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Euthanasia |
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The ethics of assisted
suicide
On Friday the House of Lords will debate Lord Joffe's private
member's bill, Assisted Dying for the Terminally Ill. If passed, the bill
will allow terminally ill adults in unbearable pain to receive medical help
in dying.
By Daniel Sokol
Medical ethicist, Imperial College London
11 May 2006
Many objections to physician-assisted suicide are based on religious
prohibitions.
These can only be countered by refuting the religion itself - a notoriously
hard thing to do - or by arguing that religious teaching actually permits
the act.
I shall not employ either of these arguments.
Harm is, at least in part, a subjective notion
Religion-based reasons will not persuade the secular folk, and hence many
objectors usually replace or supplement their arguments with non-religious
reasons.
Some of the secular reasons against physician-assisted suicide (PAS) appear
speculative or ill-informed.
Initial doubts
They remind the historically aware of the initial reactions surrounding
practices which are now widely accepted (for example, human dissection,
considered an affront to human dignity in Hippocratic times, and
vaccination, considered unnatural and a thwarting of God's will in the 19th
and 20th centuries).
Some reasons, however, are more convincing.
One such reason is that PAS will change the way members of the public view
doctors.
In the public's mind, doctors will become part-time executioners.
We cannot predict if this will occur, but even if it did at first adversely
affect the public's perspective, it is not a sufficient reason to reject the
bill.
People's views can, and do, change.
If physician-assisted suicide is morally acceptable, then the fact that
people might frown upon it does not alter the morality of the act.
Hippocratic Oath
Another common argument about PAS, especially amongst doctors, is that it
violates the Hippocratic dictum: 'first, do no harm'.
If we strictly adhered to Hippocratic teachings, abortion should also be
abolished
This principle was insightful in Hippocratic times when doctors mostly did
more harm than good - magic and superstition were rife, and efficacious
treatments few - but not in this scientific age.
The oath is now out of date. If we strictly adhered to Hippocratic
teachings, abortion should also be abolished, for the Oath says "Neither
will I give a woman means to procure an abortion".
It is therefore wrong slavishly to revere - as some still do - the
Hippocratic Oath.
If taken literally, the only way doctors could 'do no harm' would be by
declining to treat all patients.
Even simple medical procedures, such as taking a blood sample or injecting a
local anaesthetic, entail some risks to the patient.
Many procedures and treatments require doctors to inflict harm in order to
bring about some good.
In an appendectomy, the surgeon cuts open the patient's abdomen (a harm) to
remove the troublesome appendix (a benefit).
Balance of good
As the ethicist Professor Raanan Gillon points out, doctors have a duty not
to cause net harm.
In my view, physician-assisted suicide can be compatible with love, kindness
and compassion
Is PAS a net harm to the patient who wants it?
Those in favour of the act will argue that helping a terminally ill patient
to die is a benefit, not a harm.
Harm is, at least in part, a subjective notion.
What is beneficial or harmful to a particular patient is determined to some
extent by the patient's perception.
If I choose to donate a kidney to my sick brother, no one would rightfully
accuse the surgeon of having harmed me by removing the organ.
Overall, the operation would benefit me in spite of the physical harm.
Respecting a patient's autonomous wishes can itself constitute a benefit.
Thus it is far from clear that allowing doctors to help patients end their
lives infringes the dictum 'first, do no (net) harm'.
An answer to the morality of PAS can be found by reflecting on the essence
of medicine. This is no easy task.
Paracelsus, in the 16th century, wrote that medicine was grounded in love.
More recently, Sir William Osler stressed the importance of humanity, which
consists in showing 'tenderness and consideration to the weak, infinite pity
to the suffering, and broad charity to all'.
He reminded doctors to keep a 'clear head and a kind heart'.
When the late Jean Bernard, the distinguished French haematologist, was
asked by a journalist a few years ago: "technology aside, on what is
medicine based?", he replied "on love, on compassion, since medicine will
always be about man".
In my view, physician-assisted suicide can be compatible with love, kindness
and compassion.
The real difficulties lie in regulating the practice to limit the
possibility of abuse and, once that is overcome, in summing up the courage
to do what is morally right in the face of anticipated abuse and opposition.
Daniel Sokol is the co-author if Medical Ethics and Law: Surviving on the
Wards and Passing Exams.
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'They wouldn't treat an
animal like this'
Alan Rusbridger describes his father's final days 'clouded by his growing
pain and sense of betrayal' - and asks, must it be this way?
Alan Rusbridger
Friday July 01 2005
The Guardian
We all have fantasies of how we'd like to die. A soft trickle of Mozart, a
haze of distant hills, a circle of closest friends and family around you.
That, I guess, would do for most of us.
We also have firm feelings about how not to die. For myself, I would rather
not die as my father recently did.
My dad was 96 and - when the time came - was unsentimental to a fault. He'd
had a good innings, he didn't want to waste anyone's time. To the kindly
doctors and nurses assembled around his bed he spoke warmly but firmly.
"You've got much more important priorities than keeping me going," he told
them. He chose the euphemisms of his generation, but his meaning was clear:
he wanted them to end it for him.
I felt obliged to intervene on the doctors' behalf. "I'm not sure they can
do that, Daddy," I told him. The doctors smiled knowingly and nodded
agreement. My father grew irritable at their failure to understand. I did my
best to argue on the side of medical reason.
But, actually, I think my dad was right. The coming days, our last precious
time together, were clouded by his growing pain and sense of betrayal - he
blamed me and my brother for our failure to persuade the doctors to carry
out his wishes. Instead of tranquillity there was bitterness and
bewilderment.
"They wouldn't treat an animal like this," he groaned each time the ulcers
in his leg threw his whole body into spasm. He was right about that, too.
It was not quite the script the consultant had gently outlined just over two
weeks before my father eventually died. He had set out the options:
amputation of his remaining leg or letting nature take its course. "Nature"
meant anything from severe ulceration to gangrene as the circulation in his
"good" leg packed up. It could be days, or it could be weeks. We were not to
worry: they could control the pain.
My father was quite clear he couldn't face another amputation. So it was
simply a matter of nursing him to a quiet, dignified - and painless - end.
But they were wrong about the pain. My father was, so far as we could tell,
quite often in agony. And my brother and I were placed in the awkward
situation of begging, cajoling and - in the end - demanding that he be given
ever higher doses of morphine.
Different members of the medical team appeared to have different views about
what was an adequate or appropriate dose. The night team countermanded the
day team. The palliative care team didn't work weekends. At one point my
father weakly changed his mind. He couldn't take this pain any more: perhaps
he should go ahead with the amputation. But, of course, by now he was too
frail for an operation. This logic drove him into furious exasperation.
I had a tense conversation with one Macmillan nurse to whom I had suggested
raising the dose of morphine. "We have ethical and legal difficulties with
sedation," she sniffed.
"I'm not asking you to sedate him," I replied. "I'm asking you to do what he
was promised - to be allowed to die without pain."
"But if we gave him a higher dose he would fall into unconsciousness," she
said. "And then we couldn't tell if he was in discomfort or not."
Eventually he did fall into a deep sleep and we asked that the medical team
remove the drip which could have only prolonged it. A nurse explained that,
effectively, he would die of dehydration. There would come a point when his
internal organs would pack up.
My brother and I visited every day, spending hours by his bedside. But, as
luck would have it, the dehydration finally took its course at a time when
neither of us was there. So my dad died alone.
I assume everyone involved in my father's last few days behaved as they had
to. But I would defy anyone to call his ending a "good" death, or even a
particularly ethical one. Why is withholding nourishment and treatment as an
old man withers away from dehydration more ethical than intervening to help
him die at the time and in the manner of his choosing?
Were I ever to be faced with the same situation, I would like to have an
option denied to my father. I would like to choose, well, Beethoven
actually, then bid farewell to friends and family and ask that I might
gently drift away under a general anaesthetic, followed by whatever would
stop my heart as swiftly as possible.
It seems - from the current debate within the medical profession - that a
good many doctors would be willing to help, if only they could do so without
fear of prosecution. Isn't it time we let them?
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Dutch told of child
euthanasia
Dutch doctors have reported 22 mercy killings of terminally ill babies since
1997, according to a new study.
23 January, 2005
BBC News
None of the doctors involved were charged, although euthanasia for children
is illegal in the Netherlands.
The report, in the Dutch Journal of Medicine, is the first detailed
examination of child euthanasia.
The study's authors want to address under-reporting of the practice and
encourage doctors to report cases without fear of prosecution.
The cases involved babies with extreme spina bifida, a disabling birth
defect.
The study showed that prosecutors had decided not to file charges as long as
four unofficial rules were met:
- the child's medical team and independent doctors
must agree
- there is no prospect of improvement and the pain
cannot be eased
- parents give their consent
- the life must be ended in the correct medical
way
A survey has suggested Dutch doctors end the lives of about 15 to 20
disabled newborns a year but most go unreported.
"The babies are there but we were never allowed to talk about them," said
paediatrician Eduard Verhagen, of Groningen University Medical Centre, and
one of the authors of the study.
"That must change. If we take this awfully difficult decision, it must
happen with complete openness," he told De Volkskrant newspaper.
"You are trained to save the life of a child but with these children the
suffering can only be stopped by ending their lives. It takes courage to do
that."
In 2001, the Netherlands became the first country to legalise euthanasia but
doctors must follow strict rules.
The Vatican has criticised the Netherlands over its legalisation of
euthanasia.
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Dutch legalise euthanasia
The Netherlands has become the first country in the world to
legalise mercy killing after a controversial law on euthanasia came into
force on Monday.
April, 2002
BBC News
The legislation allows patients experiencing unbearable suffering to request
euthanasia, and doctors who carry out such a mercy killing to be free from
the threat of prosecution, provided they have followed strict procedures.
The country has already tolerated the practice unofficially for decades, but
parliament finally enshrined it in law last April.
The law
Patients must face a future of unbearable, interminable suffering
Request to die must be voluntary and well-considered
Doctor and patient must be convinced there is no other solution
A second medical opinion must be obtained and life must be ended in a
medically appropriate way
The patient facing incapacitation may leave a written agreement to their
death
Other states seem certain to follow the Dutch lead but opposition remains
strong across the world.
The UN Human Rights Committee has said it is not convinced that the Dutch
system can prevent abuses such as pressure being exerted on the patient.
Comparisons have also been made with Nazi Germany which put to death
thousands of handicapped children and mentally ill adults, despite the fact
that the Dutch law clearly stipulates that the request for euthanasia must
come from the patient alone, while he or she is of sound mind.
Prime Minister Wim Kok has dismissed critics who argue that Dutch doctors
now have a licence to kill. He says the idea is "bloody nonsense".
And doctors themselves say the fact that a patient is aware of the option
can itself be therapeutic.
"For many terminally ill people, the fact that they can choose to die is an
immense consolation," said general practitioner Coot Kuipers of the southern
village of Uden.
Suicide pill
The BBC's Geraldine Coughlan in The Hague says there is already debate on
widening the scope of the new law.
In one case, a group of doctors is campaigning in support of a colleague who
is appealing against a murder conviction for helping a comatose patient to
die without a request for euthanasia.
They doctors claim the case is not about mercy killing but medical ethics.
The Netherlands Voluntary Euthanasia Society is also debating whether
elderly people should be prescribed a suicide pill to be able to end their
own lives when they feel the time is right.
The doctor's role in mercy killing and the individual's right to choose to
die are some of the most complex legal and ethical aspects of the emotive
issue of euthanasia.
The euthanasia debate is strong in countries other than the Netherlands:
In Belgium, senators voted in October in favour of a euthanasia bill
In France, Health Minister Bernard Kouchner, a trained doctor, has said he
will use the Dutch decision to press for legalisation
In Australia, one region, the Northern Territory, became the first place in
the world to legalise euthanasia in 1996 before the law was overturned nine
months later
In Britain, a paralysed woman recently won the right to die in a
ground-breaking case
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