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.
SUMMARY
— 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
REFERENCES
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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