House of Lords - Assisted Dying for the Terminally Ill Bill

Select Committee on Assisted Dying for the Terminally Ill Bill Written Evidence

Memorandum by the All-Party Parliamentary Pro-Life Group

SUMMARY

1. The All-Party Parliamentary Pro-life Group upholds the sanctity of human life from conception until natural death. Every human being, regardless of disability or physical or mental health, possesses a fundamental worth and dignity for as long as he or she is alive. Recognition of the fundamental worth and dignity of every human being is the indispensable foundation of justice in society.

2. The prohibition against intentional killing is fundamental to our whole legal system. The 1993-94 House of Lords Select Committee on Medical Ethics declared that this prohibition is "the cornerstone of law and of social relationships. " (Para 237)

3. The Assisted Dying for the Terminally Ill Bill ("the Bill") would fatally undermine the prohibition. Allowing doctors to help their patients to die corrupts the doctor-patient relationship.

4. Rules in our moral and legal codes against actively causing the death of another person are not isolated fragments. They are threads in a fabric of rules that support respect for human life. The more threads we remove, the weaker the fabric becomes.

5. We do not propose to look in any detail at the substance of the Bill. Tinkering with a Bill which seeks to legalise euthanasia and assisted suicide will not spare society from its disastrous consequences.

6. We propose to focus on three particular issues; the conclusions of the House of Lords Select Committee on Medical Ethics, ethical arguments against intentional killing of the type envisaged by the Bill and practical arguments against the Bill.

THE CONCLUSIONS OF THE HOUSE OF LORDS SELECT COMMITTEE ON MEDICAL ETHICS

7. After extensive consideration the Committee's Report unanimously recommended amongst others that: There should be no change in law to permit euthanasia." (Para 278); "We recommend no change in law on assisted suicide. " (Para 295)

8. The conclusions of the Select Committee on Medical Ethics are as pertinent now as they were nine years ago. We ignore them at our peril. We fail to see what has happened in society in the intervening decade that would lead your Select Committee to endorse the Bill and thereby disagree with your predecessor's unanimous conclusion. In particular, palliative care and the management of pain have improved. "The Law in its present form needs no change for comprehensive and effective management of distress and agitation, including high doses of analgesia and sedation, at any stage of disease, which is safe and effective if given by personnel properly trained in Specialist Palliative Care. To infer otherwise is misleading and mischievous. "[151]

9. Since 1994 there have been a number of high profile cases that have sought to advance the argument for euthanasia and assisted suicide. One cannot fail to be moved by the tragic cases of individuals like Diane Pretty and Reginald Crew. We recognise the suffering of patients with Motor Neurone Disease and similarly debilitating diseases and acknowledge the anguish of the families who care for loved ones with these conditions.

10. However, it is worth recalling the conclusions of the Select Committee on Medical Ethics: "individual cases cannot reasonably establish the foundation of a policy (the legalisation of euthanasia) which would have such serious and widespread repercussions . . . the issue of euthanasia is one in which the interest of the individual cannot be separated from the interest of society as a whole. " (Para 237)

11. As parliamentarians we recognise, as no doubt you do, that we have a duty to legislate for society as a whole, not for individual cases. Experience with abortion legislation has taught us that no matter how well-intentioned proponents of legislation may be, where the legalisation of intentional killing is concerned it is impossible to introduce adequate safeguards against abuse.

ETHICAL ARGUMENTS AGAINST THE ASSISTED DYING FOR THE TERMINALLY ILL BILL

12. The Select Committee on Medical Ethics correctly noted that the prohibition on intentional killing "protects each one of us impartially, embodying the belief that all are equal." (Para 237). They had no wish to see that protection diminished.

13. There is wholeness to our human nature, not a dualistic account of a biological life and a biographical life with the latter taking precedence over the former. Human beings share equally an intrinsic dignity and value by virtue of our shared humanity.

14. Consequently, " [I]n sustaining human bodily life, in however impaired a condition, one is sustaining the person whose life it is. In refusing to choose to violate it, one respects the person in the most fundamental and indispensable way".[152]

15. It is in this context that the Select Committee on Medical Ethics referred to the prohibition on the killing of innocent human beings as providing the cornerstone of whatever rights an individual may have.

16. Nowadays we hear so much talk of autonomy, the right to do with one's life as one chooses. Autonomy is one of the buzzwords of the pro-euthanasia lobby. Properly understood the concept of autonomy, in particular the right to refuse medical treatment, is designed not to give persons a right to decide whether to live or die but to protect them from the unwanted interferences of others. The concept is rooted in the notion of the intrinsic value and dignity of the human person and thus can be overridden when autonomy is exercised in ways which contravene this notion or place other members of society at risk of harm.

17. A proper understanding of autonomy should lead you to reject Lord Joffe's Bill. The Bill has the potential to compromise the autonomy of some of the most vulnerable members of society, not least the terminally ill, the disabled and the elderly.

18. One must also consider the autonomy of members of the medical profession. The Joint Committee on Human Rights has declared the conscience clause in the Bill[153] to be contrary to the European Convention on Human Rights under Article 9(1), respect for the individual's right to freedom of thought, conscience and religion.

19. It is a sad fact that there are now very few gynaecologists practising in the United Kingdom who are opposed to abortion. Abortion is such a standard gynaecological practice that it is nigh impossible to specialise in that field and refuse to carry out abortions. Doctors opposed to abortion have been forced to specialise in other areas where no such ethical conflict arises.

20. If euthanasia and assisted suicide were legalised we would witness a similar phenomenon in geriatric care, in palliative care and in the hospice movement—regardless of whether the legislation contained a conscience clause. Doctors opposed to these practices would gradually be squeezed out.

PRACTICAL ARGUMENTS AGAINST THE ASSISTED DYING FOR THE TERMINALLY ILL BILL

21. We believe that it is no coincidence that the organisations representing those who would be affected most by the Bill—the elderly, the terminally ill, the disabled and the medical profession—are opposed to any change in the law to allow euthanasia and assisted suicide.

22. The Disability Rights Commission does not support the legalisation of voluntary euthanasia and assisted suicide. It argues that "in the current climate of discrimination against disabled people, where a lack of access to palliative care and social support means that free choice does not really exist, the threat to the lives of disabled people posed by such legislation is real and significant." [154]

23. The British Medical Association is also opposed. "The BMA has consistently opposed euthanasia and physician assisted suicide . . . we believe that in the case of euthanasia and assisted suicide, benefit for an individual in terms of having their wishes respected, is only achievable at too high a cost in terms of potential harm to society at large. "[155]

24. Beverley Malone, General Secretary of the Royal College of Nursing has declared that "The RCN believes that the practice of euthanasia is contrary to the public interest, to nursing and medical ethical principles as well as patients' civil rights. The RCN is opposed to the introduction of any legislation which would place responsibility on nurses and other medical staff to respond to a demand for termination of life from any patient . . . ".[156]

25. Bodies representing those working within the Hospice Movement and the palliative care sector argue that euthanasia, once accepted, "is uncontrollable for philosophical, logical and practical reasons rather than slippery slopes of moral laxity or idleness. Patients will almost certainly die without and against their wishes if such legislation is introduced. "[157]

26. The most recent independent UK survey of doctors' opinions on this matter[158] revealed that almost three out of four doctors (74 per cent) would refuse to perform assisted suicide if it were legalised. A clear majority (56 per cent) also considered that it would be impossible to set safe bounds to euthanasia. To the question "As a doctor do you agree with assisted suicide?" 25 per cent agreed, 60 per cent disagreed and 13 per cent were undecided. The number who rejected euthanasia was higher—61 per cent as compared with 22 per cent in favour and 14 per cent undecided. Not one palliative care doctor who responded to the survey would practice either euthanasia or assisted suicide while 66 per cent of doctors considered that the pressure for euthanasia would be lessened if there were more resources for the hospice movement.

27. In the face of such overwhelming opposition from those who would be affected most by the Bill it is impossible to envisage how it could be practically implemented.

28. One must also consider what has happened in those jurisdictions where euthanasia and/or assisted suicide has been legalised.

29. In Oregon, where assisted suicide was legalised in October 1997, more than a third of the patients in one study requested assistance in suicide because they perceived themselves as a burden to others.[159] Thankfully, only three of these patients received prescriptions for lethal medications which suggests that physicians were reluctant to accede to patients' requests for assistance with suicide.

30. Furthermore, there is little evidence of any improvement in palliative care services in Oregon. According to a recently published study by Oregon Health and Science University,[160] half of the family members of dying patients surveyed between 2002 and 2002 said their loved ones' pain was moderate or severe in the week before they died. Prior to 1997 when assisted suicide was legalised in Oregon, only one-third of family members surveyed rated the pain as moderate or severe.

31. The latest empirical evidence from the Netherlands contained in the official report by Van der Wal and Van der Maas[161] notes that the frequency of ending of life without the patient's explicit request has shown no decline over the years studied, 1990, 1995 and 2001. In 2001, the most recent year for statistics are available, 900 out of 3,800 cases of euthanasia or assisted suicide (approximately one-quarter) were without the patient's explicit request.

32. The latest official report on euthanasia in the Netherlands[162] also shows that only 54 per cent of cases of euthanasia were reported to the regulatory authority and "life terminating treatment without explicit request of the patient is still seldom reported (less than one per cent)." According to a press reports, the low notification rate is because doctors wished to avoid the "administrative hassle" of reporting a euthanasia case and were concerned they might have breached the regulations.[163]

33. In a study published in the New England Journal of Medicine in 2000 it was reported that one of the problems most frequently reported with the performance of euthanasia and physician assisted suicide in the Netherlands is a "longer than expected interval between the administration of the lethal drug . . . and the patient's death. "[164]

34. The following excerpt from this study gives a chilling glimpse into the practical difficulties with euthanasia and physician assisted suicide: "In most of these cases, the patient did not die as soon as expected or awoke from coma, and the physician felt compelled to administer a lethal injection because of the anticipated failure of the assisted suicide. In some cases, the physician administered a lethal injection because the patient had difficulty swallowing the oral medication, vomited after swallowing it, or became unconscious before swallowing all of it." So much for death with dignity.

35. Empirical evidence from the Netherlands reinforces the argument that it is impossible to set safe bounds to euthanasia so as to ensure that only those who have expressed a persistent, voluntary and well-considered request are put to death. The Dutch experience contradicts the claim that legalisation "brings euthanasia out of the closet" and subjects it to regulation. It simply produces more euthanasia, not more control.

36. Those in favour of the Bill often allege that euthanasia and physician assisted suicide are a widely known fact of medical life, but are usually carried out at the doctor's discretion or in secrecy—hence the need for legislation and proper regulation. Notwithstanding the Dutch experience where legalisation has failed to introduce greater regulation, these allegations are rarely substantiated. They are a slur on the medical profession and should not be allowed to pass unchallenged.

37. The most recent survey of medical opinion cited earlier[165] explodes the idea that people are clamouring for euthanasia. In response to a question asking how many patients had requested euthanasia during the past three years nearly half (48 per cent) of the doctors said not one; 37 per cent quoted less than five; 11 per cent gave numbers between five and 10 patients; only two per cent gave figures of more than 10. In their comments doctors said that in their experience requests for euthanasia were often "cries for help that have been resolved with good symptom control . . . they almost invariably want relief from distress".

38. The number of requests for euthanasia from relatives was even lower than from patients themselves. 68 per cent of doctors said that none had approached them in the last three years; 22 per cent quoted less than five such experiences; five per cent quoted figures between five and 10 and one per cent gave numbers of more than 10. Three per cent said they did not know or that the question was not applicable to them.

39. Proponents of euthanasia and assisted suicide also conflate these practices with perfectly legitimate end of life care. Doctors are regularly called upon to decide to withhold or withdraw life-sustaining treatment in the knowledge that death will result. However, knowledge that a certain course of conduct may bring about death does not automatically constitute euthanasia. Intention or purpose is the key. If treatment is withheld or withdrawn with the purpose of bringing about death this constitutes euthanasia and is unethical. However, it is perfectly legitimate to withhold or withdraw medical treatment when it is considered that the burdens of such treatment outweigh the benefits, or where the patient is dying and the treatment would be regarded as unduly intrusive and inappropriate or where the risks of such treatment would be excessive.

CONCLUSION

40. We urge your Committee to reject in its entirety the Assisted Dying for the Terminally Ill Bill.

41. The Bill would irrevocably and fatally damage the practice of medicine in the United Kingdom. The most vulnerable members in our society, the elderly, the terminally ill and the disabled would be at greatest risk of premature death if this Bill were implemented.

42. When there is a pressing need to tackle the under-funding and regional disparities in palliative care for the terminally ill and personal care packages for the elderly and those with disabilities it is regrettable that parliamentary time is being taken up with "assisted dying" legislation. Of far greater use to the elderly, terminally ill and those with disabilities would be some form of "assisted living" legislation.

43. We would be happy to appear before your Committee to give oral evidence.

Jim Dobbin MP

Chairman, All-Party Parliamentary Pro-life Group

Ann Winterton MP, Lord Stallard, Baroness Masham of Ilton, Claire Curtis-Thomas MP, Rt Hon Ann Widdecombe MP

Vice-Chairmen, All-Party Parliamentary Pro-life Group

Joe Benton MP, Kerry Pollard MP

Honorary Secretaries, All-Party Parliamentary Pro-life Group

Rev Martin Smyth MP, Andrew Selous MP

Honorary Treasurers, All-Party Parliamentary Pro-life Group

August 2004

151 The Patient (Assisted Dying) Bill: A joint briefing paper by the Association for Palliative Medicine and the National Council for Hospice and Specialist Palliative Care Services-May 2003. Presented in the House of Lords on 3 June 2003. Back

152 Finnis, J M, "A philosophical case against euthanasia" in Keown, J, (ed) Euthanasia Examined-Ethical, clinical and legal perspectives (Cambridge: Cambridge University Press, 1995) p 32. Back