Memorandum by Raymond Hoffenberg MD PhD
I am a retired physician and from 1983 to 1989
was President of the Royal College of Physicians of London. I
have had a longstanding interest in medical ethics, was President
of the Institute of Medical Ethics and spent two years as Visiting
Professor of Medical Ethics in the University of Queensland. My
views on the subject of assisted dying have developed after witnessing
many deaths in over 40 years of clinical practice and war service
in World War II in North Africa and Italy.
In my submission I have considered possible
objections to the practice of assisting those who are dying (as
defined in section 1(2) of the Bill) to achieve an "easy,
gentle and placid death"a phrase used by William Munk,
Harveian Librarian of the Royal College from 1857 to 1898, in
a monograph on euthanasia published in 1887. Where possible, I
have tried to respond to these objections.
1. Adopting such means to end the patient's
life should not be necessary, as modern therapy can always relieve
physical pain, and the hospice approach is able to provide the
emotional, social and spiritual care that characterises a good
2. Experienced terminal care specialists
admit there is a core of patients whose pain and suffering cannot
be relieved except by using extremely large doses of drugs that
induce states of coma or accelerate death. Dame Cicely Saunders,
the distinguished hospice specialist, estimated that pain could
not be controlled in about 2 per cent of dying hospice patients
(personal communication). Other experts estimate that not more
than 95-98 per cent of pain in terminally ill patients can be
relieved. These figures appear to be at the top end of achievement
and do not reflect what patients themselves say. In surveys of
hospice patients who were asked about their pain level shortly
before death, 5-35 per cent rated their pain as "severe"
or "unbearable"; 25 per cent said their shortness of
breath was "unbearable". Even in the best of hands the
figures for unrelieved pain are not insubstantial. Other symptoms
such as nausea and vomiting or severe itch can also be difficult
3. Additionally, to many patients loss of
capability and independence and/or the indignity of losing control
of bodily functions, including sphincters, is more frightening
and upsetting than the prospect of pain; these problems are not
easily palliated. (As an extreme example I would refer to the
case of Mrs Lilian Boyes, a dying patient to whom Dr Nigel Cox
administered a fatal dose of intravenous potassium chloride, an
act that brought him before the General Medical Council. She was
in extreme pain unresponsive to massive doses of morphine, possibly
due to the phenomenon of paradoxical pain, she had ulcers and
abscesses and gangrene that extended through her rectum into bone;
she was doubly incontinent and blind. Even if it had been possible
to control her pain, her condition was so distressing that she
and her two loving sons begged Dr Cox to put her out of her misery).
4. The reality of the situation is that
a majority of dying patients do not have access to optimal
terminal care. Richard Smith, retiring editor of the British
Medical Journal, has written "For the minority who die under
the care of palliative teams it is probably good, but there is
a suspicion that for the majority who die in acute hospitals or
nursing homes the experience is bad". For many of those who
die at home it is almost certainly worse.
5. Knowledge that a doctor practises "euthanasia"
might undermine the trust that patients have in doctors. They
might be fearful of what will be done to them in the last illness.
6. Evidence from surveys carried out in
places in which euthanasia is permitted shows that this has not
happened. On the contrary, in the Netherlands the percentage of
people in favour of continuing the practice has increased steadily
over the years. In Britain the number in favour of euthanasia
rose from about 50 per cent in the 1960s to about 80 per cent
after the Cox and Bland cases in the 1990s, suggesting that the
public actually approved of the role of doctors in assisted dying.
Surveys of elderly people in Australia confirm this view.
7. Vulnerable members of society will be
placed at risk, eg the disabled, the elderly and ethnic or other
minorities. A voluntary request for assistance in dying will be
replaced by involuntary disposal of unwanted people. Various forms
of pressure might be applied to people who want to live, especially
the elderly who might be induced to request early death by uncaring
members of the family or others.
8. In a civilised society it is highly unlikely
that a doctor, other than a pervert or a criminal (Shipman), would
acquiesce in the killing of individuals or groups, simply to get
rid of them.
9. It is probably impossible completely
to eliminate inducements or pressure but the safeguards outlined
in the Bill, if followed meticulously, should all but do so. (There
is an analogy here in the transplantation field in which free
voluntary consent to organ donation is regarded as critical, but
undue pressure or coercion is equally hard to eliminate, except
through the exercise of close scrutiny and maximal care).
10. This objection exploits the "slippery
slope" argument. The flaw in the argument is the following:
If practice A (acceding to voluntary requests) is accepted or
desired, but practice B (involuntary disposal of people) is not,
it makes no sense to ban A simply to prevent B. The right action
is to retain A and outlaw B, imposing stringent scrutiny and appropriate
punishment for those who transgress the boundary.
11. There is a risk of mistakes in diagnosis
or prognosis. There are occasional examples of patients believed
to be terminally ill who then recover and return to normal life.
12. It is impossible completely to exclude
the possibility of medical error. The likelihood of error would
be greatly reduced by the provisions of the Bill, which require
confirmation of the diagnosis and prognosis by another physician
and a specialist in palliative care. Close observation through
the 14 day period should help to minimise the chance of error.
In contemplating the possibility of assisted dying doctors could
be expected to exercise even greater care to avoid errors.
13. It may be difficult to determine the
mental competence of the individual, on which the validity of
the request for assistance is dependent. It is known that this
might fluctuate in patients with a terminal illness.
14. Competence has to be attested formally
by two doctors, a solicitor and the witness. In addition, in most
cases there will be family members who can provide information
about the mental state of the patient. If there is any doubt on
the part of any of these individuals, a psychiatric referral is
15. In present day medical ethics paramount
importance is accorded to the concept of patient autonomy. Competent
patients may decide whether or not to accept treatment, and may
reject it even if it is thought to be lifesaving. They have power
to make decisions about all aspects of their care but not to demand
treatment that is regarded by their doctors as harmful or valueless.
Presumably, it is under this rubric that patients with terminal
illness are denied assistance in dying. They have the right, if
they wish, to forgo all treatment including the ingestion of food
and water and so to die from dehydration and inanition. Thus,
they may elect to die a slow and distressing death but, having
made the decision to end their lives, they are denied the means
to achieve one that is quicker and more expeditious. Knowing that
they are suffering from a terminal illness, they are denied autonomythe
right to choose how and when they would like to die.
16. The provision of the means to end their
own lives or the knowledge that their wish to do so will be carried
out at a time of their choosing, if their suffering becomes intolerable,
can be a great comfort to those who fear the dying process more
than death itself. Experience shows that patients who are given
the means to end their lives frequently do not do so, but they
are reassured by the knowledge that they have the means to do
so if necessary.
17. It is usually agreed that there is very
little ethical (as opposed to legal) distinction between allowing
patients to die by withholding or withdrawing treatment and taking
a more active step to end their lives. In all cases the intent
is the same and the outcome is the same; only the means of achieving
the end is different. Following the Bland case, the House of Lords
gave consent in certain circumstances for the withdrawal of food
and water from patients in a persistent vegetative state. Death
follows about 10 days after withdrawal. During this time the relatives
have to watch the slow inexorable extinction of life and the nursing
staff have to wash, turn, toilet and generally tend what they
know to be an incipient corpse. Would it not be more humane for
the family and the nursing staff to expedite the process of dying?
18. There is little doubt that many doctorsgood
caring doctorsdo assist the process of dying. They do so
under the guise of the double effect principleusing large
doses of a drug in order to relieve symptoms in the knowledge
that this might shorten life. In many cases, I suspect, there
is an implicit intent to end the patient's misery by doing so.
If this intent were overt, they would expose themselves to serious
legal and professional condemnation. Had Dr Cox been less ingenuous
he might have chosen some other substance that would have hastened
death and pleaded that he had acted under the principle of double
effect without making his true intent known. A decision to allow
assisted dying as outlined in the Bill would obviate a moral and
legal contrivance, behind which many doctors take shelter.
19. It is clear from many studies that doctors
and other health professionals have little comprehension of the
real views of the public with regard to end-of-life decisions.
In a Queensland survey, in which I took part some year ago:
(i) 57 per cent of general practitioners
believed that patients would prefer to leave such decisions to
their doctor; this view was held by only 34 per cent of the community;
(ii) 84 per cent of doctors felt that patients
do not like to think about death and dying; only 31 per cent of
the community shared this view;
(iii) 62 per cent of patients were in favour
of assisted dying compared to 30 per cent of doctors,
(iv) 65 per cent of patients felt the law
should be changed to allow the process.
I suspect that a British public would respond
in a similar way.
20. I appreciate that many people object
to assisted dying on religious grounds. It stands to reason that
there should be a "conscience clause" that permits doctors
who have this belief to recuse themselves. No doctor should be
obliged to carry out any measure that is contrary to a firmly
held belief or principle.