Select Committee on Assisted Dying for the Terminally Ill Bill Minutes of Evidence

Memorandum by The Medical Ethics Alliance

  1.  The Medical Ethics Alliance is a coalition of medical and nursing associations of Hippocratic and World Faith medical bodies. It seeks to promote debate within and without the profession on health care matters. The following reflects our collective view formed over some time. Some of our constituent bodies will be making their own submissions. Thank you for giving us the chance to contribute.

  2.  Our remarks may be more wide ranging than the Bill before the Committee, but we consider that on the evidence published from other countries, it is never possible to consider only one aspect. For example, there is evidence that attempted suicides fail even when there is medical assistance. The commonest reason for this being vomiting. Thus assisted suicide also overlaps with euthanasia. The Bill acknowledges this at 1(2) where it is stated;

        "Assisted dying means the attending physician, at the patient's request, either providing the patient with the means to end the patient's life or if the patient is physically unable to do so ending the patient's life"

  3.  Autonomy;

  We share a desire to see an increase in patient autonomy. This must be balanced against the protection of the vulnerable. Paradoxically medical involvement in euthanasia and assisted suicide increases the power of those who have the medical knowledge of diagnosis, prognosis, and the means to end life. They should not be indemnified against error, intended or otherwise. This Bill would make doctors bedside judges and executioners.

  4.  Medical errors are common at the end of life and there have been many studies comparing pre mortem and post mortem diagnoses. These can show major discrepancies especially where the patient died of multiple pathologies. A common mistake being the cause of breathlessness wrongly attributed to malignancy or heart failure, when it is actually due to treatable conditions such as infection or pulmonary embolus.

  5.  Quality of Life;

  What underpins euthanasia killings are judgements on the worthwhileness of certain human lives. Though it may be at request it implies that the doctor shares the patient's evaluation of their quality of life. Consciously, or sub consciously, the doctor must believe that the patient does not have a worthwhile life. Thus the doctor is making a distinction between the worth of one life over another, a position that is in conflict with the principle that all are equal before the law. It effectively removes the protection of the homicide law from some people. How can this outlook be limited, after all many patients in similar or worse states will not ask for death? How can medical teams hold such contrasting views at the same time on different patients?

  6.  Definitions of "terminal, serious, progressive physical illness"

  Despite the distinctions made, and conditions applied, these terms raise insurmountable difficulties for clinicians. Prognosis can be extremely difficult and many conditions could fall within these terms such as chronic arthritis, Parkinsonism or even diabetes. The term "unbearable suffering", is subjective and no doubt influenced by many factors. We are extremely doubtful that this can be satisfactorily defined in law and practise has convinced us that the patients' experience of suffering is very variable. For example, the appearance of a loved one at a dying person's bedside, can transform their desire to live. Many of us will attest to the fact that the last few days of a person's life may be the most important in their lives.

  7.  The claimed unmet need for euthanasia;

  In last year's introduction of this Bill, Lord Joffe cited a number of surveys which seem to support the conclusion that there is an unmet need for euthanasia and that, in fact, the incidence is higher in countries where it is illegal. In Holland it was said that "only" 0.7 per cent of deaths were a result of ending the lives of patients without their request.

  8.  The Remmelink report from Holland [Committee to Investigate Medical Practice Concerning Euthanasia. The Hague; Ministry of Justice and Ministry of Welfare, Public Health and Culture 1991] also looked at withholding treatment such as tube feeding, [1] and the intensification of pain control with the explicit purpose of accelerating the end of life and further cases of partially intending to shortening life. The total rises to a 24,500 deaths or 19 per cent of all deaths. [2] The overwhelming majority were not requested and shows a frightening attitude by doctors.

  9.  The other thing which the Remmelink report shows, is the strict system of safeguards required by Dutch law is frequently breached with non notification or false certification as to the cause of death, being commonplace. The legal correspondent of the BMJ reported as recently as the 17 July 2004 at page 127, that;

        "New penalties proposed for Dutch Doctors who flout euthanasia laws".

  It seems that the Dutch government is concerned that only a half of euthanasia deaths are being reported. This, of course, implies that half are incorrectly being reported as due to natural causes.

  10.  More recently there has been a drift to more physician assisted suicide, from and euthanasia for the terminally ill, and to euthanasia for the chronically ill, from euthanasia for the physical illness, to euthanasia for psychological distress and from voluntary euthanasia to non voluntary euthanasia. as Hendrin says, "every guideline set up by the Dutch . . . has been modified and violated."[3]

  11.  Seriously Flawed Australian Studies

  Three ardent supporters of euthanasia in Australia [Kuhse, Singer & Baume], claim that euthanasia is more common in countries where it is illegal [4]. But they conflated the categories of "not prolonging life", and "hastening death" and fail to distinguish between foresight and intended consequences. They have added in the figures from good palliative care, where palliative care doctors did not prolong the dying process, thus artificially inflating their figures. Their survey, supposedly repeated the questions in the Remmelink investigation, but mistranslated the Dutch questions. [4]. Their paper has been strongly criticised in Australia.

  12.  It has been seriously questioned by the Council of Australia and New Zealand Society of Palliative Medicine, and was criticised by the leading Australian oncologist Professor Alex Crandon, who also said that none of the directors of gynaecological cancer services had heard of a single doctor practising secret euthanasia.

  13.  Euthanasia and assisted suicide rates in Holland, Belgium, Switzerland, Sweden, Denmark and Italy were compared on the basis of an anonymous questionnaire sent to doctors, and over 20,000 deaths were studied. [5] Euthanasia deaths were 65 times commoner in Holland than Italy, and none were reported from Sweden. This study corrects the misleading conclusions of the flawed Australian study.

  14.  The Logic of Euthanasia;

  If euthanasia is a good thing for those asking for it, why is it not also a good thing for those who are as ill, or even more ill, but who have not asked for it?

  15.  Financial Considerations

  Anyone with direct experience of the NHS, will know there is a relentless pressure to comply with protocols, especially where resources are concerned. There is always a downward pressure on doctors to be thrifty.

  16.  The Slippery Slope;

  Though Lord Joffe last year denied this occurs, there has already been a progression for euthanasia from physical to mental illness in Holland. There has also been discussion of euthanasia for "existential reasons", though this has not been made legal so far.

  17.  "It is already happening here";

  Studies purporting to show a significant percentage of doctors have taken active steps to end patients' lives, need to be interpreted with caution. In this day of medical teams and colleague oversight, why has there been no reporting of this to statutory bodies? The absence of reporting to the GMC speaks for itself, and criminal prosecutions are exceedingly rare, and the chances of falsifying death certificates will be substantially reduced if the recommendations outlined in the Shipman enquiry, are implemented.

  18.  Again there is scope for misunderstanding given the principle of double effect, and the legitimate administration of sedation or analgesia, and its possible foreseen, but not intended effects. Reference to the appropriate dosages recommended by palliative care authorities or the Royal College of Anaesthetists, should be the standard. Surveys which do not refer clearly to double effect, or the recognised treatment regimes, are very likely to be misleading.

  19.  Attitudes to Euthanasia and Assisted Suicide taken by those in health and the ill;

  There is ample evidence that what people want for themselves when illness is a distant possibility, is very different from that when illness comes. The sick do not choose the same as the well. National polls amongst the well, should therefore be treated very cautiously. It is interesting that the terminally ill can almost always be trusted to manage their own drugs, often having in their possession a potentially lethal dose.

  20.  Nor should we project upon the sick our own feelings as carers, doctors or nurses. Retrospective studies such as that quoted by Seale and Addington-Hall [6] reflect the views of relatives and carers not the patients themselves. There are studies showing that the terminally ill predominantly wish to live on.

  21.  There have also been studies showing that depression may lead to a desire to hasten death, as well as feeling a burden to others. Where these are absent there is little likelihood of patients wanting death hastened. There is no evidence that people with motor neurone disease commit suicide when they still can.

  22.  The case of Dianne Pretty which went to the European Court of Human Rights, demonstrates this, as well as clarifying the legal position, that there is no such thing as the so called "right to die", let alone at the hand of another.


    —  The interests of the individual cannot be separated from the interests of society as a whole.

    —  Euthanasia is out of control in Holland where it was first legalised.

    —  Economic interests of health providers exert a pressure towards the least costly management of the dying.

    —  Attempts to define "severe suffering" will soon be extended to more and more categories of the sick and this is why the disabled fear a change in the law.

    —  There is no logical reason why if euthanasia is "good" for some, it is not also "good" for others, thus creating a pressure for voluntary euthanasia to become non voluntary.

    —  Paradoxically assisted suicide and euthanasia increases medical paternalism, rather than patient autonomy.

    —  It will lead to a dangerous change in the attitude of doctors towards the very sick and dying.

20 July 2004


  1.  Committee to investigate Medical Practice Concerning Euthanasia. Medical Decisions at the End of Life. II Euthanasia survey report. The Hague: Ministry of Justice and Ministry of Welfare, Public Health and Culture. 1991.

  2.  Jochemsen H, Keown J. Voluntary euthanasia under control? Further empirical evidence from the Netherlands. J Med Ethics 1999;25 16-21.

  3.  Hendrin H. Physician-assisted suicide and euthanasia in the Netherlands. JAMA 1997;277:1720-1722.

  4.  Kuhse H, Singer P, Baum P, Clark M, Rickman M. End-of-life decisions in Australian Medical Practice. Med J Aus 1997,166: 191-196.

  5.  Van der Heide A, Deliens L, Nilstun T, Norup M, Paci E, Van der Wal G, Van der Maas P, on behalf of the EURLD consortium. End-of-life decision making in six European countries: descriptive study. Lancet 2003;361: 345-350.

  6.  Seale C, Addington-Hall J. Euthanasia:The role of good care. Soc Sci Med 1995;40: 581-587.

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