirmed its opposition to the legalisation of euthanasia.[24]
If care is aimed at achieving "the best possible quality
of life for patients and their families" by focusing on a
patient's physical, psychosocial, and spiritual suffering, requests
for assisted dying are extremely uncommon. The answer is not to
change the law, but rather to improve our standards of care.
SECTION TWO
Specific critique of the bill
1. The definition of "terminal illness"
in section 1(2)[25]—does
it include only illness that despite treatment would result inevitably
in the patient's death within a few months (eg. disseminated cancer,
motor neurone disease etc), or does it include illness that would
result inevitably in the patient's death within a few months if
not treated (eg severe asthma, COPD, diabetes, many infections,
congestive heart failure, peritonitis, severe psychoses, some
chronic inflammatory conditions, anorexia etc)? A patient with
one of these latter conditions might argue that they did not want
to be treated, and that by virtue of then having a "terminal
condition" might request assisted dying.
The state of Idaho in 1977 passed a law defining
a terminal condition as "an incurable physical condition
caused by disease or illness which . . . shortens the life of
the patient." This could include almost any medical condition.
Dr Jack Kevorkian's definition was "any disease that curtails
life even for a day."
2. The definition of "unbearable suffering"[26]
is not objectively defined. Some patients find symptoms that most
consider tolerable to be unacceptable.
3. Section 7 introduces a legal obligation
for doctors with a conscientious objection to refer any patient
requesting assisted dying to doctors with no conscientious objection.
This amounts to forced complicity, and presumably those who refuse
to comply are thereby committing an offence under the Act?
4. Section 7(2), whereby an attending physician
who conscientiously objects, is obliged to refer the patient to
another attending physician makes a mockery of the definition
of attending physician given in the bill as the doctor who has
"primary responsibility for the care of the patient".
5. The fact that assisted dying can be carried
out on the authority of two doctors without any further review
or appeal until after the patient is dead (section 13(2)) virtually
ensures that anyone requesting assisted dying persistently enough
will eventually receive it.
6. Under the bill there is no need for the
four people involved in the assisted suicide process to have met
the patient before and only the solicitor and witness have to
satisfy themselves of his/her identity. The laxity of these provisions
will encourage the foundation of special clinics to streamline
the process, providing the requisite personnel and allowing completion
of the declaration in a single visit, with a further visit two
weeks later for the assisted dying procedure.
7. Psychiatric referrals (section 8) to
assess whether the patient is suffering from a psychiatric or
psychological condition causing impaired judgement are only required
under the Act if in the opinion of the attending or consultant
physician the patient may not be competent. But the attending
or consultant physician may lack the skill to assess competence
or impaired judgement, especially if the latter is secondary to
depression.
8. Doctors are protected from prosecution
under the Act (section 10(1-2)) if they are acting in "good
faith". In other words, if the doctor believes that he/she
is right in deciding that the patient fulfils the statutory criteria,
they cannot be prosecuted. This makes nonsense of basic legal
principles where the clinical or legal judgement of any doctor
must be subject to objective independent assessment and scrutiny.
9. All historical ethical codes (eg Hippocratic
Oath, Declaration of Geneva, International Code of Medical Ethics,
WMA Statement of Marbella) declare euthanasia and assisted suicide
to be unethical. It follows logically that all doctors who perform
or assist in either euthanasia or assisted suicide are in breach
of those oaths and declarations. Section 10(3) is therefore nonsense.
It also undermines the medical profession's right and responsibility
to regulate the behaviour of its own members in this matter.
10. Wilful falsification or forgery of a
declaration made with the intent of causing a patient's death
(section 11(1)) will in the main prove impossible to establish
because the key witness, the patient, will be dead. The same holds
for witness statements.
11. Section 12 will encourage patients choosing
assisted suicide or euthanasia in order to benefit their immediate
families. It will also place huge pressure on patients to request
early death in order that their families might benefit from insurance
money, rather than being faced with medical fees for ongoing care.
12. Sending a copy of the file to the monitoring
committee after euthanasia has been performed means that suspicious
cases cannot be investigated prior to the death of the patient.
Furthermore, section 16(1) gives the Secretary of State authority
to dispense with record keeping about euthanasia altogether.
13. The declaration form contains no place
for the signatures of attending and consulting physician.
14. Although this bill only seeks to establish
euthanasia or assisted suicide as a right for competent adult
patients, that may prove unsustainable. Once the Mental Capacity
Bill comes into law there will be nothing to stop a patient enacting
an advance directive for this "treatment option" should
they become incompetent and develop "unbearable suffering"
according to their own definition.
CONCLUSION
The above facts and arguments lead to the conclusion
that:
1. Euthanasia and assisted suicide should
not be legalised.
2. The proposed bill is fundamentally flawed
and would substantially change the way medicine is practised in
this country.
3. The bill should not proceed.
August 2004
1 www.cmf.org.uk/ethics/submissions/euth_sub.htm Back
2
www.cmf.org.uk/cmffiles/euthanasia.htm Back
3
www.cmf.org.uk/cmffiles/pas.htm Back
4
For example: Burke, R (on the application of) v The General Medical
Council Rev 1 [2004] EWHC 1879 (Admin) (30 July 2004). Back
5
Jochemson H and Keown J. Voluntary euthanasia under control?
Further empirical evidence from the Netherlands. JME 1999;25:16-21. Back
6
Onwuteaka-Philipsen BD et al. Euthanasia and other end-of-life
decisions in the Netherlands in 1990, 1995 and 2001. Lancet
2003; 362: 395-9. Back
7
Rees W et al. "Patients with Terminal Cancer"
who have neither terminal illness nor cancer. BMJ 1987;295:318-9. Back
8
Select Committee on Medical Ethics. Report. London: HMSO, 1994.
(House of Lords paper 21-I). Back
9
Baroness Finlay of Llandaff. Hansard[HL]; 6 June 2003 at 1599. Back
10
Kelly B et al. Terminally ill cancer patients' wish to
hasten death. Pall Med 2002;16: 339-345. Lord Joffe referred
to this research in his 2003 House of Lords briefing paper. Back
11
Chochinov HM et al. Desire for death in the terminally
ill. Am J Psychiatry 1995;152: 1185-1191. Back
12
Maguire P. Improving the detection of psychiatric problems in
cancer patients. Soc Sci Med 1985;20: 819-23. Back
13
Emanuel EJ et al. Attitudes and desires related to euthanasia
and physician-assisted suicide among terminally ill patients and
their caregivers. JAMA 2000;284: 2460-2468. Back
14
See for example www.ves.org.uk/publicopinion.html Back
15
Hellema H. Dutch doctors support life termination in dementia.
BMJ 1993; 306:1364. Back
16
Sheldon T. Judges make historic ruling on euthanasia. BMJ
1994; 309:7-8. Back
17
van der Heide A et al. Medical end-of-life decisions made
for neonates and infants in the Netherlands. Lancet 1997;
350(9073):251-5. Back
18
Dutch doctors pushed on to "slippery slope" over euthanasia.
Independent 1993; Wednesday 17 February p 8. Back
19
van der Maas PJ et al. Euthanasia and other medical decisions
concerning the end of life. Lancet 1991; 338:669-74. Back
20
Onwuteaka-Philipsen BD et al. Euthanasia and other end-of-life
decisions in the Netherlands in 1990, 1995 and 2001. Lancet
2003; 362:395-9. Back
21
Hendin H et al. Physician-assisted suicide and euthanasia
in the Netherlands. JAMA 1997; 277:1720-2. Back
22
Sheldon T. Only half of Dutch doctors report euthanasia, study
says. BMJ 2003; 326:1164. Back
23
Portenoy RK et al. Determinants of the willingness to
endorse assisted suicide. A survey of physicians, nurses and social
workers. Psychosomatics 1997; 38:277-87. Back
24
Materstvedt LJ. Palliative care on the "slippery slope"
towards euthanasia? Pall Med 2003; 17:387-92. Back
25
"terminal illness" means an illness which in the opinion
of the consulting physician is inevitably progressive, the effects
of which cannot be reversed by treatment (although treatment may
be successful in relieving symptoms temporarily) and which will
be likely to result in the patient's death within a few months
at most. Back
26
"unbearable suffering" means suffering whether by reason
of pain or otherwise which the patient finds so severe as to be
unacceptable and results from the patient's terminal illness. Back
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