Memorandum by Professor John Saunders
The Bill is ostensibly an extension of individual
freedom in an area where there are still great anxieties: the
manner of our dying concerns us all. It is also well known that
the process of dying is the source of distress, pain, anguish
and existential suffering for many people. The Bill seeks to address
this by assisting those with a terminal illness to have their
lives actively terminated. It is my contention that the proposal,
while humane in its intention, is unnecessary and will result,
on balance, in serious and irreversible harms.
My credibility in making these assertions rests
upon a lengthy career at the sharp end of acute general medicine,
caring for a very broad spectrum of patients admitted acutely
to hospital. I have been almost continuously engaged in this since
graduating in 1968, for most of this time on a one in three on
call basis; and as a consultant in a district general hospital
since 1981. I have probably been involved in the deaths of 1,000-3,000
patients in that time, all causes, all ages. I have also reflected
on these issues philosophically and, as a result of my interest
in the ethics and philosophy of medicine, hold an honorary senior
lectureship at Cardiff University (University of Wales College
of Medicine) and an honorary professorship in the Centre for Philosophy,
Humanities and Law in Health Care, University of Wales Swansea.
I am currently hon Secretary to the Committee for Ethical Issues
in Medicine, Royal College of Physicians of London, as well as
involvement in a range of advisory capacities to national bodies.
My concerns about the Bill are, briefly, as
follows:
— Its title is dishonest. Assisting
dying is the responsibility of all doctors and other health care
professionals involved with dying patients and particularly those
in the specialty of palliative care medicine. This Bill is about
active killing. At the very least its title should be changed
to the Euthanasia and Assisted Suicide Bill. The choice of title
suggests weasel words in order confuse a poorly informed section
of the public. It confuses assistance in dying with assistance
to die.
— The demand for what the Bill offers
is actually small. Publicity for Dutch and Belgian legislation
will increase demand as for any consumer product. This correlates
poorly with need. My views about euthanasia are not known to my
patients. Yet of the thousands who I estimate must have died under
my care or received a terminal diagnosis, the numbers who have
requested euthanasia can be counted on my fingers. I acknowledge
that this is partly a reflection that patients do not ask for
something that they know to be illegal. Nevertheless, having been
"along side" so many patients at life's end, I think
it significant that this request has been articulated so rarely.
— Not only is demand small (—and
opinion polls are not a reliable guide, for there are good data
demonstrating how our views change dramatically when placed in
the real situation: see, for example, the study of quadriparetic
patients from Liverpool—), but need is small also. The indication
for killing the already terminally ill is suggested as unbearable
suffering. While palliative care sometimes fails in its objectives,
this is usually due to bad palliative care, not to untreatable
suffering. Uncontrollable pain, for example, is rare. The case
of Dr Cox and Lilian Boyes, for example, has been quoted as an
example of this; but, as was noted at Cox's trial, the assistance
of specialists in palliative care medicine or pain control had
never been made. Imperfect palliative care indicates the need
for better education of health care professionals, not killing
the patient.
— The existential suffering and terminal
distress experienced by some patients is not something that can
be addressed within the time scale proposed in the Bill. Trust
takes time to establish. A peaceful and fulfilled end is better
achieved by the overt expression and resolution of deep personal
conflicts. The terminal phase of an illness may offer a special
part of life of inestimable value, as so many patients have testified—unexpectedly.
— Covert euthanasia will not be reduced
by the Bill. The practice is likely to extend to cases not currently
covered as active killing becomes accepted. This has already been
seen and documented in the Netherlands. Definitions of "terminally
ill" can be stretched (is a patient with anorexia nervosa
terminally ill?), freedom from external pressure can be reconsidered
and so on.
— Baroness O'Neill has pointed out
that the Kantian understanding of autonomy is misinterpreted to
mean the licence for an individual to do as he pleases. In reality,
autonomy is always limited by the social nature of human life.
We have obligations, whether we want them or not. Ownership (—in
this case of my life—) does not logically lead to the moral
freedom to destroy it when I like. Suicide may have been decriminalised
out of recognition that criminal sanction is not an effective
way to discourage suicidal conduct. The 1961 legislation "in
no way lessens, nor should it lessen the respect for the sanctity
of human life which we all share", to quote the minister
in the Commons at the time. As an illustration of the principle,
we do not find it morally acceptable for an owner to destroy a
major work of art, even if his legal right to do so is unquestioned.
Most of us disapproved when Mrs Churchill destroyed Sutherland's
portrait of her husband. This Bill threatens the traditional prohibition
of intentional killing. We will all suffer if this is breached.
— The social ethos of Western society
with its strong insistence on the value of human life, even when
severely disabled, is likely to be eroded by the Bill. It is easy
to stoke up demand for reform by opinion poll: most people supported
going to war in 1914, for example. The effects of unwise change
may take a long time, but will be difficult, if not impossible
to reverse. The social ethos should not be taken for granted.
Our freedoms and respect for life are still not shared by many,
perhaps most, people in the world. A change in ethos may encourage
particular cultural groups to regard themselves even more as a
"nuisance" and opt for euthanasia to relieve other family
members. A human life has an objective value that morally constrains
autonomy.
— The Bill is illogical in its time
limits. If the basis for euthanasia is the (freely expressed)
wish of the patient, there is no logical reason to limit this
to the terminally ill. Why draw a line here? The Bill's proponents
should either acknowledge that a simplified view of autonomy is
not the moral basis for the Bill; or be honest enough to extend
the Bill to those who are not ill at all. The only reason for
limiting it to those who are terminally ill seems to be that in
the event of error, the loss of life (measured in time rather
than quality) is smaller. If on the other hand the moral justification
is the reduction of the sum total of human suffering, then the
moral basis is flawed by all the problems of utilitarian calculus.
— A lengthy experience has taught me
that prognosticating in the terminally ill is fraught with difficulty.
I am frequently wrong. The intervals in this Bill are far too
long for accurate prognostication in many, perhaps most, cases.
The result can easily be legislation that robs individuals of
a significant part of the final part of their lives.
— The Abortion Act has changed the
attitude of doctors towards abortion (whether for the better or
worse is not my point). This Bill if enacted will change the attitude
of doctors towards the terminally ill and erode the traditional
view of the sanctity of life to a view of life as essentially
instrumental ie not something valuable in itself, but only valuable
for what one can do with it. I do not believe this will be a healthy
change.
— There is no reason why active killing
should be the role of doctors. This point is addressed in the
submission from the Royal College of Physicians. Skills to kill
are easy to teach and like many practical procedures could be
delegated to another. I don't lose attachment to, or solidarity
with, my patient because I ask a surgeon to replace his heart
valve or a physiotherapist to assist his mobility after stroke.
The Bill is entirely silent on the reason for involving doctors
in this activity.
— Finally, I would wish to emphasise
the tremendous vulnerability of the terminally ill. The pressure
to do the right thing at the end of life may be enormous for many
patients. What could be more "right" than relieving
the burdens of others—especially if they appear reluctant
to carry them. The changing ethos resulting with this Bill could
lead to grave social evils. I am sure that none of the protagonists
in the debate over this Bill are casual or indifferent to human
misery and suffering. But the case has not been made that intentionally
killing people is a better or more dignified solution than relief
of suffering by means where death may be a predictable, but not
intended, consequence.
|
